ANTABUSE TREATMENT FOR ALCOHOLISM: AN EVIDENCE-BASED HANDBOOK FOR MEDICAL AND NON-MEDICAL CLINICIANS.

APPENDIX 3.

FEAR AND LOATHING IN WESTMINSTER. Attitudes to probation-linked disulfiram in London and elsewhere.

The late Prof Griffith Edwards, Britain’s first professor of the study and treatment of addiction, had been a friend and supporter for more than a decade. Following the publication in 1971 of my neuroradiological and psychometric study of alcoholic brain damage discussed in Appendix 2,[1] he introduced and commended me to several prominent academics involved with alcoholism research who were planning similar studies with the newly-invented CT scanner, which became available for clinical use and research in 1974. His alcoholism textbooks routinely mentioned and endorsed both disulfiram and the need for supervised consumtion. In 1984, about a year after our probation-linked disulfiram paper[2] appeared in the BMJ, I received a superficially friendly ‘Dear Colin’ letter from Griff informing me that while he knew John Smith and I meant well in linking disulfiram with probation, he thought it was not ethical and was therefore asking the General Medical Council to give a ruling on the matter. I did not conclude from this that Griff was trying to have me struck off but Griff was the GMC’s chief advisor on addiction matters. He was also, as I learned later, not the sort of man to tolerate dissent from his views and he clearly expected the GMC to do his bidding.

A week or two later, an equally polite but more neutral letter arrived from the GMC, confirming that Griff had written to them and asking for my views. I explained why I thought our programme was not unethical and cited the two US probation-linked studies in support. Soon, another GMC letter informed me that they entirely agreed with me and that the matter was closed; but it was not closed as far as Griff was concerned. A few years later, a prominent alcohol clinician, who was one of Griff’s colleagues at the time, told me that Griff had been ‘incandescent’ about the GMC’s failure to back him but the first I knew of Griff’s displeasure was when he cut me dead at an addiction meeting a few months later. He never spoke to me again.

This being the early 1980s, our programme – which I suppose was Britain’s first ‘drug court’ - had also attracted the attention of the sort of probation officers and social workers who identified themselves as ‘radical’. That term was synonymous with the Hard Left and – then as now - the Labour Party was in a state of ideological civil war between the majority of its MPs and electorate and activists from various Marxist, Trotskyist and Maoist groupuscules. They were opposed to making any sort of sanction a condition of probation and generally regarded breaches of a probation order as something to be discussed at leisure with the offender, instead of quickly reporting the breaches to the magistrates who had, with the offender’s agreement, attached the conditions. Radical probation officers regarded returning offenders to court for breaches as a last resort, rather than a first or early one, as it usually should be. (See the brief discussion, at the end of the chapter on probation-linked treatment, of the successful ‘instant justice’ programme for alcohol-related offenders in Dakota. A similar programme has recently started in parts of Lincolnshire and Yorkshire.) It was apparently a probation officer of this kind who had brought the matter to Griff’s attention, though if Griff himself held any radical left-wing views, he concealed them very effectively.

The probation officers’ union convened a special meeting at which John Smith and I had to defend ourselves before a largely hostile audience. Some of them seemed to have come straight from Central Casting and evidently believed that crime was an invention of the hated bourgeoisie, a legitimate form of income redistribution, or would disappear come the Revolution. To what I think was his subsequent embarrassment, they also persuaded Dr Richard Smith (then a rising junior editor of the BMJ and later, its editor) to tell the meeting that disulfiram was unacceptable because it might have - side effects! While all John Smith’s colleagues and Westminster’s chief probation officer had approved of the programme and resisted the radicals, a new chief took over around 1986 who, though not in the radical camp, was less supportive. His main concern seemed to be a bureaucratic one; that neither probation officers nor – a fortiori – the receptionists were qualified to administer medicines. We pointed out, to no avail, that equally unqualified mothers up and down the land were routinely trusted to administer medicines to their infants, for whom getting the dosage and timing right was much more crucial than in the case of disulfiram. 

A few years later, I learned that I had unknowingly become a member of a small and rather select club of addiction researchers who greatly admired Griff’s academic contributions (and his oratorical skills) but had been expelled by him, for reasons that were usually less clear than in my own case, from the addiction Garden of Eden. One is now a well-known professor at a Commonwealth university. Another, Prof Timothy Peters, was for a while the editor of Addiction Biology, the neurophysiologically-focused sister journal to Addiction, Griff’s own editorial fiefdom. Increasingly irritated by Griff’s attempts to interfere with his editorial independence (during one of which he tried to persuade Timothy not to publish a review paper[3] I had submitted) Timothy eventually announced his resignation as editor in a letter sent to all past and potential contributors and peer-reviewers, crisply denouncing Griff’s Stalinist habits. Like Finn Hardt in Copenhagen, Timothy was a gastroenterologist whose brief extended to liver disease, and thus introduced him to the world of alcoholism.  He also happens to be one of the country’s few experts on porphyria – a rather uncommon affliction in Britain - and since retiring, he has published several papers conclusively exploding the theory that Mad King George III suffered from that condition.[4] The most likely diagnosis is manic-depressive or ‘bipolar’ illness, presenting mainly as recurrent mania with far fewer depressive episodes,[5] followed towards the end of his long life by dementia, probably of the Alzheimer variety.[6] His research also indicated that King James I/VI – of the King James Bible – suffered from a very much rarer genetic condition that eventually caused his death from kidney disease and hypertension at only 58.

Peter Bourne soon moved on from alcoholism treatment but not, at first, in a conventional academic direction. Shortly after his disulfiram paper was accepted, he volunteered for medical service in Viet-Nam, where he flew on combat missions, sometimes under fire, collecting blood and urine specimens from aircrew and infantrymen to measure various stress hormones.[7] Returning to Atlanta, the capital of Georgia, he became friendly with the governor of the state, a man called Jimmy Carter. By this time, Peter had become interested in drug policy and when Carter became President, Peter moved to Washington to help co-ordinate a new policy with less emphasis on the hopeless ‘war on drugs’ and more on treatment provision. If Carter had managed a second term, Peter’s suggestions might have borne more therapeutic and legislative fruit.

Later still, as well as writing a biography of Fidel Castro, he helped to found MEDICC (Medical Education Cooperation with Cuba) an organization that, among other things, assists would-be medical students – including US citizens – who are too poor to study in their own countries to obtain good medical training and qualifications.[8] (I mention this to make the point that advocating probation-linked disulfiram is quite compatible with holding generally liberal socio-political views, as both Peter and I do.) He was born in Oxford before his Australian academic father moved to the US and – still very active in his late 70s – has returned to that city to take up a professorship. He and his wife also breeds llamas at their farm in Wales.

In late 1986, having established that the successful disulfiram programme described by Haynes[9] in 1973 was still very active, I visited Colorado Springs to find out more. The head of probation kindly put me up at his big family house and I remember sitting with him in their hot pool, daiquiri in hand and snowflakes falling from the evening sky onto our steaming bodies, as he told me how the programme began. In the 1960s, his predecessor regularly played golf with the superintendent of the local psychiatric hospital. Not surprisingly, the problem of how best to deal with the town’s numerous recurrent alcoholic offenders came up from time to time and the superintendent had a suggestion. Alcoholism, he pointed out, was a mental illness. If people who were mentally ill committed offences as a result of their illness, they could be made the subject of court orders requiring them to have treatment. Disulfiram was one of those treatments and therefore the courts could require them either to take it as a condition of remaining at liberty or to risk being incarcerated in the hospital or the local jail.

This was a much more take-it-or-leave-it approach than our own probation-linked programme. First of all, only a minority of John’s probationers were likely to receive a prison sentence. Some had already spent a few days sobering up in the cells after being arrested and the magistrates usually thought that was quite enough for relatively minor and infrequent offenders who would normally attract no more than a fine or a caution, or be ‘bound over’ to be of good behavior for the next 12 months. Secondly, offenders could only be given a probation order if they agreed to the terms. The probation order was not like the relevant sections of the British Mental Health Act, then and now, that enabled courts to require psychotic offenders to have treatment that included medication, even if they didn’t want it. However, if you think the possibility of compulsory psychiatric admission for alcoholism that was the background to the Colorado Springs approach did not exist in Britain at the time, consider this case history.

One day in the early 1980s, I was phoned by the wife of a psychoanalyst who lived and consulted in that quasi-cathedral close of the Freudian church adjacent to the Tavistock Clinic and the Institute of Psychoanalysis in Hampstead, just down the hill from Freud’s last residence when he came to London from Vienna shortly before WW2. He had already been in trouble with the General Medical Council because of his drinking and his wife was very worried that if he came to their attention again, he would be suspended or worse. Could I at least come to his consulting room and try to persuade him to go into hospital, even for a few days? I went there and found him barely conscious but conscious enough to tell me in rather un-psychoanalytical language that he was going nowhere. Until 1983, Britain’s Mental Health Act allowed for the possibility that patients could be compulsorily admitted for alcoholism (and other sorts of drug abuse) if, as with other psychiatric disorders, their behaviour was a danger to themselves or others. The legislation was rarely invoked, probably because alcoholics are not popular patients and because they could not be detained once they had sobered up unless they had another sectionable mental illness. However, the legislation undoubtedly existed and I told the prostrate Freudian that if he would not agree to admission, I and his wife could and would sign the relevant papers for a 72-hour admission for assessment (social workers were not invariably involved in those days) and send him there in an ambulance. ‘Just you try it’, he said – more or less. We did. The ambulance-men tied him, for his safety, to his antique psychoanalytical chair, loaded him into their vehicle and took him to one of London’s best private clinics, where he stayed for long enough to defuse the situation.  I think he also stayed dry for quite some time but about ten years later, he came before the GMC again. Since I was one of their approved consultants, I was asked by the GMC’s Health Committee if I would be willing to supervise him and report on his progress. I was very willing (and curious) but he – understandably – was not and insisted that the job be given to someone else.

August 2018.

[1] Brewer C, Perrett L. Brain damage due to alcohol consumption: a psychometric, air-encephalographic and EEG study. British Journal of Addiction 1971;66:170-82 

[2] Brewer C, Smith J.  Probation-linked supervised disulfiram in the treatment of habitual drunken offenders: results of a pilot study.  BMJ 1983;287:1282-83.

[3] Brewer C. Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation. Addiction Biology 1997;2:291-302

[4] Peters T, Wilkinson D. King George III and porphyria: a clinical re-examination of the historical evidence History of Psychiatry 2010. 21(1) 3–19

[5] According to a bit of psychiatric gossip from an authoritative source that I heard recently, another prominent descendant of the Hanoverian dynasty that has provided our monarchs since 1714 received a discreet course of ECT many years ago, thus strengthening the evidence for a manic-depressive Hanoverian family history. Timothy’s papers about the discredited porphyria hypothesis also show the dangers of approaching any therapeutic issue from an already fixed ideological position – a situation all too common in addiction research.

[6] Peters T. King George III and the porphyria myth – causes, consequences and re-evaluation of his mental illness with computer diagnostics. Clin Med 2015 Vol 15, No 2: 168–72

[7] Rose RM, Bourne PG, Poe RO, Mougey EH, Collins DR, Mason JW. Androgen responses to stress. II. Excretion of testosterone, epitestosterone, androsterone and etiocholanolone during basic combat training and under threat of attack. Psychosom Med. 1969 Sep-Oct;31(5):418-36.

[8] medicc.org/ns/

[9] Haynes SN. Contingency management in a municipally administered Antabuse program for alcoholics. J Behav Ther Exper Psychiat 1973;4:31-32.