“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”
– Hippocratic Oath
LOOKING BACK over the fifty plus years since John Yerbury Dent (1888-1962) it is clear that little of what he espoused during his lifelong study of drug dependency and its treatment has had any lasting influence. Largely regarded with disbelief during his lifetime, and discredited or ignored in death, has meant that his legacy is minimal. However, medical history is littered with stories of radical ideas and deep truths that are obscured when handled by others. Perhaps, therefore, as we survey the subsequent and current wreckage of U.K. drugs policy, Dent is worth re-examining in terms of what he believed and how he treated addiction rather than the fallacies that, unchallenged, have been allowed to endure. The current paradigm will never be properly understood until we realise how we got here and therefore it must be remembered that Dent was a pioneer who first encountered addiction as an independent doctor armed with nothing but the courage of his convictions. When Dent wrote “A man who is trying isn’t succeeding.” (1) It was probably in rueful recognition of his own early attempts to define and beat addiction against a hostile and defensive medical profession whose tendency of treating inebriety with alcohol was something he felt compelled to rectify. Ultimately, Dent evolved into an extraordinarily successful physician who seemingly didn’t have to try too hard to help people in an area of medicine that nowadays, reflected by ever worsening statistics, struggles to meet the challenges set.
These then are the salient points of what Dent believed and more importantly, practised. Unencumbered by current procedural requirements according to ‘the evidence’ provided by ‘research’ sponsored by Pharma, arbitrary red tape or interference by government, autonomous doctors like Dent could do what they liked based on empiricism. (Expansion of these standards and what underpinned them can be found in the hyperlinked Chapters) Post Shipman the modern GP just keeps its head down.
1) Dent’s aim (and strictly in accordance with his patient’s wishes) was an abstinence model. His method evolved to be equally pharmocotherapeutic and psychosocial, based on an individual psychology and pathology. The empowered patient was encouraged to embrace adaptive and immediately self-rewarding patterns of behaviour reinforced by a broad range of support that today would be interpreted as holistic. The extent that the use of APO’ facillitated changes in subsequent behaviour is uncertain and today represents a hole (some may say a chasm) in neuroscientific understanding. Chapter One, Chapter Three
2) Dent was the first doctor to recognise that anxiety and substance abuse disorders shared a comorbidity. In 1941 he wrote; “addiction is only a special form of anxiety……..the two subjects interlock in a multitude of ways, and, to a large extent the treatments of addiction and of other forms of anxiety are often the same……It is the inefficiency between two alternating behaviours that is meant by the term “anxiety”. To do or not to do, that is the anxiety.” (2) Chapter One
3) Dent was the first to realise that this “inefficiency” was the result of a neural imbalance that had an adaptive dimension: “Every change in a man’s environment has to be met by some change in himself.” (3) The polarity or chemical structures within the brain are altered by worry, depression and anxiety that can lead to self-medication with drugs and subsequent dependency. Dent was the first doctor to offer a neuropharmacological solution to this problem. Today this is the norm though it must be stressed Dent’s route was not dangerous, nor did it lead to addiction to any other drug, prescribed or otherwise. Chapter Three.
4) The prevalence among the medical profession – induced by drug companies – to prescribe unnecessarily was something that Dent consistently railed against. In this regard Dent was seen to be out of step with the emerging enthusiasm for psychotropics but today, in respect of society’s over-reliance on legal drugs, Dent’s concern was certainly well-founded. Dent’s sole motivation was healthy patients and not his, or anyone else’s, vested interest. In respect of the “medicalisation of misery” that is increasingly reported by dissatisfied and litigious patients, the press and countless medical texts Dent’s unshakeable brand of ethical integrity and the preventative culture it embraced can therefore be seen as conspicuous by its absence from much of health care today. In turn this has contributed to a breakdown in trust in the doctor/patient relationship. Chapter One , Chapter Six
5) If you went to the doctor with a broken arm would you accept a treatment that involved him breaking your leg? As ridiculous as this sounds, it is analogous to medicine’s willingness to replace one drug dependency with another. Dent would not have found this sensible nor ethical and we should wonder why neuroscience since the 1950s has failed to provide solutions aimed at abstinence instead of its enthusiasm for drug maintenance. It is hypothesised that research into apomorphine (Apo’) could have provided dopamine analogue therapies and an ethical choice amongst those who earnestly sought deliverance from any form of dependency. Chapter Two
6) Dent was well aware that in the 1950s American doctors envied their British counterparts for the way they had contained opiate dependency. We should contemplate why our own government has progressively tried to fix what wasn’t broken, and with progressively disastrous consequences for so many. Of course this was predicted by many, including Dent. Chapter FIVE
7) The British doctor in the 1950s enjoyed an autonomy which has been ceded in favour of more restrictions, an adversarial culture, bureaucracy and hollow promises about “research”. As successive British Governments have striven to curb addiction with ever more punitive and senseless legislation the problem has only got worse. In the mid 50’s there were approximately fifty opiate dependents in the U.K. Today this figure could be as high as 500,000! As Gabor Mate said in the excellent documentary film by Eugene Jerecki, “The House I Live In“ (2012) “The question we have to ask is not why it (The War on Drugs) is a failure but why is it persisted with? I am beginning to think that maybe it is a success! What if it is a success in terms by keeping police forces busy, private jails thriving, legal establishments justified in their self generated activity, pharmaceuticals rich? What if it’s a success in different terms than the publicly stated ones?” (4) Indeed, so perhaps, once and for all, a British Government should come clean about what amounts to legislative denial and finally tell the truth. A small step in the right direction might be to introduce decriminalisation based on the scientific and historical evidence similar to the initiatives recently adopted in Holland, Portugal, Uruguay and even some states in America. Dent believed that medicine was primarily a matter for the medical profession, that governments should take their lead from their scientists and doctors working at the sharp end. The perplexing way recent British governments refuses to listen to its own experts is a source of growing concern.
8) Dent firmly believed in the power of the word in fashioning adaptive and beneficial strategies for overcoming drug dependence. Today the importance of “the word” is widely understood but academic hubris insisting that Dent employed a purely ‘mechanistic’ strategy may be interpreted as a convenient “excuse” by science and psychiatry to ditch any curiosity into the true efficacy of Apo’ modus Dent. The damage emanating from this interpretation is impossible to gauge but the prevalence among addiction therapists ever since for protracted approaches that has led to other black markets, countless premature deaths, disease and dependencies is surely worth considering. As Oluf Martenson-Larsen wrote in 1987; “I have known Dent and Feldmann the last died three years ago and still fought for Apomorphine, as I do….but the damned Benzodiazepines may have been easier for my silly colleagues to prescribe so I must also treat valium addicts with Apomorphine.“(5) The simple truth is that Dent fought for Apo’ because it represented a preventative culture quite unlike the culture of dependence championed by Big Pharma and psychiatry and even some neuroscientists. It is their approach which has led to the vicious cycle of prescribed maintenance, with tragic world wide consequences for society and countless individuals. If science and medicine couldn’t grasp the importance of this critical distinction what chance had the patient??? Recently deaths in the UK attributable to “METHADONE ABUSE“ (Office for National Statistics) have risen sharply and average over 400 each year and recently (Feb 2014) a two year old died from allegedly drinking her parent’s prescription. What is Apomorphine?, Chapter One, Chapter Three, Chapter Six.
9) Dent knew that addiction changed brain chemistry or, in terms of what is currently interpreted as “incentive sensitisation” which asserts that though all drugs of abuse vary considerably in terms of their neuro-biological effect, they all elevate the dopaminergic levels within the brain to some degree. It is a measure of the intellectual vacuum that surrounded and succeeded Dent that nobody was curious about what role Apo’, the drug with the closest synthetic match for this endogenous neuro-chemical, might have in facilitating recovery from anxiety, mental disturbances and drug seeking or addictive behaviour. I have been reliably informed that Apo’ has been “superseded”, but not when, or by what? Furthermore nobody seems too clear on the precise action that Apo’ has on the addicted brain and whether for some, relative to other remedies, it might still be preferable. It seems fair to conclude, therefore, that Apo’ has suffered from scientific neglect and in a period when the problem of drug dependency has grown exponentially. Chapter Four
10) APO’ IS NOT AVERSION. (What is Apomorphine?) Dent, long ago, in his medical infancy, believed that the benefit of Apo’ was due to an aversive/contra conditioning response but later realised that its efficacy was dependent on chemical changes within the brain. His last protocol, taken from an interview conducted by IAN SOMMERVILLE in 1961 and linked HERE so anyone can form their own conclusion as to whether “apomorphine modus Dent” possessed any counter-conditioning dimension. (with acknowledgement and thanks to the courageous Isabelle AUBERT-BAUDRON who initiated her own extensive research into Apo’ as a detox tool)
(N.B. Ian Sommerville’s account has no mention of Dent’s appreciation of the intricacy of psychology, biology and the social processes, or of his use of suggestion, CBT, etc. which would have been used as appropriate. Also, the use of the word “cure”; Dent preferred “treatment” as “cure”, he believed, was a questionable concept in respect of addiction and ultimately the responsibility of the patient.)
Today the British medical and scientific view is that Apo’ was just used in an “aversive” capacity! In “The Treatment of Addiction Problems – 5th Edition” it is included under the heading “Aversion Therapy” – “Such counter-conditioning techniques have included chemically induced nausea (using emetine and apomorphine)….” (6) Dent,himself, acknowledged that if he had really wanted to use aversion treatment he would have used emetine as the sickness it provokes is far more ghastly and terrifying than anything produced by Apo’. But, if this publication is anything to go by then it appears to discount even the possibility that Apo’ could have any other therapeutic property which is perhaps a pity as the same chapter in the same book starts; “In very general terms, about one third of individuals entering treatment for alcohol problems derive little or no benefit.” (6)
Generally the scientific community holds great store by that intellectual edifice; “evidence based medicine” (the available literature here) even if occasionally it comes across as singularly incurious. In respect of Apo’ it appears to want it both ways? How can it be considered to be “aversion” when treatment with Apo’ wasn’t used to illicit any contra-conditioned response or even paired with any other drug? How, I wonder, could the scientific community begin to explain the numerous anecdotal coincidences such as this independent account by a Swedish doctor, Arne Tallberg whose use of Apo’ in clinical practice echoes precisely those observations by Larsen, Dent, Feldmann, Beil & Trojan and others;
“The effect (even on the most comatose drunkard) is striking and almost unbelievable. After the time stated (3-4 hours) the patient has cleaned up, left the bed, has taken a shower, combed his hair, and is able to talk and discuss his situation………the most interesting thing about the apomorphine treatment is that it does not hinder the patient’s drinking, like antabuse, it takes away the desire to drink, the compulsion, to drink. He simply does not want to drink anymore, and several of my patients have also stopped or reduced their smoking and coffee. They seem to be not in need of stimulants, they are calm, well balanced, active eager to work and improve their actual situation which they can look at and discuss in an objective and creative way.” (7)
Of course, this is just anecdotal but the similarity with Dent’s own remarks made at St Pancras workhouse in the early 1920s is striking and further corroborated by the medical journalist Anne-Lise Gotzsche who, observed the Danish psychiatrist Professor K.A. Lock Halvorsen treatment of alcohol dependents with Apo’, noting;
“It is not unusual for the patient to feel completely, bright, sober normal and hungry by lunchtime on the first day of treatment. Injections may be continued for a couple of weeks and thereafter the patient is maintained on capsules containing anything from 5mg to 60mg. The dose is generally reduced over a period of time and the patient is seen on an outpatient basis once a week.” (8)
This reflects the observations by Beil and Trojan who, after a trial of 126 alcohol and opiate dependents in 1976, wrote;
“The patients developed more insight and became more motivated for psychotherapeutic treatment. Treated with a high-dose schedule the patient may soon return to work; usually after the second or the third week. By this time some alcoholics expressed the wish to start working again. It has to be pointed out that – in accordance with all the other authors – we did not find hints of a beginning dependence on apomorphine.” (9)
Most arguments concerning drugs policies come and go and when they return appear just as unresolved as first time round. Indeed it would be fair to say that this issue – is research loaded in favour of ethics or big business?, has actually got many times worse since Dent appealed for research into the efficacy of Apo’, the question is why? Maybe part of the answer is contained in the above observation by Beil & Trojan (1976) when they pointed out; ‘in accordance with all others – we did not find that Apo’ had any addictive property’ and by so doing also offer an interpretation into why, today, some drugs remain strictly ‘off limits’ in respect of research and development. Pointedly, why would any pharma company sponsor research into non-addictive compounds which might reduce the number of doctors worldwide who for decades have been prescribing addictive drugs that contribute to increased profits for these self same conglomerates? As THIS ARTICLE EXEMPLIFIES we actually seem worse off in this regard than ever before as some scientists justifiably complain that their efforts are increasingly being hampered by arbitary classification on banned substances, red tape and political interference. When Dent wrote in 1955 “Soon we (British doctors) will only be able to prescribe what is seen to be permissible by Whitehall and Anslinger“ (10) he couldn’t have known how prophetic these words would become. The story of Apo’ can therefore be seen as an early casualty of how ethics in medicine has been steadily and cruelly eroded by the commercial imperative abetted ever since by a constant running sewer of cynical bureaucrats and spineless politicians.
In the modern era there has only been one team of scientists curious about the true property of Apo’. Coming from mainland Europe they probably realised that the world isn’t flat or Apo’ aversive many decades ago and did what should have happened in the 50s and 60s and ran a comparative study between two groups; healthy controls and alcohol dependents.
To be continued……..