Conversation with Hamid Ghodse
2007; Wiley; Volume: 102; Issue: 2 Linguagem: Inglês
10.1111/j.1360-0443.2006.01659.x
ISSN1360-0443
Tópico(s)Historical and modern epidemiology studies
ResumoAddictionVolume 102, Issue 2 p. 197-205 Free Access Conversation with Hamid Ghodse First published: 15 January 2007 https://doi.org/10.1111/j.1360-0443.2006.01659.xCitations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL In this occasional series we record the views and experiences of people who have especially contributed to the evolution of ideas in the Journal's field of interest. Hamid Ghodse obtained his medical training in Iran before qualifying in psychiatry in the United Kingdom. He went on to establish an important addiction centre at St George's Hospital, London and made many personal contributions to the research literature. His influence has, however, also been international and he is president of the United Nations International Narcotics Control Board. He is an internationalist par excellence. FROM TEHRAN TO TOOTING Addiction (A): On looking through your publications, the first was in 1964; a guide-book in basic sciences for university entrance in Iran. Some years later we find you in Tooting with more than 300 publications to your name—so let us examine the journey from Teheran to Tooting. Could you say something about your family background and influences, and how you chose to go to medical school? Hamid Ghodse (HG): I am from a large family; I am one of nine and I am the eldest son of that family. My father was a civil servant and my mother was a teacher and later in life a headmistress, and she then had her own private school under her own name, Daneshmand School, which was her surname in Teheran. The family had strong educational interests and, for example, a number of my maternal aunts were teachers. A: What sparked your interest in medicine as a subject? HG: My nickname as a baby and a child was ‘Doctor’, possibly because I was quite chubby like one of the local doctors. Many years later my wife and children thought that my family in Iran were so formal in calling me ‘Doctor’, but they were in fact, referring only to my nickname. I was always fascinated with biology, and not just because of that nickname. I was intrigued by nature and although I was not bad at science subjects, my strongest interest was biological science. Medicine met that interest more than any other subject, and so I very much enjoyed my time as a medical student, from 1959 to 1965. A: Were you interested in psychiatry as an undergraduate? HG: Even before I went to medical school, I was interested in behavioural science and psychology. I was known among my friends and family for reading such authors as Dostoyevski, Rousseau, Sartre, Freud and also Konrad Lorenz. A: How was psychiatry taught in your medical school—was it inspiring? HG: Not at all, not really that much. Our psychiatric training was very brief and limited. The teachers were neuropsychiatrists and very much organic and biological in their approach and so I cannot say the subject was taught comprehensively, covering all schools of thought and theories. Among the good aspects, we saw psychiatric patients from the general hospital out-patient department, and also in the community. TO THE UNITED KINGDOM AND A TRAINING IN PSYCHIATRY A: You went on to complete your MD in 1965, on ‘The physical and mental complications of non-sterile deliveries at home’. What attracted you to this topic? HG: At that time, I was not sure whether to follow a medical career in psychiatry or obstetrics. I therefore chose a thesis which allowed me to study both. I was also fortunate in having a very good supervisor. A: A few years later you came to London. Why England, and what were your medical aspirations? HG: I first came to England in 1957 as a Boy Scout, attending the Jubilee Jamboree in Sutton Coldfield. This was the centenary of Baden-Powell's birthday and the fiftieth anniversary of the Scout organization. I was one of the few scouts from Iran and for the first time we left our country to participate in a meeting of 84 000 people from all over the world. During that period a family at Neath in South Wales invited me to stay with them for a week; our friendship started from there and subsequently, most years up to my graduation, I used to stay with them for the summer holidays. They had two sons of nearly the same age as me and treated me like one of the family. When I qualified as a doctor, I felt Britain was the natural place for my postgraduate studies because I already had my adoptive family in Wales. Whenever I arrived in Neath the local newspapers welcomed my arrival with a photograph and a column about my travels. At that age, such a welcome from the people of Neath was very rewarding and pleasant. ‘Whenever I arrived in Neath the local newspapers welcomed my arrival with a photograph and a column about my travels. At that age, such a welcome from the people of Neath was very rewarding and pleasant.’ A: Were you intent on studying psychiatry at that time? HG: By that time I knew that I wanted to become a psychiatrist. I was able to avoid some of the problems that doctors often have when they move to a new country by staying with my Welsh family. I first worked as a senior house officer at Morgannwg Hospital in Bridgend, South Wales. It was an excellent psychiatric hospital. The medical superintendent was the late Dr Marshall Annear, who was not only a very good role model and mentor, but also organized the postgraduate training programme. I learned a great deal and this was a good introduction to medicine in the United Kingdom. A: What led you to further studies in London and who were your main influences? HG: The late Professor Linford Rees was Professor of Psychological Medicine at St Bartholomew's Hospital in London and I knew his family in Wales. He was lecturing at Morgannwg Hospital and suggested that I should apply for the psychiatric training rotation at Hackney and Barts. A vacancy arose: I was very lucky and got the job. Among the main influences in Wales were Marshall Annear, who was a superb teacher and an excellent organizer of meetings and training courses, and Dr Alan Lloyd who was an excellent clinical teacher. Professor Linford Rees was truly in a class of his own as a clinician and I always looked up to him. He was not only a wonderful teacher and a wise mentor but also such a genuinely nice person to get to know—and whoever knew Linford will remember him in that way. He died only a year ago. I was considered a member of his family and I spent every Christmas Day, in the years before my marriage, in Purley in Linford's house. His son, the late David Rees, was an eminent surgeon and was Best Man at my wedding. Linford's other children, Angharad, a prominent actress, Catrin and Vaughan and their children are life-long family friends. A: Did you then start to develop an interest in drug and alcohol problems? HG: At the end of the 1960s there was tremendous concern at the apparent increase in drug misuse, and particularly of heroin, in London. Any doctor could prescribe heroin and even cocaine to addicts, and of course some private doctors acquired a reputation for being a ‘soft touch’ and for giving the addict whatever he or she asked for. The Misuse of Drugs Act 1967 limited private prescribing, and also led to the opening of the drug dependency units, or ‘DDUs’. One of the first was at Hackney Hospital, which was part of the Barts group of hospitals in north-east London, in 1968 and it was part of my training to work there. A: Did the staff in the DDUs really know what they were doing at that time? The clinics were an innovation and few doctors had any experience of these patients and their problems. HG: You are quite right, and at first we had little experience. Some patients were on huge doses of heroin and cocaine and stimulants [1,2]. I can remember assessing patients on prescribed daily doses of many hundred mg of heroin and perhaps 3–400 mg cocaine. It was reported at the time that one doctor prescribed 6 kg of heroin for his patients in 1 year. Those first patients we treated in a haphazard way on a trial-and-error basis. None of us were trained on how to deal with these particular addicts of that sort of severity. But we did attempt a relatively sound medical practice, following a few simple principles. For example, some patients were required to inject the drug in front of you to demonstrate that they were tolerant. ‘I can remember assessing patients on prescribed daily doses of many hundred mg of heroin and perhaps 3–400 mg cocaine. It was reported at the time that one doctor prescribed 6 kg of heroin for his patients in 1 year.’ A: Why were you attracted to working with those patients at that time? This was probably not a popular area of psychiatry and many doctors regarded addicts as undeserving and a bit of a nuisance. HG: Before I worked in the Hackney DDU it never occurred to me that one day I would become a specialist in the treatment of addiction. But when I started treating drug addicts, I became more and more interested in the way in which people unwittingly become addicted. My learning process became more and more reinforced and I developed a strong interest in these complex human behaviours. Drawing on my background in biological medicine, I started to develop some lines of research [3]. What was very intriguing at the time was the possible association between opiate addiction and a ‘sweet tooth’, or fondness for a high sugar content in the diet. Also, many heroin addicts had dental problems. I started reading more about it and then thought that it was worth investigating. I questioned addicts about their diet and life-style and went on to measure glucose tolerance and other endocrinological effects of opioids in heroin-dependent patients [4]. This was at a time when measuring prolactin levels or measuring gastric emptying were new and developing techniques and it was very rewarding to be one of the very few experimenting with the methodologies [5]. This work continued over some years, and eventually formed my PhD thesis and publications in the BMJ and other high-ranking learned journals. I was again lucky to have worked with a very friendly and highly academic consultant, Dr John Reed. A: What were your thoughts about a future psychiatric career and your next steps? HG: Well, in 1971, I had moved from the St Bartholomew's rotation to the Maudsley. I felt that was a personal achievement because entry to the Maudsley was very competitive. This proved to be an excellent start to a comprehensive training and I passed the Diploma in Psychological Medicine in 1974. By then I had almost finished my registrar training and I moved to the Institute of Psychiatry (IOP) as a research psychiatrist. I was halfway through my PhD. I was attracted to an academic career and had already worked in the professorial unit at St Bartholomew's Hospital. A: At that time Dr Aubrey Lewis was still at the Institute—he retired in 1966 but he carried on as an Emeritus Professor What was his influence on you and your colleagues? HG: Aubrey Lewis had retired when I was there, and so I did not work for him as a trainee. He continued to use an office next to the library and I have very good memories of him. On a few occasions he asked for my help in relation to some long letters written in Persian by colleagues. He was a very caring individual. The late Sir Denis Hill was encouraging me and I was truly fortunate to have had a chance to work with teachers such as Bob Cawley, Philip Connell, Felix Post, Bob Hobson, Lionel Herzov, John Corbett, Dennis Leigh, Oliver Briscoe, Sir Michael Rutter and Raymond Levy. I received advice and support from Alwyn Lishman, Bob Kendall, Hans Eysenck and a number of other superb teachers and clinicians at the Maudsley at the time, all of whom became my very dear friends. As for my contemporaries, a number of them are very eminent leaders in their field, There were many bright, motivated and ambitious colleagues. The atmosphere of the junior common room was very supportive but it was also, I think, a very competitive environment—a golden age of Denmark Hill, which produced most of the clinical academics and senior clinicians for all the other teaching hospitals. THE ADDICTION RESEARCH UNIT A: You then moved sideways into research and went to the addictions research unit (ARU)? HG: When I first wanted to go to the Institute after I finished my general training in psychiatry, I was encouraged to join a UK/US project in the psychiatry of old age. Then a position in the addiction research unit emerged and that was my preference, especially as I was already doing my PhD in that field. A: What research programme did you join at the ARU and who were you working with? HG: This was another opportunity to meet and work with a man who influenced not only my future career but also my way of looking at and approaching research. I had known about Griffith Edwards from my training at the Maudsley. When I joined his unit I continued with my biological studies for my PhD as well as other studies not related to the PhD but associated with biological aspects of addictions. The whole of the environment of the ARU was multi-disciplinary, but predominantly with a social and behavioural orientation and with a number of high flyers among young psychologists, behavioural scientists and sociologists. I became more familiar with the social sciences and I learned a great deal about the social aspects of human behaviour and psychiatry in general and addiction in particular. Griffith has remained a life-long teacher and family friend. A: Your papers then reflect a developing interest in the medical impact of drug use, for example overdoses, drug users attending accident and emergency departments, and then mortality. Tell us about that work. HG: That arose from interests within the ARU; I gradually got into the epidemiological aspects and user surveys of the 1960s, looking at the drug addict in new towns. I started to consider the medical indicators of drug misuse and devised a survey of the London casualty units. This led on to a body of work that became, in a way, classical studies on the medical impact of drug misuse. I studied nearly 70 casualty departments in Greater London using about eight medical students as researchers—each day they would go to the casualty with a questionnaire which had to be completed. We were interested in any presenting problem related to drug misuse, including self-poisoning. We were a little surprised to find that across all those London casualty units, there were something like just under 2000 episodes or presentations a month, related to drug misuse. Also, there was a central London cluster in that five of the hospitals in that area saw more than half of the drug misusers [6–9]. A: This work was very influential? HG: The methodology actually became an integrated part of the casualty department's monitoring system. Subsequently, the study continued for 12 months in certain selected hospitals, and then the methodology was adopted by the World Health Organization as a practical means of monitoring the impact of drug abuse and related problems in A&E departments in many other countries. There was a wider impact, in that the Department of Health recognized that emergency services for drug misusers were scarce and also that many of them were overdosing, and then going to central London casualty departments where they presented with a range of problems and occasional disruption to the care of others. So these patients were referred from casualty to the newly established City Roads drugs project, which offered community-based detoxification. That was a good response at that time—City Roads continues to exist and offers a wider range of services. Of course, today the number of problem drug misusers is far greater, and they are seen in A&E departments country-wide. A: Were there other outcomes from the repeated London casualty surveys? HG: Because we repeated the surveys over subsequent years, we started to pick up changes in doctors' prescribing habits and noticed increasing problems relating to the misuse of prescribed barbiturates. There were pressures to bring barbiturates under statutory control, but the imposition of even limited controls at that time would certainly have been resented by many doctors. In the light of research findings, and with funding from the Department of Health, the Campaign on the Use and Restriction of Barbiturates (CURB) started to help doctors to reduce the prescribing of barbiturates and to educate the public about the hazards of unnecessary consumption of hypnotics and sedatives. Jamison et al., in their book Dealing With Drug Misuse: Crisis—Intervention in the City[9], state that ‘of most significance in influencing government to pay some attention to the issue was the research carried out by Hamid Ghodse’. In further work, we also examined the attitudes and opinions of casualty staff in relation to drug misusers. We conducted a study of more than 1400 A&E department staff, including nurses, doctors and ambulance personnel, on how they responded to drug addicts presenting with overdoses and other problems. We found some differences between these groups of workers [10]. ‘We conducted a study of more than 1400 A&E department staff, including nurses, doctors and ambulance personnel, on how they responded to drug addicts presenting with overdoses and other problems.’ A: Who were your academic colleagues at the ARU at this time? HG: There were a number of excellent colleagues—the culture was very helpful in many ways in forging relationships with other disciplines and the ARU provided me with the opportunity to work with psychologists, sociologists, statisticians and clinical and basic scientists such as Jim Orford, Gerry Stimson, Ray Hodgson, Margaret Sheehan, Edna Oppenheimer, Bram Oppenheim, Ilana Crome, Michael Russell, Gloria Litman and Herb Bloomberg and David Robinson—all of whom are pioneers in various aspects of addictive behaviour. Griffith was able to attract scientists and researchers from different disciplines into the field of addictions and created an environment that nurtured and fertilized ideas so that it became a centre of excellence in the field. This was a golden era of the research in addictions in the United Kingdom. The ARU was housed in a two-storey prefabricated building at the front of the Maudsley hospital. Although we had our own little offices we interacted in different ways, with easy access to each other's opinions; it did not feel competitive at that time, but very supportive [11,12]. A: By 1978, you had completed your academic and professional training. What happened next? THE MOVE TO ST GEORGE'S HOSPITAL HG: I was not actually looking for a consultant post. I was quite comfortable to remain at the IOP but one day I had a letter from Professor Eugene Paykel, inviting me to apply for the post of consultant and senior lecturer in the psychiatry of addiction at St George's and St Thomas' Hospitals. At that time, St George's Hospital was at Hyde Park Corner in central London, and had a small psychiatric out-patient and associated addiction clinic at St George's, Tooting. There was also a DDU at St Thomas' Hospital, including an in-patient addiction treatment unit at Tooting Bec Hospital in south London. This was the largest such unit in the United Kingdom, with 26 beds catering for a wide range of addiction problems. I joined Dr Thomas Bewley, who looked after the out-patients at St Thomas'. I worked in St George's out-patient department and we shared the in-patients at Tooting Bec. Thomas, who subsequently became the Dean of the Royal College of Psychiatrists and then President, was an excellent clinician and medical politician. It was an excellent opportunity to work with such an experienced senior consultant colleague and I learned a good deal from him, not only in dealing with most difficult and complicated patients but also about senior management skills. He and his wife Dame Beulah Bewley remain valued friends. St George's University of London had a very comprehensive academic department of mental health sciences. Influential within it was Professor Arthur Crisp, an international renowned authority on eating disorders. It was a great pleasure to join him at St George's. St George's University of London had a very comprehensive academic department of mental health sciences. Influential within it was Professor Arthur Crisp, an international renowned authority on eating disorders. It was a great pleasure to join him at St George's. A: At that time, London and many other cities experienced a marked increase in the numbers of heroin misusers. How did that impact on your clinical work? HG: At that time the number of heroin addicts was fairly steady with a very small rise every year—this meant that we could admit patients with very complex needs, who were extremely difficult to manage in the community, to the in-patient unit. The Tooting Bec unit was the only unit in the country which had no restrictions on admission. Any drug-dependent individual, with any type of problem, could be admitted from anywhere in the country. Multiple diagnoses of addictions, mental illness and physical conditions were the norm rather than exceptions. Some patients were even under sections of the Mental Health Act. It was truly a medico-psychiatric ward providing most types of treatment. This was a period when many patients were polydrug-dependent and barbiturates and other drugs were commonly abused [13–16]. The unit provided excellent grounding for trainees and for research. Thomas Bewley and his team and my team worked very closely together at that time. A: But then you established an in-patient unit at Springfield Hospital. HG: With changes in the health service and with new managers, Tooting Bec Hospital, which was a big mental hospital with more than 1000 beds, was due to be closed and the patients cared for in community settings. This was a very positive step for most patients but not for severely dependent drug misusers with severe behaviour problems—they did not have anywhere else to go for care apart from the Tooting Bec unit or the very expensive intensive care units of the general hospitals with frequent short admissions. As the managers aggressively pursued their short-sighted plan I had to take the case to public debate and complained nationally on the radio, television and press. I succeeded in saving the unit by transferring it to the nearby Springfield Hospital, where I created a tri-stage model of care, with care in an acute unit followed by a recovery phase and supplemented by day care—a model of care which has been followed elsewhere [2,17–19]. I believe that this outcome—of transferring the in-patient unit—was a tremendous success achieved as a result of the campaign by patients, their relatives and staff, and I am proud of this. A VERY SUCCESSFUL UNIVERSITY DEPARTMENT A: And your addictions base then developed further and greatly? HG: Springfield Hospital, in south-west London, is part of St George's Hospital and medical school. When I started as a consultant at St George's the addiction team had half of my time, a few sessions of a medical assistant, who was paid by St Thomas', a nurse and a part-time secretary. When I left St George's, addiction services comprised a university department of addictive behaviour with over 200 staff, 85 of them in the academic department and others in 10 community-based clinics, out-patient units and outreach, and in-patient units together with a dedicated alcohol service. The staff included three professors, two readers and eight senior lecturers and eventually the research and development income of our addiction department exceeded that of the rest of mental health. These achievements were due to the dedication and hard work of all staff, including Andrew Johns, James Edeh, Colin Drummond, Sally Porter, Mohammed Abousaleh, Fabrizio Schifano, Judy Myles, Nek Oyefeso, Sally Porter, Ken Checinski, Mark Prunty, Carmel Clancy, Fiona Marshall, Jan Annan, Alison Keating, Ken Umani, Kate Borrett and many others. In particular, I have to mention Dr Gill Tregenza, who welcomed me to the service when I joined St George's and St Thomas' and who worked with me throughout. ‘When I started as a consultant at St George’s, the addiction team had half of my time, a few sessions of a medical assistant, who was paid by St Thomas', a nurse and a part-time secretary. When I left St George's, addiction services comprised a university department of addictive behaviour with over 200 staff, 85 of them in the academic department . . .’ A: One of your research interests at that time involved a novel method of assessing opiate dependence. Could you describe this for us? HG: I was always searching for a better assessment tool for the accurate diagnosis of dependence on psychoactive drugs. There were, of course, a number of clinical assessment tools available but I wanted to have a safe and objective way, tolerable to the patient, of determining whether a substance misuser has become physically dependent on opiates and different classes of drugs. Investigation into the possibilities of such a test for opiates was a good starting point, not only because I have always been fascinated by the pharmacology of these classes of drugs but also because, for everyday clinical practice, it would be extremely useful to have an objective test. It is well known that if opiates are prescribed unnecessarily, this can lead to increased mortality and the diversion of controlled drugs to the black market. A: So how did you approach this problem? HG: After conducting a pilot study with some encouraging results, I discussed the project with a good friend and colleague, Professor Steven Smith, who was in charge of the department of pharmacology at St Thomas' Hospital and medical school, and he agreed to help me with the development of the opiate addiction test. He had a particular interest in and expertise on the effects of drugs on the pupil of the eye. The test involved the objective measurement of the pupils of both eyes. The next stage of the project was the development of a simple and precise way to carry out this measurement and I was successful in attracting a medical physicist, Dr Dan Taylor, to the idea and, with a grant from the Medical Research Council, we developed a dedicated video-computer based binocular pupillometer. Both the opiate addiction test and its dedicated pupillometer have been internationally patented and I was very pleased to learn that it was selected as a millennium product—‘one of a collection of the most innovative products created in Britain for the new Millennium’. It was exhibited at the Millennium Dome in 2000, it won the Trade and Industry SMART and SPUR Awards, and was also the runner-up for the Aneurin Bevan NHS Award. The pupillometer part of the opiate addiction test is now being manufactured by Procyon [20–23]. ‘The pupillometer part of the opiate addiction test is now being manufactured by Procyon.’ PRESIDENCY OF THE UN INTERNATIONAL NARCOTICS CONTROL BOARD A: Moving to your international activities, you are of course the current President of the International Narcotics Control Board (INCB), and I imagine not many people will be familiar with the role of that organization. HG: The International Narcotics Control Board is the independent and quasi-judicial United Nations control organ for the implementation of the United Nations drug conventions. It was established in 1968 by the Single Convention on Narcotic Drugs, but there had been predecessor organizations under the former Conventions since the time of the League of Nations. The Board is independent of governments as well as of the United Nations. Broadly speaking, it deals with two aspects of drug control: with regard to licit manufacture, commerce and sale of drugs, the Board endeavours to ensure that adequate supplies are available for medical and scientific uses, and that leakage from licit sources to illicit traffic do not occur. The Board also monitors governments' control of chemicals used in the illicit manufacture of drugs and assists them in preventing diversion of these chemicals into illicit traffic. The Board also identifies where weaknesses in the international control systems exist and contributes to correcting the situation. In brief, the Board is the guardian and the watchdog of the International Drug Control Conventions [24]. A: Now we can read further details about the work of the INCB in the most recent Annual Report which has just been published, and it is clear that the Board is currently involved in matters of great political sensitivity so perhaps the full story of your activities there will have to come at a later time. HG: Indeed, that is quite right. A: However, when we consider the current role of the INCB, many of the international conventions controlling drug misuse are some years old—for example, the Single Convention dates from 1961. Do these conventions and treaties still have relevance today? HG: More relevant today than at that time. The 1925 Convention, which created the predecessor of the Board, the Permanent Central Opium Board (PCB) came into force in 1928. The PCB started its work in 1929 and in the intervening period at least 100 tonnes of manufactured alkaloids (opiates and cocaine) from the pharmaceutical indust
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