series, vol 7. Totawa, NJ: Humana Press. 214 pp.
[review Clin Invest Med 1996;19(4): 292-293.]
Copyright 1996, Canadian Medical Association
In the preface, the editor indicates that the papers in this book take a new and critical approach to the role of alcohol in damage to life and property. This is good news, since one of the problems in this field has been the uncritical acceptance of data and conclusions from poorly designed studies and from nonscientific surveys. The editor also acknowledges that the increased risk of injury or death associated with alcohol depends on the situation. This too is good. To date, the emphasis has been placed solely on the consumption of alcohol, and situational variables have been largely ignored. He goes on to state that "the key to preventing or reducing risky behaviour" is "an understanding of how alcohol increases the risk of injury" and suggests that "treatment to reduce alcohol's modification of physiological function" should be included in intervention campaigns to prevent alcohol-related accidents. These statements are positively wonderful and totally unexpected. Authors in this field generally equate the consumption of alcohol with risky behaviour and ignore the physiological effects of alcohol, the mechanism by which alcohol alters brain function and increases risky behaviour, and the body's response to the continued presence of alcohol. To suggest that blocking alcohol's physiological effects should be considered as a way of reducing accidents is a new and even radical approach. The preface concludes with the statement that this book is the first "to bring together key critical reviews of the effects of alcohol and cocaine on accident causation" and that it "offers what we believe are effective strategies and programs designed to bring risky consumption under optimal control."
Hooray, I thought, at last, here is a book that brings together rigorous, multifaceted scientific analyses of the inappropriate and dangerous behaviours caused by the interactions of alcohol, brain function and the environment. Historically, studies in this field have not been adequately controlled and have not considered basic pharmacological concepts such as dose-
response, time-course, the development of tolerance, and factors that potentiate or attenuate the actions of alcohol. The field is also full of reports that completely ignore differences in brain function among people and differences in the performance demands among various test situations, and that draw conclusions that are not supported by the data collected.
Eagerly, I read on . . . only to be disappointed. The substance of the book does not fulfil the promise of the preface. The papers typically start out well enough, with an introduction that discusses some of the shortcomings of studies in a particular field. They then go on to present data from studies in which some of these shortcomings were taken into account. However, the papers invariably end by accepting the same old conclusions from the studies that had been rightly identified as flawed. Well, so much for the critical reviews. None of the papers addresses "how alcohol increases the risk of injury" or "treatment to reduce alcohol's modification of physiological function" or even, for that matter, what effect alcohol has on physiological functions. Well, so much for understanding the key to preventing or reducing risky behaviour. None of the reviews evaluates pharmacological concepts such as dose-response, time-course, tolerance and potentiating or attenuating factors. Nor do the papers consider psychological factors, such as the degree of overlearning of the task being tested, or the amount of experience with alcohol in the test situation (state-dependent learning) as opposed to experience with alcohol in general (tolerance) or altered functioning of the person's brain due to hypoglycemia, sleepiness, affective state and so on in combination with alcohol. Well, so much for new initiatives to bring risky consumption under optimal control. And finally, on a nit-picking level, I wondered, shouldn't cocaine get more than one 10-page paper? The title of the book gives cocaine dual billing with alcohol, but the contents do not.
This book does have some neat things going for it. It is easy to read, and each paper presents interesting ideas in a fairly well-written manner. Many of the authors point out the difficulties in obtaining appropriate control data for studies in this area and caution against the acceptance of inadequately controlled studies. Otherwise, however, the papers are uncritical, seem to give equal weight to data from well-controlled, poorly controlled and uncontrolled studies, and do not lead to an improvement in the understanding of any aspect of the problems posed by alcohol or cocaine. In a back-handed way, this book highlights, by omission, some of the very serious pitfalls and obstacles facing research in the field of alcohol and accidents. The paper on youth and alcohol reports that studies with adolescents have revealed that pre-existing high-risk lifestyle and personality factors predict involvement in a car accident. These studies suggest that drinking and driving is only one aspect of a syndrome of high-risk behaviours and that people in a certain group have more accidents, whether they have been drinking or not. This should lead researchers to question the interaction of alcohol and personality factors and to determine how much a specific blood-alcohol concentration increases the risk in the already high-risk behaviour of this group, in comparison with a group of low-risk-taking people. But, apparently, this has not been done. Individual and situational differences are still being disregarded in data interpretation. In the paper on alcohol and aviation safety, a study of the effects of alcohol on the performance of pilots in a flight simulator is discussed with equal weight given to significant differences and to differences that do not reach statistical significance. This indicates a very serious deficiency in the authors' understanding of the role of statistical analyses in scientific investigations. These authors also present, without comment, two studies with directly contradictory results. Furthermore, they do not question the reported observation that, in pilots given enough alcohol to produce a blood-alcohol concentration of 100 mg of alcohol in 100 mL of blood, alcohol "impairment of performance was still present eight hours after the subjects reached [the target] 0.10%" blood-alcohol concentration. This is very problematic for the interpretation of the effects of alcohol on performance, since, at the standard elimination rate of 124 ± 10 mg ethanol per kilogram body weight per hour, the blood-alcohol concentration of these subjects would have returned to zero about 2.5 hours before the 8-hour test. Consequently, this reported 8-hour impairment reflects something other than the action of alcohol on performance.
The paper on the treatment of people convicted of driving while intoxicated indicates that "the linkage between drinking and accidents is rather tenuous to a individual driver" and that "culpability should be assessed individually for each case and include an assessment of the drivers' actual blood alcohol content, risky driving behaviours, and the context of the behaviour." Although these statements seem reasonable, have face validity and may be scientifically relevant, in creating and enforcing drinking-and-driving laws, only the blood alcohol content of the driver is considered. Indeed, the tone of this book, and of research in this field in general, implies that blood-
alcohol content truly is the only relevant factor.
I am disappointed that this book did not live up to its promise. However, at least some of the investigators in this field are starting to question the traditional approaches and the standard interpretations of data. Perhaps a book with the qualities of critical analysis and scientific rigour that this book lacks will appear soon.
In the meantime, this book provides a very readable summary of a variety of studies of the association between alcohol or cocaine and accidents. The individual papers are well written and interesting. They do include some caveats concerning the traditional approaches and conclusions of existing research. This book would be useful for any health care professional who is looking for an overview of current data and ideas in the field of alcohol (or cocaine) and accidents. However, it falls short as a critical scientific review of past investigations, as a guide for implementing treatment programs or as a blueprint for future research.
J. Steven Richardson
The full text may also be ordered from the Canada Institute for Scientific and Technical Information (CISTI) or Institute for Scientific Information (ISI).