Sunday, August 07, 2011

Book Review of "Junk Medicine" by Theodore Dalrymple (Harriman House Ltd)

Review by Dr. Alick Dowling -- review originaly prepared for the Bristol Med Chi society. The "junk" referred to is alleged drugs of addiction, principally opiates

This book will be of special interest to members of the Bristol Med Chi and the Bristol BMA. Many flocked to hear Theodore Dalrymple at the annual joint meeting in Bristol, Jan 2005. He spoke on ‘The Story of the Corruption of Britain’, summarized in The Spectator 22 Jan 2005 describing his retirement from the NHS in ‘A Doctor’s Farewell’. He has regular columns in the BMJ, Spectator and other outlets such as The Wall Street Journal. In his alter ego he is also an admired book reviewer. This book published in the UK in September appeared last year in the USA as Romancing Opiates. Theodore Dalrymple himself summarized it in the article: ‘Poppycock’ in The Wall Street Journal 25 May 2006.

His sardonic wit is famous and readers familiar with his written style could legitimately wonder how he entices patients to speak so frankly. It seems unbelievable they could actually say what he reports. Those who assume his speech resembles his written style suspect him of invention, but anyone who had the opportunity to talk to him at the Bristol meeting found him courteous, cheerful, smiling readily and listening attentively. It must be difficult for his patients to remain hostile when confronted by an engaging smiling face eager to listen to anything you say. In short, his charm disarms those patients inclined to be surly. A less sympathetic questioner would not have so soothing an effect. Dalrymple’s columns make compulsive reading because he can convey succinctly, yet with humour, their usually bleak message.

In Junk Medicine he questions the long-held belief, popular since 1822 when Thomas De Quincey published The Confessions of an English Opium Eater, that addiction to opiates is a medical problem, when it is not a medical but really a moral or social problem. This message is encapsulated in the subtitle ‘Doctors, Lies and the Addiction Bureaucracy’.

It is stated explicitly in the Introduction: “Addiction to opiates is a pretend rather than a real illness, treatment of which is pretend rather than real treatment. How and why addicts came to lie to doctors, how and why doctors came to return the compliment, and how and why society in general swallowed the lies wholesale, is explored in this book.”

At the beginning of his career as a doctor and psychiatrist in prisons Dalrymple accepted uncritically the belief – which he now knows to be a myth – that addiction was a medical problem to be treated by doctors. As the incidence of addiction increased steeply, despite and probably because of, the increasing number of drug clinics he began to think about it more.

He does not rely exclusively on medical or pharmacological sources though these are fully discussed in Chapter 1 ‘Lies! Lies! Lies!’ The title Junk Medicine is not an oxymoron but a reference to Junkie, William Burroughs’s autobiographical first book in 1953. Under the subheading ‘The Addictive Nature of Opiates’ Dalrymple dismisses Junkie in his characteristic way: “This book is a mixture of self-serving lies and exhibitionist frankness typical of the genre of opiate confessional. In one of his rare moments of truthfulness, probably accidental and certainly without realization of the moral significance of what he is saying, the psychopathic Burroughs writes: ‘You don’t wake up one morning and decide to be a drug addict. It takes at least three months’ shooting twice a day to get any habit at all.’ In other words, the establishment of an addiction requires a certain discipline or determination.”

Later in Chapter 1 under the heading ‘The Alleged Horrors of Withdrawal’ we read “But are the withdrawal symptoms from heroin (and other opiates) so very terrible? In the standard view of heroin addiction, they are. But let me quote from some of the major medical textbooks of our day: ‘Although opiate withdrawal is not life-threatening, patients can become extremely dysphoric. (Jay H. Stein, Internal Medicine, 5th edition, St Louis: C. V. Mosby, 1999, p. 2297)’. ‘Dysphoric’ means, of course, unhappy or disgruntled, though ‘dysphoric’ sounds very much more precise, technical, and medical: In other words, they are unhappy or disgruntled because they are not getting what they want. But, to adapt P. G. Wodehouse slightly, which of us is gruntled all the time?”

In the middle Chapter 2 –‘The Literature of Exaggeration and Self-Dramatisation’ The author uses his literary knowledge to explore the historical reasons why such a widely held false belief, including the impossibility that heroin or opiate addicts can stop without unbearable suffering, can be traced back to the mass credulity in descriptions by such writers as De Quincey and Coleridge on opiate addiction. Theodore Dalrymple with his interest in English and foreign literature and writing is akin to another much admired medical writer of the last century, Richard Asher (1912-1969) now out of fashion but well worth reading. The latter was also eager to espouse unpopular causes and was a champion of common sense.

In Chapter 3 ‘The Show Must Go On’ the recurring theme is the influence of bureaucracy. When a ‘Drugs Tsar’ was appointed in the UK, it was only to be expected that there would be an ‘Empire’ for him to administer. And so it was: bureaucrats built the appropriate house of cards that took over the whole edifice of drug treatment clinics. The doctors and ancillary staff who work in them accept the assumptions on which they are run, including the idea, quite contrary to common sense, of substituting methadone for opiates. Though it is a house of cards, it will be difficult to dismantle: the bureaucrats have fixed the cards with glue, and the inmates have no incentive to destroy their place of employment – and has anyone heard of bureaucrats being defeated on their chosen pitch?

In ‘Auxiliary Workers’ Need for Addicts’ Dr Dalrymple tells of how he once pointed out that there was no ‘evidence-based medicine’ to support methadone substitution for opiates; a medical colleague “reacted with something akin to a cry of panic: You’re challenging the consensus, he said, as if to do so were automatically to be wrong, or worse still, wicked. The apparatchik mentality is far from unique to the former Soviet Union.”

Under his final subheading ‘What Is To Be Done?’ the author discusses whether opiates should be legalized. We might expect Theodore Dalrymple, with a reputation for dogmatic statements, to have a decided view, but he puts the alternatives clearly and with moderation, and comes to a conclusion with some reluctance that “on balance, therefore, I think that the arguments against legalization, however formulated, are stronger than those in favour.”

At the end of this section he writes: “I would suggest the closure of all clinics claiming to treat drug addicts, the modern bureaucratic institutionalization of Romantic ideas. This would put an end to the harmful pretence that addicts are ill and in need of treatment. In the former Soviet Union, there was a saying of the workers that ‘We pretend to work, and they pretend to pay us.’ Drug addicts could say something similar to capture the reality of the current system: ‘We pretend to be ill, and they pretend to cure us.’ Henceforth, instead, doctors should treat addicts only for the serious physical complications of drug addiction: abscesses, viral infections and the like. Addicts would then have to face the truth. Whatever their background, they are as responsible for their actions as anyone else. The truth will not necessarily set them free, but neither will it enchain them in ‘mind-forg’d manacles’.”

The Appendix ‘A Short Anthology of Nonsense’ provides examples to show how the influence of De Quincey and his followers still underlies the view that opiate withdrawal is so difficult and painful that no victim should be expected to undergo something so dreadful. These examples make melancholy reading. It is depressing to realise how many of the young are still wilfully misled by literary traditions that persist in books like Trainspotting, (1993) – later a popular film.

Junk Medicine is a well presented, and well produced book; even its index is worth reading, with many literary references, including Wodehouse and Violet Elizabeth. (Somerset Maugham gets one page reference, though he appears in the Appendix as well as Chapter 3). My only regret is that the impressive structure of the overall argument is not displayed in the list of Contents. That parsimoniously lists only the Introduction, the three Chapters, and the Appendix and Index. To omit the very relevant, witty and instructive subheadings, hidden in the text of the three Chapters, is a shame. These subheadings divide the logical argument into short essays typical of Theodore Dalrymple’s style, a master of concision. They are like a series of gems joined into the three necklaces that constitute the three main Chapters – a total of twenty-seven essays. For example, Chapter 1 has eleven essays distinguished by subheadings such as: The Misconception of the Problem, The Standard or Orthodox View, The Alleged Horrors of Withdrawal, The Alleged Need for Treatment, The New Methadone.

It is a pity that all eleven are not set out in full in the list of Contents as that would help the reader to find gems he wants to re-read. All will bear re-reading. And of course the same is true of Chapter 2, devoted to The Literary Tradition, and of Chapter 3 bringing the argument to its conclusion, divided respectively into seven and nine no less compact and forceful essays.

This book is one to be welcomed wholeheartedly, and needs to be read widely both by doctors, who will enjoy the education it gives so refreshingly, and by the ‘drug-treating community’ who perhaps will not.

Received via email from the author

Device designed to beat obesity helps cure diabetes

Very interesting. Obesity is sometimes held to CAUSE Diabetes but note below that the diabetes remits BEFORE weight loss. It's consistent with the view that obesity challenges diabetes but does not cause it

An implanted sleeve that looks like a giant sausage skin is being used to tackle the most common form of diabetes. The 2ft-long device, developed as an incision-less alternative to a type of weight-loss surgery known as a duodenal switch, can reverse the disease within weeks.

The duodenum is the name for the first 10 to 12in of the small intestine, which attaches to the stomach. A duodenal switch is a keyhole procedure that involves making two incisions at the start and end of the duodenum. The lower part of the intestine is attached to the stomach, forming a new pathway.

Food then bypasses most of the duodenum, which limits absorption.
Long-term risks include hernia and bowel obstruction.

The device, the EndoBarrier, is designed to have the same effects as surgery but is far safer. It is a plastic sleeve that lines the duodenum, meaning food can only be absorbed lower down the intestine.

The procedure is performed under anaesthetic in less than an hour. The sleeve – made from a thin plastic – is inserted via the mouth and passed into the digestive tract using a thin tube. Once in place, a sprung titanium anchor prevents it slipping out. It is removed after a year.

During trials researchers found that in obese patients who also suffered diabetes, the disease went into remission. Initially experts believed it was a result of weight loss – but many patients were able to stop taking their diabetes medication before they began to lose weight.

The discovery has led to clinical trials at three hospitals, which found the implant also seems to lower cholesterol levels and blood pressure.

Type 2 diabetes is a chronic condition caused by too much sugar in the blood. Initial symptoms include extreme thirst, tiredness and blurred vision. Sufferers are five times more likely to suffer from heart disease and strokes and can suffer sight loss, nerve damage and kidney disease. Ten per cent of all NHS spending – £9 billion a year – goes on treating diabetes, and £130 million is spent on tablets alone.

Type 2 diabetes occurs due to problems with the way the body handles insulin, a hormone that controls the amount of glucose in the blood.

When we eat, the digestive system breaks down food to release the nutrients from it. These nutrients, including glucose, enter your bloodstream. Normally, insulin is produced by the pancreas to move glucose from the blood into the cells, where it is broken down to produce energy.

It is thought that type 2 diabetes is a result of the body being unable to produce enough insulin or because the cells in the body do not react properly to insulin.

Affecting 2.8 million Britons, poor diet, lack of exercise, carrying excess weight as well as a family history contribute to the development of the disease. The condition is treated with drugs designed to increase insulin production or reduce insulin resistance, but these do not stop the progression of diabetes, and some can also have side effects such as nausea, weight gain or liver damage.

With the EndoBarrier, the duodenum is bypassed, altering the balance of hormones in the body leading to a reversal in diabetes symptoms. ‘Food passing through the intestine triggers the release of hormones in the body,’ says Dr John Mason, consultant gastroenterologist at Trafford Healthcare NHS Trust, who implanted the first EndoBarrier in the UK. ‘These hormones have different functions, including signalling that the pancreas gland should release insulin.’

Results from a new study at Musgrove Park Hospital, Taunton, Somerset, show that in 72 per cent of cases, diabetic patients went into remission after the EndoBarrier was fitted, and after a year all had no need for medication.

‘The operation is available only privately,’ says Dr Mason. ‘The NHS has yet to decide on whether it should be a treatment.’ The operation costs £8,000. One patient to benefit is Jason McCullen, 39, an IT consultant from Sale, Manchester. He developed diabetes in 2009. He had the EndoBarrier implanted at Trafford Hospital, Manchester this year. ‘I didn’t feel any pain afterwards. My waist over the past three months has gone from 42in to 38in. And I don’t need medication.’


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