DrugsDrugs

According to Courtwright, writing drug history "is like peering through a microscope with a low-powered lens. The observer can see a good deal of the specimen, but only by sacrificing detail." This makes for interesting reading.

The book's first section describes emergence of the world's drug market and competition between the principal psychoactive compounds, alcoholic and caffeinated beverages, tobacco, opiates, cannabis, coca, and cocaine. The United States has become the melting pot for drugs of abuse. Coming from widely different regions, virtually all drugs of abuse have followed disposable income and are widely available.

Access to drugs of abuse is strongly related to cheap price, availability, and prevalence of use. Courtwright explains that

Cubans once smoked 30 percent of all cigars made in Cuba, that Asian communities which grow and sell opium have consistently higher addiction rates than those which do not . . . , that Kentuckians suffer exceptionally high rates of lung cancer—all of this strongly suggests that proximity, and hence familiarity and availability matters. . . .

Lack of availability has served as the basis of short-lived geographic cures; the cocaine addict who moves from Manhattan, NY, to Kansas might have a temporary "cure." Drug Enforcement Administration initiatives that reduce access or increase price and state and federal taxation on tobacco and alcohol make considerable sense because they limit availability.

Drugs is used by Courtwright "as a convenient and neutral term of reference for a long list of psychoactive substances, licit or illicit, mild or potent, deployed for medical and non-medical purposes. . . . All can be abused. . . ." Medications can become drugs of abuse. Cocaine, when medically administered, is a safe and effective topical vasoconstrictor and local anesthetic. Cocaine, when self-administered for euphoria, can stimulate its own taking and cause addiction and other negative health consequences. Tobacco smoke, which includes nicotine as the principal psychoactive addictive ingredient, kills about 440 000 Americans yearly. The nicotine patch, which includes nicotine as a replacement therapy, does not have abuse potential or street value, and is not used unless the patient is highly motivated. Opiates are safely administered, even self-administered for pain relief, but extremely addictive when self-administered for euphoria. All drugs of abuse are self-administered but not equally, whether by experimental animals or humans. The more compelling the drug, the more work, pain, and suffering the addict is willing to endure. Cocaine and heroin are much more compelling than other drugs of abuse; addicts work harder and endure more for a dose compared with other drugs. Having illicit drugs remain illegal is logical to reduce familiarity and availability.

"Prayer, fasting, meditation and exercise are the preferred means of transforming consciousness," Courtwright writes:

Drugs transiently mimic only the feeling, not the disciplined knowing, of true mystical experience. They are false religions, chemical idols that distract the faithful and lead them down the path of self-destruction. Hence the unequivocal condemnations of drug abuse in the Catholic catechism, the Buddhist sila, and other basic moral codifications.

He offers an important lesson that he finds in history:

When familiar drugs are processed in unfamiliar ways, increasing their potency to unprecedented levels, heightened abuse inevitably, if not always evenly, follows. This is an important and recurring theme in drug history. Wine is to brandy as opium is to morphine, coca is to cocaine (crack) or shag tobacco is to the modern cigarette. The history of psychoactive substances resembles that of the arms race. Technological change continuously raises the human stakes.

Courtwright's history suggests that false medical claims are simply a Trojan horse leading a new drug to a robust consumer market. Will marijuana users figure out how to make it more potent, more addicting in the tradition of coca leaves or to crack? It is worth remembering tobacco's history as a "medicine": "[t]obacco could heal all manner of wounds, sores, and aches . . . it got a reputation as a great antidote against all venom and pestilential diseases . . . No London tobacconist, legend has it, ever succumbed to the Great Plague."

Courtwright describes how "[t]he ongoing cigarette revolution, which taught Americans to absorb drugs through their lungs, facilitated the spread of marijuana smoking, as did the abundant domestic supply," and comments on the complementarity of tobacco and marijuana "in virtually every culture," with tobacco being "a gateway to cannabis experimentation." Marijuana smoking is particularly compelling and available to smokers.¹

Courtwright writes, "The idea that most drugs are dangerous substances best used in limited amounts under medical supervision has become the official attitude. . . . What is it about drugs that generates so much demand?" Satiety for drugs is an oxymoron. Drugs of abuse target important brain areas to induce a hunger and new drive state that would not otherwise be present. In some, use causes immediate consequences, in others this hunger cannot be easily satiated. One dose of cocaine has been shown to change the brain for days.^{2 - 3} "Ecstasy" or MDMA (N-methyl-3,4-methylenedioxyamphetamine) is associated with both short- and long-term brain changes.⁴ No one smokes tobacco for hoarseness, or smelly clothes, or to develop cancer. Yet the desire to stop often succumbs to seeing one's favorite pack, talking about smoking, or declining nicotine levels, triggering craving and use. Ignoring drugs of abuse and related cues appears to be quite difficult for the user but easy for the person who has not had an illicit drug experience.⁵ Use, narrowing of interests, and pathological learning lead to additional use, and if the consequences do not cause injury or death, addiction can develop. Even withdrawal may serve only to increase the brain reward produced by the drug of abuse.⁶

This book is well written and easy to read. It is not quite a seminal reference text in the area of drug history like The American Disease,⁷ but it does provide very useful information.

Walter Shelley has been a leader in teaching dermatology for nearly a half century. His books, articles, and lectures have inspired many young physicians to specialize in dermatology, this reviewer among them. Since his marriage to Dorinda Shelley, their collaboration has produced a vast number of unique articles and textbooks. Advanced Dermatologic Therapy II is their latest effort, and it is outstanding.

Although the title would lead the reader to believe that this is a second edition of the 1987 Advanced Dermatologic Therapy, this is an entirely new textbook. The Shelleys perceive their new text as a "search engine" for exploring therapeutic options for dermatologic disorders.

The large textbook contains 1217 pages, with full color, literally packed with information on dermatologic therapy. The format consists of individual chapters for most of the common skin disorders seen by dermatologists, arranged alphabetically from abscess to xeroderma pigmentosum.

Treatment options for nearly 300 diseases are thoroughly reviewed. Each disease chapter begins with a section of key words in blue summarizing important therapeutic options. Case studies follow, illustrating interesting variations on each disorder. Next is a list of references with the important points summarized. Thousands of journal articles are cited with a concise summary of each. This format allows a reader to rapidly scan a series of advanced dermatologic therapeutic options.

There are more than 204 illustrations in this book, and they are excellent. But this is not an atlas of dermatology. Rather, the authors assume that the reader already has an advanced knowledge of dermatology. Advanced Dermatology Therapy II is a reference book intended for experienced dermatologists who have already made a diagnosis and wish to explore a wide range of therapeutic options.

The writing is succinct and clear. A charming feature is the inclusion of excerpts from the Shelleys' "Portrait of a Practice: A Dermatologic Diary," which was published monthly for more than 5 years in Cutis. These excerpts personalize the text by combining the Shelleys' down-home writing style with clever clinical insights.

In the chapter on cheilitis, for instance, there are four diary excerpts, each demonstrating a variation on this disorder. Each clinical case reveals an obscure causative agent and how the Shelleys approached treatment. Twenty-five journal references on treatment of cheilitis follow with summaries of the salient points.

So many other dermatologic texts are imitations of each other, but everything about this book is unique. Even the insides of the covers are used thoughtfully. Illustrations can be found here of the therapeutic "wheels of fortune" featuring injectables, systemic treatment, and topicals. If ever there were a textbook that should be on the shelves of every dermatologist, this is it. It is a wonderful gift from two dedicated and respected teachers.

In the 19th century, Lister, Koch, and Pasteur defined the biological basis of medical science. Semmelweis and Nightingale showed the beneficial effects of implementing the new science. In the mid-20th century Austin Bradford Hill devised methods of measuring effects of scientific medicine on patients. Avedis Donadebian provided the theory and framework to examine health system quality. Osler Peterson published the first modern measurements of medical practice quality. Yet, implementation of contemporary quality improvement results remains far from ideal in daily medical practice. We need only review, for example, the multiple studies over the past five decades documenting simultaneous overuse of ineffective treatment and underuse of beneficial care.

How is it possible that modern medicine still does not provide care of known benefit sufficiently and correctly? Quite simply, deficiencies in medical quality are due to inadequacies of organization, delivery, and financing systems. We have known this since reports from the Institute of Medicine's Committee on Costs of Medical Care in the late 1920s through mid-1930s.

Changes that we have implemented to correct such deficiencies, such as Medicare and Medicaid, have been piecemeal and uncoordinated, with unintended and undesirable consequences on quality and cost. The patchwork approach has served us ill, as we run from crisis to crisis, allowing the fear of "cost" to drive all systematic attempts at problem definition and solution development. Such an approach is always doomed to promise much and deliver little.

In its report Crossing the Quality Chasm, the Committee on Quality of Healthcare in America has done yeoman work in defining the deficiencies of organization, financing, and delivery in US health care systems and formulating recommendations. Consensus from such a broad array of representatives must convince us that the problems are worse than we thought and that delaying implementation may lead to catastrophe.

It is difficult to fault any of the committee's five objectives (such as improving health) and 13 recommendations to redesign the US health care system so as to improve quality outcomes (for example, that "health care should be safe, effective, patient-centered, timely, efficient, and equitable"). The enormous body of compelling evidence marshaled to support the analysis and recommendations is difficult to refute. Opponents can only ignore the committee's findings. There is prodigious evidence to warrant wholesale internal system changes of clinical practice, patient adherence with therapy, continuing medical education, delivery of care by organizations and institutions, financing, and on and on. The committee astutely used outcomes of specific processes as prime measures of system quality effects, for example, relating specific patient care to predefined health outcomes.

Some might argue that the committee wimped out by not describing specific means to implement their recommended changes. I think not. In health care it is clear from experience that recommendations for implementation to effect broad and deep change are ignored by systems used to incremental change. Defining problems of quality as problems of complex systems, in both biological and mathematical terms, and setting the principles, framework, and means to confront and solve the problems is the first and most important step. Let others implement. Principles of management clearly state that those who design change should be separate from those who implement change. Developing a new medical care quality system is a scientific enterprise; implementing it is a political one.

The rarely discussed report by the Institute of Medicine's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry, Envisioning the National Healthcare Quality Report, already started the implementation process. The report led Congress to enact the Healthcare Research and Quality Act of 1999, requiring the Agency for Healthcare Research and Quality to prepare an annual report of trends in health care quality. These will serve as a base against which changing health outcomes can be measured.

Crossing the Quality Chasm is the state-of-the-art report on redesigning our health care system. It is required reading for all of us in health care. If we implement the committee's recommendations, we will truly have created a health care system revolution. Even with partial implementation, change would be profound. Given our national discomfort with revolution in any institution, the authors were inordinately clever to couch revolutionary health care system organization, finance, and delivery change within an eminently acceptable subject like medical quality. Who could be against improving quality? Let us hope, though, that Max Planck's prophecy is not fulfilled yet again: "A new truth does not triumph by convincing its opponents . . . but rather because they eventually die." I don't think we can wait that long.

Wolff's Headache and Other Head Pain was a valuable part of any physician's book collection in 1948. The book's value was based in the systematic approach and study that Dr Wolff had applied to headache care. The current seventh edition, prepared by Drs Silberstein, Lipton, and Dalessio, maintains the value of the original text by remaining a clinically useful, easily managed resource.

The text has four parts, which focus on general aspects of headache, primary headache disorders, secondary headache disorders, and special situations. In more than 600 pages the text touches on the common headache conditions and many recognizable but unusual ones. Wolff's Headache provides numerous useful clinical details, and this edition notably increases information about the rapidly expanding pharmacology of migraine therapy.

The overview section begins with an amazing chapter, which includes "Headache Games," 10 insightful and, at times, entertaining, recognizable patient scenarios. Such a collection of patient stories should be assembled for many chronic illnesses, because experienced clinicians' solutions could help all physicians better understand the clinical situations that they face. This chapter alone makes the book worth owning. The remaining chapters in the overview section are all of basic interest, like "Epidemiology and Impact of Headache," which includes little known economic information.

The primary headache disorders section includes migraine, tension-type, chronic daily, and cluster headaches. This section is particularly necessary owing to the enlarged pharmacopoeia for migraine treatment. Extensive tables assist the reader with quick reference to drug choices and effectiveness. The text includes dosing data and is organized so that the clinician can find drugs of choice easily. Therapy for chronic daily headache is not well described, but chronic migraine is extensively discussed. Many treatment options for this difficult clinical situation are provided. Cluster headache receives a good pathogenesis section.

The third section is very valuable, as it provides a quick reference to the typical features of secondary headaches. A well-constructed index aids in finding the situation of concern and verifying the nature of the encountered headache. While no headache is ever truly consistent, the atypical nature of a headache may direct the physician to seek needed additional testing. Chapters on headaches related to head trauma, vascular disease, and infections, and on cervicogenic and eye-related headache are useful. The chapter on cervicogenic (neck origin) headache is short, and some elaboration of therapy choices, including nonmedical approaches, would have been valuable. Patients may be over-eager to blame their eyes, but many headaches are eye-triggered. The chapter on eye-related headache is well done and worth reviewing, if only to help debunk patients' misconceptions. The space devoted to head pains is short considering the book's title. Tables of mechanisms and therapy data might have worked well for easy review.

The section on special headache situations includes a nice chapter on youth. "Practice Points for Doctors to Consider" gives the "meat-and-potatoes" of good headache care and is strongly recommended. The points made will be recognizable to any good physician, but practice often calls for these skills. Locating the chapters about behavioral management and communication at the end of the book is a limitation; both are important and might be missed.

Wolff's Headache and Other Head Pain is a valuable general resource that the active physician should keep close at hand.