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 . 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 . 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 . 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, 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 .
‘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 .
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 industry in Europe passed into illicit traffic. In 1906, 30 000 tonnes of opium were produced in China alone and in the same year an additional 3500 tonnes were imported into the country. Consumption in China alone at the beginning of the 20th century is therefore estimated to have been more than 3000 tonnes in morphine equivalent. In comparison today, world-wide medical consumption of all opiates amounts to approximately 280 tonnes morphine equivalent annually. The illicit consumption of opiates is estimated now to be about 380 tonnes in morphine equivalent annually. In 1914 10 million of a total 450 million population of China were opium addicts and in some towns in Iran 10% of the population were regular opium smokers. In the United States the number of patent medicines whose ingredients were kept secret was estimated at 50 000 in 1905 and a large proportion of those products contained cocaine, opium, morphine or other dangerous drugs. According to the government's report, 90% of narcotic drugs in the United States were used for non-medical purpose and in 1912 the number of cocaine and heroin fatalities in the United States exceeded 5000. The easy availability of opiate-based patent medicines led to large scale ‘home-drugging’ in the United Kingdom; similar widespread and uncontrolled use of narcotics was manifest in other European and Asian countries and opium dens were commonplace [24–27].
‘Consumption in China alone at the beginning of the 20th century is therefore estimated to have been more than 3000 tonnes in morphine equivalent. In comparison today, world-wide medical consumption of all opiates amounts to approximately 280 tonnes morphine equivalent annually.’
A: So, some of the news is good?
HG: You can therefore see that opiate addiction situation today, although it is serious, is in no way comparable with the addiction epidemic that prevailed when narcotic drugs were available without restriction. The situation is the same for psychotropic drugs during the 1950s, 1960s and 1970s. It is important to recognize that the control methods of the existing international treaties have been very successful in preventing the diversion of controlled drugs from legal sources into illicit channels. They have also contributed, to a large extent, to the elimination of the world's greatest addiction epidemics which were created in the 19th century and at the beginning of the 20th century, when the opium trade and opium smoking and the free sale of morphine, heroin and cocaine were legal. If you look at those elements you will see, of course, that the international drug control measures have played an important part and will continue to do so in the reduction of the problem .
A: Now looking through your papers there are one or two you have published with a certain Dr Barbara Ghodse, who is your wife. Could you say something of the importance or influence of family on your work?
HG: Oh very much so. I think Barbara has always been extremely helpful; not only has she been an excellent supportive wife, but a very good mother for our three children. She is a qualified doctor, and for a number of years she was very busy at home looking after all of us. She is now a Health Service manager.
A: It is sometimes argued that people should be allowed to take drugs because any complications affect only themselves. You may not agree if you are looking at the people around the individual drug user.
HG: If the addiction is going only to damage you without affecting anybody else, then that sort of argument might have a place. However, substance misuse has an impact on family members, neighbours, employers, employees and society in general—it is then very difficult to say that addiction is only a personal misery, a personal problem [29,30].
A: This is an area of medicine in which the patients are seen largely as undeserving and as having brought the problems on themselves. How did you maintain your enthusiasm over many years of scientific and clinical work?
HG: Of course addiction work can be frustrating, but at the same time the way in which I look at it is very much in a professional, clinical manner. For example, if someone breaks their leg skiing, you do not say ‘bad luck, but why did you go skiing?’. If somebody misuses drugs or alcohol and acquires a health problem, then they need a medical response that is not judgemental. I suggest that it is important to de-stigmatize the state of addictions, but not necessarily the act of the substance abuse—you have to differentiate between these two issues.
A: You talked earlier of your ambition to be a good addiction clinician. What would your advice be to the person who is trying to be a better doctor for drug users and alcohol users?
HG: Well, I think that the first thing an addiction doctor needs, in addition to a professional objective perspective, is a compassionate view of the condition and its impact. This means keeping in touch with the patient, with the family, with the community. It is also important to keep up to date with the knowledge and not to rely on personal dogma. As new developments emerge, you have to constantly re-evaluate your own knowledge and practice.
Addiction to me has always been a vast area to research. The more we start to look at the questions, the more questions emerge. Therefore, there is still a wealth of research to do on the question of addiction and this stimulates me even at my age, and of course colleagues remain very important to me. I had an opportunity to meet with Abraham Wikler, who was really inspiring, and I was fortunate, through my collaboration with the World Health Organization, to meet and to work with colleagues from different parts of the world, many of whom became family friends. I consider them to be my greatest asset, people that I can turn to for inspiration, for reflection and advice on difficult research questions. If they are visiting or passing through London or we get together at meetings, wherever they are in the world. This provides an opportunity to meet and talk and make the most of their wisdom. Jerome Jaffe, Harold Kalant, Bob Dupont, Herb Kleber, Tomoji Yanagita, Bob Shuster, Bob Newman, Mary Jeanne Kreek, Donald Jasinski, Eduard Babayan, Cai Zhiji, Maria Medina-Mora, Herbert Okun, Inayat Khan, Sevil Atasoy, Mohan Bhatnagar, Elisaldo Carlini, Tatianan Dmitrieva, Philip O.Emafo, Gilberto Gerra, Mel Levitsky, Robert Lousberg, Rainer Schmid, Uribe Granja, Brian Watters and the late Bro Rexed are few of many friends of whom I have fond memories of debate and discussion.
‘I had an opportunity . . . to work with colleagues from different parts of the world, many of whom became family friends. I consider them to be my greatest asset, people that I can turn to for inspiration, for reflection and advice on difficult research questions.’
A: There is of course a wealth of addiction knowledge and experience. Sometimes clinicians express a deep sense of frustration that the people who commission addiction services do not appear to be much influenced by that evidence. We know quite a bit about which treatments work yet sometimes it appears very difficult to persuade the people with the money to buy in effect, evidence based services. Do you have any comment on that?
HG: Yes, indeed, that can be very frustrating and it is not correct, but I can understand why it might be very difficult to get rid of the prejudice and the biases against drug and alcohol misusers.
Addicts are often regarded as moral failures and it is commonly said ‘Once an addict, always an addict’. The belief that the addictions were untreatable arose because relapse was not seen as part of the phenomenon of addiction but as a consequence. There are many relapsing conditions in medicine, but the attitude towards them is not stigmatised. For example, patients with other relapsing conditions such as arthritis are not generally regarded as unworthy of treatment.
A: Have you no areas of professional disappointment or things that you would have liked to have done better?
HG: There are a number of issues that I wish I had had the chance to pursue further—for example, to continue my research on the nature of addiction and craving. I continue to argue for the study of addiction as a serious academic subject in medical schools—there is a long, long, way to go, but I am sure that my colleagues will get there.
A: When you look back on the work that you have done, is there an Iranian legacy in the sense that, because you are from a different country with a different upbringing that you might look at some current health issues differently?
HG: It is very difficult to identify an Iranian ‘component’, I think. After all, I have now spent more than half my life in the United Kingdom and during all of that time I have been an independent practitioner. Of course, there are certain things in me which are part of my culture—more part of my Iranian culture than part of the British culture. But I cannot pinpoint such characteristics. I do not regard myself as more emotional or more compassionate than my colleagues but I have certainly learned a great deal from them.
A: I am aware that some colleagues have said that, in working with you, it is as if you are a village elder. You appear to know everything that is going on in your own village and the village over the hill, and the local town and the next country. Perhaps they are surprised by your ability to know about local events in some detail, as well as distant events in the field of addiction.
HG: Well, that description is quite right in that I believe that you have to keep in touch with your immediate colleagues and events, and also retain an awareness of the wider scientific and clinical community.
A: Thank you.