“Healthy citizens are the greatest asset a country can have”
— Winston Churchill
In Britain during the 1950s a combination of medical conservatism, a lack of public money, bureaucracy and an ill-founded enthusiasm for psychiatry stifled research into bio-chemical initiatives and un-patentable compounds like Apo’. Benzodiazepines began to flood in from America as even the possibility of catecholamine neuro transmission (Dopamine is one of this group) was dismissed out of hand at a London symposium (1960) dominated by Sir Henry Dale, 1875-1968.
In any case few were prepared to forgive Dent for his mistake in thinking that the main determining factor in Apo’s efficacy was attributable to aversion. It did not matter how often he (and others) said that it was not aversion, few were prepared to listen. Evidence of this can be seen in the interview by Max Glatt who succeeded Dent as editor of S.S.A. and reported in the British Medical Journal in 1983. He said of the Society in the 50s:
“The strong man was John Yerbury Dent, a charismatic personality. He believed in Apomorphine not as an aversion treatment but because of his theory that it had some effect on the hindbrain………I think most of us agreed with Dr Hobson at the time when he said that Dent without apomorphine would be better than apomorphine without Dent…..”
This was twenty-nine years after the original comment by Hobson (above) but still not a flicker of curiosity about Apo’; Apo’ was still aversion, Dent was still “charismatic” and his personality, rather than the arguments, were still being used to justify intellectual paralysis. Even if Dent had had more charisma in his shadow than a trainload of drug reps at a trade fair it wouldn’t have had the slightest effect on whether Apo has “some effect on the hindbrain.” Of course, when Apo’ was shown to provide symptomatic relief for Parkinson’s Disease it should have offered a clue that it did indeed have quite a dramatic effect on the hindbrain that could still play a restorative role for those who have had their brain pathways compromised by addiction. (DA Dysregulation)
This myopia was unfathomable particularly as, across the North Sea, in Europe and particularly in Scandinavia, and in the fields of mental health and addiction Apo’ was generating much interest in just exactly what effect Apo’ did have on the “hindbrain” and without any help from Dent’s charisma. Dr Harry Feldmann and Dr G. de Morsier in Geneva, Switzerland and George Lyttle in Belfast had already had independent success with variations of treatments involving Apo’ then, from the late 60’s, C. Carlsson in Sweden, Hanswilhelm Beil and Alf Trojan (claiming 65% success with trial of 123 addicts to both opiates and alcohol) in Germany, O. Martenson-Larsen and Professor Lock Halvorsen in Denmark, Arne Tahlberg in Tyreso, Sweden, and S.B. Jensen et al in Copenhagen all suggested that Apo’ in a variety of social contexts and clinical settings was therapeutic and not “aversion”.
We should ponder why, when others were so interested, the British and American medical establishments were not and whether the same incuriosity extended to other forms of therapy? Hiding behind the nonsense of Dent’s personality was idiotic in the first place but given that all these other practitioners and researchers had independently used the same drug to treat the same disease and broadly arrived at the same or similar conclusions you could be forgiven for thinking that the medical establishments in America and Britain were having their curiosity squashed by an unenlightened conformity.
Dr Hobson, and others may have believed that you had to deal with chronic addiction with psychiatry and that the origins of addiction were the result of a psychological issue and that Dent was too obstinate in his view to the contrary. But, given that addiction today is primarily dealt with holistically and with a range of bio-chemical approaches, how much damage has been done by using a false premise (aversion or charisma) to justify ignorance? And pertinently, how much damage has been done to sufferers who have ended up with an additional or worse addiction?? Apo’ is a unique compound among the group of dopamine (DA) agonists because it alone has affinity with all the DA receptors and most importantly D1 and D2, those primarily involved in the mechanisms that mediate the reward pathways. It is proposed that if research had taken place in this area of medicine and DA analogues developed then we’d be looking at this problem today with an entirely different perspective.
Sixty years ago Dent, was up against it. Still battling the prejudice that saw addiction as a moral failure, he asked “Would you ask a diabetic to pull his socks up?” Additionally, with no fresh ideas or scientific breakthroughs to the unresolved arguments between those who favoured a bio-chemical or psychic approach there was a stalemate. These antagonisms led to an impasse that America and Big Pharma would be happy to exploit.
From a lay perspective it seems quite ridiculous that any profession, particularly one endeavouring to improve health, should behave in this way but society hadn’t banished its underlying prejudice and self-righteous attitude towards addiction sufferers which, even today, is still encouraged by dull politicians more interested in placating those with a punitive agenda?
Dent’s methodology was allied to a simple purpose: healthy patients. Perhaps those that ignored him were not convinced by the need to invest in reducing the cost to society of a growing problem, but minuscule in the 1950s compared to what it has become today. These were different times, with high level political preoccupations: the Cold War, re-invigorating the economy and new technologies dominated thinking. It is only now, sixty, or seventy years later that we can see the dangers emanating from the unbridled enthusiasm for psychotropic medications with dubious ethical credibility, the ‘pill a day’ culture and maintenance therapies that Dent, ever the impatient iconoclast was powerless to prevent.
As a practising physician he was endeavouring to correct neural imbalance, which he’d accurately identified, and which he sought to correct on his own with a variety of strategies that included a short, safe biochemical route. He did not kill anyone and nor did he make anyone addicted to any other substance…..on the contrary! He had also been successful in an area of medicine where there had been little or no treatment and within a society that thought inebriety merited punishment before care or compassion.
Whatever the finer and unanswered points of what Apo’ delivers Dent certainly did enough to be taken seriously particularly as today the bio-chemical route is usually the first port of call for those looking to beat the compulsion of addiction. But, most importantly, the grotesque medicalisation of the misery of addiction by Big Pharma abetted by lazy doctors is of great concern. In light of all this Apo’ can be seen as countermanding what is clearly the foundation for the commercial success of many of today’s drugs; it was not addictive. If medical science could have established this as a guiding principle behind the treatment of addiction would we better off now than we are? If those who seemed only interested in dismissing Apo’ had actually had a handle on not only what Apo’ does but more importantly what it represented would a broader range of solutions promising an abstinence model have been sought and applied?
Dent was a profound person with a unique understanding of how medicine was being subverted by geo-political aims but subsequent consideration of his philosophy shares a shallowness which would make a puddle in August appear deep. Apart from the nonsense about Dent’s “charisma”, and Apo’ being “aversion” it ultimately boiled down to the superficial “Dent was resolutely committed to a biological explanation.” (Virginia Berridge). This assessment emerged in the 1980s but at the time of Dent’s death the British Medical Journal had a different and more accurate view, Dent’s obituary stated:
“He took a spacial interest in ophthalmology in his early days, but spent most of his life in the study of treatment of the chronic alcoholic. In this he obtained remarkable success and and an international reputation, and his patients came back to see him from time to time from all over the world. He claimed about 75% success in treatment, and gave the credit to his use apomorphine which he regarded as much more than an aversion treatment. He never regarded himself as a psychiatrist, yet he radiated encouragement, enthusiasm, and confidence which must have been at least supportive to his pharmacological practice.” BMJ, Feb 1962
The deconstruction of Dent demands scrutiny particularly in light of the deplorable legacy that subsequent generations of addiction sufferers have had to endure. If our policy makers, addiction specialists and medical historians couldn’t understand these issues what chance the sufferer? And none of this can be brushed off as irrelevant because it happened a long time ago, the problem of dependency on drugs both legal and illegal is arguably a leading blight of modern life, a direct consequence of embracing the ‘pill a day culture’ advocated by bureaucrats not medicine enshrined in the hippocratic oath. The principles that Dent embraced and his methods were indivisible and more pertinent today precisely because we have acquiesced in an area of health care and neuroscience that has singularly failed and continues to fail to meet the challenges set by society. There is no other area of health which, year on year, represented by worsening statistics, puts greater strain on worldwide health agencies, widens socio-economic divisions and contributes to direct and indirect negative consequences for so many.
Clearly not a politician, without a diplomatic gene anywhere in his body, Dent still got drawn in to trying to organise emergent drugs policy. For someone who could not curb his feelings when encountering those with less lofty ideals this was clearly doomed. Invited onto the “Interim Committee on Alcoholism” in 1952 he soon resigned citing “conflicts of interest” and failing to convince others that the only point in going to Westminster would be to “bang heads together”!
Neither was Dent a natural organiser and yet he became involved in running the Society for the Study of Addiction (SSA), editing its Journal for twenty years during the critical period when medicine was assimilated into the bureaucracy of the NHS. Unlike the risk averse atmosphere of today, a more experiential approach to medicine was considered appropriate, with “heroic” doctors prepared to try new drugs on themselves before their patients. Many believed that new compounds would improve the human condition and in particular that the human brain could be chemically helped to recover from anxieties and dependencies. Reading what Dent wrote in 1947 it is striking how initially trusting and naïve he was;
‘The present century has produced a new and much larger crop of drugs which do not occur in nature; they are made synthetically. They are more selective and they can be varied to almost any extent. We are at the beginning of a new era. Now that our brains are becoming much more controllable than they were in the past, can we look forward to a saner civilisation? There can be hardly any doubt that we can.’
Dent was among the first to recognise that addiction warranted fundamental policy change in order to reduce the disease burden and hidden costs to society. He had encountered and chipped away at the punitive attitudes reluctant to accept his premise of “care before punishment” and the hidebound conservatism within his profession. But Dent was surely too confident with his faith in the new era, a sort of “Huxleyian utopia”. “Big Pharma” was emerging as a global power and, once established, where would ethics and efficacy fit into the thinking of an industry that routinely spends more on lobbying and packaging than research and development? Generic drugs like Apo’ may have offered a potentially more ethical and effective approach than the addictive Benzodiazepines, amphetamines, psychotropics and maintenance therapies that dominated the second half of the twentieth century, but Apo’ would not make money and turkeys do not vote for Christmas. Accordingly, the psychotropic invasion, aided and abetted by a bewildering range of new disorders with variable degrees of legitimacy, have created a paradigm shift which Dent’s father would have found quite incomprehensible. “Remember, if you don’t prescribe him anything you wont have done him any harm…..”
Dent, a man for all seasons, endlessly positive and revered by his patients, did as much for the cause of addiction and its treatment as anyone of his generation but he was increasingly being squeezed out by emerging forces that saw healthcare as a business to be exploited. Dent, with his principled views on keeping treatment simple, aimed towards an abstinence model and with a holistic approach based on individual pathology/psychology found himself increasingly at odds with the emerging trends in Britain and beyond. He, ultimately, deplored these developments but resolutely refused to curb his convictions. British medicine was increasingly being dominated by those taking their cues from bureaucrats and politicians and smothering their principles with a veneer of unreadable scientific papers which increasingly appeared incongruent and irrelevant in the face of a problem actually dominated by drug cartels, idiotic pricing strategies, the vicious cycle between addiction and recidivism and a lobbying system drawn more to inducements by drug reps than any considerations of efficacy. Dent wanted serious investment for nationwide treatment centres that would deliver care close to the community. He thought the emerging “rehab industry” as unscrupulous adding; (see caption below)
This is particular interesting in respect of the potentially “rewarding” dimension of Apo’ modus Dent which should be much better understood today than in the 50s and 60s. Indeed, if this had ever been properly scrutinized in light of what we now know about adaptive reinforcement allied to cognitive repair, biological and behavioural psychiatrists may have considered that Dent’s Apo’ initiative worked due to its power to shape reward through a positive feedback mechanism. The “back brain”, suddenly flooded with synthetic dopamine (Apo’), was able to resist the cue inducement to seek and use drugs and supplant damaging memories with new, life affirming strategies. Part placebo, part neurobiological and always holistic this was neither dangerous or addictive. It was a treatment that left the empowered patient free of anxiety, one that espoused principles consistent with “operant conditioning” and, to be absolutely clear, not “aversive” at all. Far more Skinnerian than Pavlovian in point of fact.
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