Source: The New England Journal of Medicine 
Reviewer: Edward Nunes, M.D. 
Pubdate: March 12, 1998 
Volume: 338, Number 11 

Cocaine Addiction: Theory, Research, and Treatment

By Jerome J. Platt. 458 pp. Cambridge, Mass., Harvard University Press, 1997. 
ISBN 0-674-13632-2 

Over a century ago, the active ingredient in the coca leaf was purified,
and the first cases of cocaine dependence were described in North America
and Western Europe. Overlooked for many years, cocaine resurfaced as a
public health problem in the 1980s. Today, among the major addictions,
cocaine dependence remains the most elusive. Alcohol, opiates, and nicotine
all produce characteristic withdrawal syndromes, which respond to treatment
with pharmacologic agonists or sympatholytic agents. For cocaine, the
withdrawal syndrome is more evanescent, and its treatment implications
remain unclear. For alcohol, opiate, and nicotine dependence, a growing
list of medications is available to help induce remission or prevent
relapse, including the aversive agent disulfiram, the long-acting opiate
agonist methadone, the long-acting opiate antagonist naltrexone, and
nicotine-replacement therapies with patch and gum delivery systems. Recent
advances include naltrexone for alcoholism, the long-acting agonist
levomethadyl acetate hydrochloride for opiate dependence, and the
antidepressant bupropion for smoking cessation. Cocaine has yet to yield to
agonist, antagonist, or antidepressant strategies, although intensive work
is ongoing, and there have been hints. Several psychotherapeutic and
behavioral strategies have shown promise. This progress and the development
of effective medications for the other addictions reinforce the importance
of the research effort in this area and inspire confidence that it will
continue to bear fruit. 

Cocaine Addiction, by Jerome Platt, is a compendium of research on cocaine
to date. The author has admirably tackled the task of organizing and
summarizing over a thousand references from the scientific and clinical
literature. This is not a book primarily about the basic neurobiology and
pharmacology of cocaine. Rather, the focus is predominantly clinical.
Within that broad limit all essential aspects are covered, including
history, pharmacology, clinical features, epidemiology, associated
psychopathology, medical complications, and nonpharmacologic and
pharmacologic treatment approaches. An entire chapter is devoted to cocaine
and sexual behavior, unusual for a book of this type, but important given
the role of drug abuse in the human immunodeficiency virus epidemic.
Throughout, the emphasis is on detailed description of research studies and
review papers. This enhances the usefulness of this book as a reference,
although in the midst of some sections it is hard to keep track of the
gist. Most chapters end with conclusion sections that provide succinct
summaries and criticisms, and I recommend reviewing the conclusions first
before embarking on each chapter. 

The single-authored format has the advantage of a consistent style and the
absence of either duplication or large gaps in coverage. However, it would
be difficult for any one author to be intimately familiar with all the
literatures reviewed in a book of this scope, and indeed some sections are
not sufficiently critical of the studies reviewed. For example, the chapter
on pharmacotherapy conveys an overly optimistic impression of the efficacy
of several medications based on the results of small, preliminary studies.
In several cases these results have not been confirmed in larger,
well-controlled clinical trials published recently. It is a general
limitation of this book that there are few references beyond 1994.
Nevertheless, Cocaine Addiction provides a solid guide to the literature
that will be useful to newcomers and as a reference for experienced hands.
The study of cocaine abuse is a nascent field lacking clear consensus in
many areas. Serious students may, at points, wish to visit the primary
references identified in this book and reach their own conclusions. 

Edward Nunes, M.D. 
Columbia University College of Physicians and Surgeons 
New York, NY 10032

Copyright  1998 by the Massachusetts Medical Society