The editor indicates that this handbook is designed to present the emergency physician with some of the classic patient presentations of commonly abused substances in a quick, easy-to-read format. The authors are all emergency medicine physicians, clinical toxicologists, or other health care professionals based in the Minneapolis/St Paul, Minnesota area.
The book is organized using a color scheme of different color tabs for each class of abused drugs. What is described as a road map to drugs of abuse is located on the inside of the front cover. This is the grouping of drugs of abuse into one of seven different categories. Each category has a list of the toxic symptoms by organ system, and then a list of the drugs and substances discussed in the handbook for that category of drugs of abuse. In addition to the presenting signs and symptoms associated with acute toxicity, there is a section describing the presentation of chronic users. The seven drug of abuse sections are stimulants, narcotics/opiates, sedative-hypnotics, herbs and plants, hallucinogens, volatile substances, and newer and other agents. The road map is not completed for herbs and plants and the newer agents sections, both of which include a variety of drugs with unrelated toxicity. The sections include a total of 26 drug and drug chapters such as amphetamines, benzodiazepines, khat, PCP, volatile substances, and ketamine. Each chapter is organized into seven clinical sections: a case, history and societal impact, pharmacology and pathophysiology, making the diagnosis, the differential diagnosis, and emergency department management, along with a list of diagnostic clues. Each chapter is referenced. There is an eighth section which includes an appendix with street terminology for common drugs of abuse.
The organization and content of the handbook indicates that the primary focus of the handbook is to assist the emergency physician in the differential diagnosis of drug of abuse toxicity. While the handbook can be of benefit for this purpose, it is not clear of what benefit the case presentation at the beginning of each chapter and the section on the history and societal impact (often the longest section of each chapter) contribute. In addition, having a more consistent clinically useful discussion of the role of urine drug testing and interpretation of test results would be of value. While some of the chapters have extremely good sections, others are lacking when it comes to interpretation.
Some of the sections limit the number of drugs included. The sedative-hypnotic section includes chapters on benzodiazepines and rohypnol (flunitrazepam). It is not clear why flunitrazepam was not included in the benzodiazepine chapter, and why other sedative-hypnotic agents such as zolpidem and meprobamate were not included. In addition, the anticholinergic class of drugs, often abused by adolescents, is not included except for under the jimson weed listing, and cannot be identified applying a patient's presenting signs and symptoms to the road map. Dextromethorphan, a drug which was becoming a common drug of abuse at the time this book was prepared, is mentioned in guide to using the book, but not included in any other sections.
It is extremely difficult to create a comprehensive, clinically useful handbook for the clinician that covers the volatile, changing world of drugs of abuse, and the editor acknowledges this problem in the book's introduction. This handbook is directed toward typical drugs of abuse, the substances that the clinician generally needs the least help in identifying. While this text may be useful for the clinician who rarely is asked to evaluate patients for potential drug abuse, it is unlikely that many emergency physicians fit in this category given the frequency of that drug abuse in emergency department patients has become. While the road map approach to using patient signs and symptoms is an appropriate approach to determining drug of abuse toxicity, the road map in this handbook is not extremely useful.
Wm. A. Watson, Pharm.D., D.A.B.A.T.,F.A.A.C.T., F.C.C.P.
South Texas Poison Center
University of Texas Health Science Center atSan Antonio
San Antonio, Texas, USA
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