Dr Lovell's Casebook, or the addiction argument revisited (Warning. It's long)

Since my rebuttal of Ben Lovell’s comment about alcoholics and withdrawal syndromes, I have received three contributions from persons with the surname ‘Lovell ‘. One of them has had to be slightly modified as it employed a word we don’t allow here.

 

Two of them (though the forenames are different)  make the point that Ben Lovell is a qualified doctor, and wishes to be referred to as ‘Dr Lovell’. Happy to oblige, though there are doctors, usually senior specialist consultants, who prefer to be referred to as ‘Mr’, a title which can surely never be insulting. 

 

But one has to ask in that case if these Lovells are perhaps connected?

 

The first, from (Dr) Ben Lovell, reads as follows:

 

‘Mr Hitchens, My title is Dr Lovell, rather than Mr Lovell. For someone very quick with sarcasm when you feel your missives have not been read clearly. You do not pay close attention to my own. I base my argument on medicine that I see in my everyday practice. The nervous system forms a dependency on certain substances. A graded reduction and withdrawal of said substances. A sudden withdrawal leads to withdrawal effects, such as delirium tremens, which is a medical emergency. It carries a 10% fatality. You form your arguments armed with an online medical encyclopaedia. I trust readers will make the appropriate inferences from that. You argue that DT is a manifestation of chronic alcohol abuse, rather than of its discontinuation. You are wrong.  Another visitor to this site asks you to comment on the babies of heroin addicted mothers who are born with opiate addiction and suffer withdrawal. I would also like to invite you to the A&E department, and witness alcohol withdrawal first hand. Maybe once you have seen a spindly homeless person being held down by four burly security guards, screaming at hallucinations and flipping in and out of full-blown seizures, then watch him rapidly return to normal after drinking alcohol. Then, fully informed, you could assert your opinion.’

 

The second, from Rhiann Lovell, reads, more pithily:

 

‘For the record it's Dr Lovell. And maybe lay off the thesaurus next time so you sound a little less like a tw*t. ‘

 

 

Then there’s a third, also from Ben Lovell, but regrettably not immediately posted by the moderator because of its length  (this has now been belatedly rectified, with apologies) . As a result of its late posting, I have only just seen it. It runs:

 

‘I fear you are crediting me with slightly more cunning than I deserve - I certainly don't mean to muddy the waters of the debate, and I thought I was responding clearly - apologies if I was not doing so. To respond to your claim "who does he represent", I am speaking as a medical registrar working in acute medicine in a London NHS hospital; perhaps I should have stated that at the outset. "How long after deprivation begins can they usually be observed? Would an immediate resumption of heavy drinking end the symptoms? Or would it worsen them? If not, in what way are they symptoms of ‘withdrawal’ Where is the work on this?" Ok, the DT's classically start at around 36 hours of withdrawal, and the seizures at around 72 hours. This is pretty predictable in most alcohol abusers, regardless of their alcohol intake. If you are interested in reading this for yourself, I find the GP notebook a useful resource, but you could find it in most medical textbooks. As I say to my medical student - I would be a bit wary of online medical resources. It really isn't relevant to the debate, but I must insist that I have never seen barbiturates used ever in the practice of medicine, and I would be very wary of resources that claim otherwise) "The heavy drinker has (as discussed elsewhere) a craving, a desire, even a greed, for his drink. If he stops drinking he will perhaps suffer in various ways, though he will benefit hugely as well. But far from ‘depending’ upon it, he is killing himself by his weakness, and he can stop when he chooses. The sooner he stops, the easier it will be, and the less damage he will have done." You'll have no argument with me on that one. It is very depressing to see the same faces in A&E over and over again, suffering from alcohol withdrawal after swearing they had given up for good. Please note the ONLY point I am trying to make is that withdrawal of alcohol and opiates from a chronic abuser must be done slowly and carefully. To do it quickly is dangerous and results in some pretty nasty complications. I just want to make a biological point, a medical one. Biological dependency exists,  unfortunately; I heartily wished it didn't but it does. Finally - you accuse me of being patronising. I apologise, that was not my intention. But after reading your comments: "Mr Lovell wags his finger again..." "What is more ‘strange’ is Mr Lovell’s apparent inability to cope with the fact that somebody disagrees with him..." "though the answer to this question is so blazingly obvious (and is given below) that I am amazed that Mr Lovell cannot seen it for himself.... I don't think you can be entirely absolved from blame on the patronising front. But let''s not disgrace ourselves with name-calling. I would like to echo your sentiment: "I urge readers to study carefully what I have written, and reach their own conclusions." '

 

I will now answer these.

 

The one from Rhiann Lovell, it seems to me, answers itself. And it fails to follow the other Lovell’s advice about name-calling.

 

The two from the doctor will take a little longer. Now, in one of his contributions yesterday, Dr Lovell chided me for not knowing  ( as he saw it) that Delirium Tremens  is a symptom of withdrawal, *not* (my emphasis) ingestion of alcohol’.  He said (wagging his finger) :’ A cursory Internet search would have saved you from embarrassment on this one’.

 

I then made a cursory Internet search, on his recommendation, which quite clearly showed that he is the one who needs to be embarrassed. Medical opinion, easily found and consistently described in more than one place, attributes DTs to ingestion of alcohol, *as well as* to ‘withdrawal’ .  Older medical opinion (superseded for reasons we can guess at) took more or less the opposite view. The view 100 years ago was that DTs were caused by ingestion itself, and not by withdrawal.

 

My reward for taking his advice and making a cursory Internet search (in the full knowledge that it was cursory, and enturely becayae he recommended this course)  is to be told off thus by Dr Lovell  ‘You form your arguments armed with an online medical encyclopaedia. I trust readers will make the appropriate inferences from that.’

 

They can if they want. But they should note that I was openly and consciously doing as he suggested.  I was simply showing that, even with a cursory Internet search, Dr Lovell’s assertions could be shown to be plain wrong. He said, remember,  that that DTs are (specifically) *not* a symptom of ingestion of alcohol. This is demonstrably mistaken.

 

If one goes a little deeper, say to the archives of the Journal of the American Medical Association (JAMA) going back into the last century, one can find many, many references to Delirium Tremens which make no reference whatever to ‘withdrawal.’

 

It does begin to creep in as a topic in the middle 20th century , I found in a letter to that journal, (published on 14th June 1965, (JAMA. June 14 1965, vol 192, No. 11, page 1014) a letter from a Buffalo, NY doctor (whose name is alas illegible on the PDF, but may be Marvin Buck) which discusses a claim that DTs can be prevented by *gradual* withdrawal of alcohol or the so-called tapering-off treatment. The change in emphasis, of course, accompanies the development of drugs supposedly able to ‘treat’  ‘symptoms’ of ‘withdrawal’ from ‘alcoholism’ . What is most interesting to me is the Buffalo doctor’s statement that ‘In many years of treating alcoholics I have seen delirium tremens occur in the acutely intoxicated stage as well as (my emphasis) a withdrawal phenomenon. I have also seen it occur where the daily amount of alcohol intake is diminished and not stopped.’

 

He adds :’Strangely enough, many severe alcoholics never go into delirium tremens, even with withdrawal.’

 

This letter answers some of my questions to Dr Lovell. It also seems to me to cast doubt on the assertion that DTs are exclusively or necessarily associated with ‘withdrawal’ from an addiction, or are a universal ‘symptom’ of that addiction. (Or that they ‘classically’ occur at certain intervals. Equally ‘classically’, they do not occur at those intervals, it would seem) .

 

It’s clear from the letter that as long ago as 1965 doctors were using drugs of various kinds (rather than alcohol itself, which I think was once used in this way )  to try to wean heavy drinkers off their drink. No doubt this process has greatly expanded and accelerated since then, alongside the arrival of drugs to ‘treat’ large numbers of other hard-to-define, questionable or subjectively diagnosable complaints. As to whether this is an advance for the patients I am  not sure. People are still dying of drink all the time, and the main variable in that is the state of public morality and the state of the laws restricting the sale of alcohol, plus the price of alcohol.   It is certainly an advance for the pharmaceutical companies.

 

I’d also note that the 1911 Encyclopaedia Britannica is rather interesting on this subject. I haven’t room to reproduce the whole article, which is fascinating and available easily on the Internet here http://www.1911encyclopedia.org/Delirium

 

But I think this passage is of some interest (I have added some emphases)  : ‘Delirium tremens is one of a train of symptoms of what is termed in medical nomenclature acute alcoholism, or excessive indulgence in alcohol. It must, however, be observed that this disorder, although arising in this manner, rarely comes on as the result of a single debauch in a person unaccustomed to the abuse of stimulants, but generally occurs in cases where the nervous system has been already subjected for a length of time to the poisonous action of alcohol, so that the complaint might be more properly regarded as acute supervening on chronic alcoholism. It is equally to be borne in mind that many habitual drunkards never suffer from delirium tremens.

 

‘It was long supposed, and is indeed still believed by some, that delirium tremens only comes on when the supply of alcohol has been suddenly cut off; but this view is now generally rejected, and there is abundant evidence to show that the attack comes on while the patient is still continuing to drink. Even in those cases where several days have elapsed between the cessation from drinking and the seizure, it will be found that in the interval the premonitory symptoms of delirium tremens have shown themselves, one of which is aversion to drink as well as food - the attack being in most instances preceded by marked derangement of the digestive functions. Occasionally the attack is precipitated in persons predisposed to it by the occurrence of some acute disease, such as pneumonia, by accidents, such as burns, also by severe mental strain, and by the deprivation of food, even where the supply of alcohol is less than would have been likely to produce it otherwise. Where, on the other hand, the quantity of alcohol taken has been very large, the attack is sometimes ushered in by fits of an epileptiform character.’

 

Since the only evidence of the onset of DTs can be obtained by observation, I really do not see how this could be said to be superseded, even though it is a century old. What is clearly shown here is that this is an old controversy, and one in which it is quite respectable to believe that DTs are not restricted to those ‘withdrawing’ from alcohol.

 

Mr Lovell says :’ The nervous system forms a dependency on certain substances. A graded reduction and withdrawal of said substances. A sudden withdrawal leads to withdrawal effects, such as delirium tremens, which is a medical emergency. It carries a 10% fatality.’

 

This appears to me to be a series of questionable assertions of opinion, followed by some undisputable statements of fact.  What does the statement ‘the nervous system forms a dependency on certain substances’ actually *mean*. How can it be objectively shown? How can the human body become ‘dependent’ on a poisonous chemical which is doing it grave damage?

 

Then there is this interesting ‘post hoc,  ergo propter hoc’ assertion: ‘A sudden withdrawal leads to withdrawal effects ‘

 

A sudden withdrawal does not provably *lead* to these effects. We know it is not always followed by them. It can do so, and sometimes does. But it sometimes does not. We also know that these effects may take place in someone who has not ‘withdrawn’ from alcohol at all.  The furthest we can go to is to say that withdrawal *may* be followed by *effects*. Even to call them *withdrawal effects* is to prejudge the causation. 

 

It is impossible to assert in these circumstances, that the effects are *caused* by withdrawal. The evidence tends to suggest (given that DTs may appear in those who withdraw and those who don’t)  that the cause of the DTs is  the underlying damage done by long-term alcohol abuse. Other things may *trigger* the outbreak, but the cause is the long-term abuse of drink.  Causation is quite complicated, as the dope lobby are always telling me.

 

 

I have no doubt that DTs are an emergency, and that those who suffer from this are by definition already very ill from long-term alcohol abuse. But this does not establish that they are ‘addicted’ to drink, merely that they have done themselves grave damage by drinking too much.

 

Dr Lovell then plays the emotional card. This is often a sign that the debater is in a bit of difficulty. But this can’t be said of Dr Lovell because he doesn’t know he is in difficulty, and thinks (who knows how?) that he has won a point he hasn’t. For first, he writes :’ You argue that DT is a manifestation of chronic alcohol abuse, rather than its discontinuation. You are wrong.’

 

He has not, in fact,  shown me to be wrong, or offered any evidence that I am wrong

 

He then says :’ Another visitor to this site asks you to comment on the babies of heroin addicted mothers who are born with opiate addiction and suffer withdrawal.’

 

What has that to do with anything under discussion? Once again, these mothers can stop taking heroin if they want to. The damage they do to their innocent babies is real (as is the damage done to babies in the womb by several other drugs, not all illegal). But the babies , having no choice in the matter,  cannot be said to be ‘addicted’ to a substance they have never voluntarily ingested and from which they can be protected by careful outside intervention as soon as they are born, and crtainly long before they are conscious of the problem. No doubt it is unpleasant for them to be weaned off heroin, but that is not evidence of the existence of ‘addiction’.

 

He adds: ’I would also like to invite you to the A&E department, and witness alcohol withdrawal first hand. Maybe once you have seen a spindly homeless person being held down by four burly security guards, screaming at hallucinations and flipping in and out of full-blown seizures, then watch him rapidly return to normal after drinking alcohol. Then, fully informed, you could assert your opinion.’

 

Again, what is the argument here?  The picture is tragic, but proves nothing. We know nothing about this person. Does he also take illegal drugs?  Does he take them with alcohol? Has he been given prescribed drugs? How long has he been drinking heavily?  In how many ways is he ill or damaged?

 

Drunkenness takes many shapes, and the main lesson from all of them is that we are better off not enslaving ourselves to drink. It is very bad for us.  I have seen a normally-proportioned middle-aged journalist, screaming and visibly fouling himself, carried forcibly from a newspaper office by four burly colleagues, shortly after he had resumed drinking alcohol after a long abstention. I have also seen many talented and previously healthy men decline into illness, memory loss, uncontrollable rage and (in some cases) death because of their long-term alcohol abuse. And I have seen some of them abruptly cease drinking because they chose to do so.

 

I think this also answers the points in the second, longer contribution.  The 36-hour rule does not seem to me to be much use if people can get DTs without withdrawing, and can withdraw without getting DTs. I can’t argue about barbiturates, as I simply don’t know.  I know they are mentioned as suitable for use in public literature on the subject. It doesn’t seem to me to be very important in any case. I just sought to demonstrate that another of his assertions was , at least, doubtful.

What is important, and what he simply doesn’t address at all, so far is his curious inability to see that the drug companies might have an interest in selling their products, and that some doctors have undoubtedly been co-opted into helping them do so, through lavish perks and gifts. Nor does he seem to be able to see that this might have in any way influenced medical attitudes towards this subject, and created a strong financial interest in the medicalization of drunkenness, and the convenient narrowing of DTs from a general consequence of excessive drinking to a ‘symptom’ of ’withdrawal’, so that drugs can then be recommended as a ‘treatment’ for this ‘symptom’.

 

One further thing I would say.  The use of the expression ‘dependency’ is an implicit prejudgement of the subject under discussion. The fact that you get unpleasant symptoms when you stop ingesting something that is bad for you cannot, in my view, be taken to mean that you are ’dependent’ on it.  Your body may be habituated to it, and so produce hangover-like symptoms of varying strengths when you cease using it. But you won’t die of ceasing to use it, whereas you may well die of carrying on. 

But you will very quickly recover once you have stopped using it, unless you have done permanent damage to yourself by long term use, which may assert itself whether you give up or don’t give up. 

By the way,  even some prescription drugs (of course, he’ll know this) cannot be abandoned abruptly but must be stopped gradually, to avoid unpleasant effects.   

I quite agree that my comments in response to the doctor’s patronising remarks were themselves patronising. I would add that this is because they were meant to be. I am not sure his were the rule here is that if you can't take a joke, you shouldn't have joined.

I must get back to my thesaurus.