Drug Abuse Handbook PDF

Preface

By the time this weighty volume is published, more than 10 years will have passed since I first approached Taylor & Francis (formerly CRC Press) about this project. I was surprised and delighted when they agreed to undertake this second edition. In the preface to the first edition I told readers that "a tremendous amount" had been learned about the problem of drug abuse, and I observed that most of the learning had been done not by pathologists, or even toxicologists, but rather by molecular biologists and neurochemists. That observation remains true today, even after all of the opiate receptors have been cloned, at a time when it impossible to look at drug–receptor interactions in ways that were inconceivable only a decade ago.

In the preface to the first edition I also complained about the slow progress being made in more traditional, less "exotic" fields. The advent of the phenomenally popular CSI television show helped raise public awareness of crime scene investigation. Industry is certainly aware of the amazing progress and has not been slow to capitalize upon it, even to the extent of funding some badly need research. The same kind of progress in understanding the effects of drug abuse has not occurred in the field of pathology, or any other medical specialties, for that matter. To the best of my knowledge, during the last decade, The National Institute of Drug Abuse (NIDA) has not funded even a single pathologist interested in studying the effects of abused drugs on the heart, or pancreas, or any other organ in the body; no pathologist sits on any of the NIH review boards. Some might say this is the very opposite of progress. There is very little difference between the way doctors treat cases of drug toxicity nowadays and the way they did so 30 years ago. The last really great advance in this field was the introduction of naloxone. "Compassionate," or not, the medical management of sick drug users is no more a priority of our current administration than of the previous one.

Like it or not, the scientific study of drug abuse–related disease constitutes an important part of forensic science. When are drugs the cause of death and when do they cause impairment? It turns out that the metabolism of different drugs varies greatly from individual to individual. Some of these differences remain apparent even after death, but many, if not most, are not visible to the naked eye. Not many medical examiners have the training, let alone the equipment, to test for invisible disease.

Does a very high fluoxetene level in a dead child signify a lethal overdose, or attempted murder, or is it a fluke of nature? The questions are more than academic, because the answers may determine whether criminal charges will be filed against the parents. Accordingly, this second edition of the handbook contains new chapters on both toxicogenetics and on the genetics of sudden cardiac death. Anyone who felt that they had mastered the art of DNA had best rethink their conclusions. Far from being a developed discipline, DNA testing is still only in its infancy. Should there be a third edition of this book, it will no doubt focus largely on DNA-related science; a great deal more than matching up single nucleotide polymorphisms is involved.

Readers will also note the addition of a section on legal notions of causation. Doctors have known for years that the search for scientific truth is best carried on outside of the courtroom. What most doctors do not know is that in the minds of jury members, their opinions carry no more, and no less, weight than the opinion of any laboratory technician. Worse, both doctor and technician are likely to have only a vague idea of what constitutes proof, and what constitutes junk science.

But, in fact, there is an easy way to tell: just use the scientific method. Most of this book is concerned with forensic science, the clinical management of toxic patients, and the management of addicted patients. At some point there must a convergence of these fields, and at some point all of these different disciplines become an evidence-based field. Case reports describing possible episodes of drug toxicity in solitary patients 30 years ago are insufficient to establish causation, not in the courtroom and not in the laboratory. Isolated post-mortem blood drug levels, no matter how "significant," are insufficient to establish the cause of death. A great deal more work and knowledge are required before that can be done. No matter how great the scientific advances of the next decade, there will be no real and lasting impact on everyday practice, at least not until what we do is, in fact, evidence based.

As should be apparent from the size of this volume, many individuals expended considerable energy to produce this book. It is probably a good thing that this book took so long to prepare because most of the truly exciting discoveries have occurred only in the last few years.

My thanks to all of the contributors, and my best wishes to the next editor. I do hope he or she will have more positive and exciting things to report.