What is Apo’?
Apomorphine (Apo’) is a prescription-only drug with a chequered history. Discovered in the 1800s, it was originally used as an emetic (it can empty a stomach in seconds) and became a mainstay in veterinary practice. It was also associated with punishment and bizarre “cures” for homosexuality typified by this quote from “Philomena” (2013) by Martin Sixsmith:
“David pulled himself together. He told him about the aversion therapy: how they had tried to cure his sinful desires by strapping electrodes to his genitals, by giving him apomorphine to make him vomit at the sight of pictures of naked men; how he was locked in a windowless room in a psychiatric ward; how it went on and on and on.”
Much of this was mythical but in the precise world of scientific reality Apo’ is now used in effective and safe regulation of the on-off periods experienced by sufferers of Parkinson’s disease, it has also been used for erectile dysfunction and is regarded as a useful investigative tool within the pharmaceutical industry. In the middle of the 1900s it was also found to be effective in the treatment of anxiety and drug dependency and in particular amongst doctors and their patients who favoured abstinence over any form of drug maintenance or replacement therapy. It is to this last area that this website is primarily devoted.
As a tool against addiction Apo’ is therefore ill served by the suffix “morphine”. Whilst it is true that Apomorphine is derived from a chemical ratio of both morphine and hydrochloric acid boiled at 140 degrees centigrade, it actually shares none of the properties of morphine. To be clear:
- Morphine is an opiate that delivers a euphoric effect; Apo’ does not.
- Morphine is highly addictive; Apo’ is not. There is no black market for Apo’.
- Morphine is an analgesic (pain killer); Apo’ is not.
So, what is Apo’ and what does it do?
- Apo’ is an inert colourless liquid that, if spilled, stains green.
- Apo’ has a short half-life which means its (pharmacokinetic) effect within the body wears off quickly.
- Apo’ is a ‘generic’ drug; one that cannot be patented to make fortunes for any particular drug company unless allied to a novel way of administration; pump, inhalant, transdermal patch, etc. or, unless its chemical structure is ‘tweaked’ to combine with other compounds.
Above all else Apo’ is best known as one of a group of drugs called ‘dopamine agonists’ which have some affinity with the naturally-occurring chemical and neurotransmitter dopamine. However, Apo’ is a unique drug amongst this group because it alone has an almost exact synthetic match for dopamine with some affinity for all its receptor sites; D1 through to D5. This is of particular interest in respect of addiction because dopamine reinforces motivational behaviour central to our wellbeing, comfort and survival. Consequently when we take a drug for the first time our brains are briefly hijacked to think that this salient experience is critical to survival. In that way dopamine stimulates us to remember and learn the strategies that led to that “high” so we can repeat them in the future.
This mechanism is termed the “reward system”, or pathway, and it is partly to this reinforcing impulse that addiction is attributed. It is also understood that those who suffer from addiction often have flawed dopamine function. Somewhere in their brains the wires are crossed, either due to a heritable trait or as a consequence of addiction itself. It is therefore hypothesised that the dopamine agonist Apo’ repairs some of this lost function and the addict, with improved cognition and reduced cravings, can benefit from subsequent adjunct therapies enabling him to break the old, destructive habits, replacing them with positive life affirming strategies.
In this way it was claimed that treatment with Apo’ had a neurobiological stimulus that facilitated adaptive behaviour for the recovering addict but very few people were convinced. Apo’ as a detox tool was ignored or discredited; it was assumed its only therapeutic dimension was attributable to a contra-conditioning stimulus known as “aversion” (similar to the Philomena quote above). This fallacy endures to this day. Apo’ was also discredited as being “dangerous”, “addictive” and reliant on the doctor’s “charisma” for success.
Subsequently, however, none of this was corroborated by a number of independent and unrelated practitioners who also used Apo’ against addiction. They too found that it was therapeutic, that it was not “aversion” and not even addictive or dangerous. The question is why such a discrepancy between these opposing interpretations and what is the truth?
It is extremely unlikely that Apo’ as a successful treatment for addiction will ever be sought or offered. It belongs to a different era when doctors knew their patients and could lead them step by step through the pain of withdrawal towards recovery. This was a neuropharmacological treatment based on an individual pathology and psychology, and identified by compassionate specialists who, armed with decades of experience and hundreds of successful treatments, knew how to avoid the pitfalls and relapse.
However, and this point cannot be overemphasised, as a historical barometer of our drugs laws and the dogma that has helped define them the “apomorphine story” is of great, if neglected, significance. The fact that nobody chose to examine the true “efficacy” of Apo’ reveals much about this confused and compromised area of medicine that, by the 1950s, had become increasingly tangled in the insidious web of geo-politics, the lead up to the unwinnable”war on drugs” and the medicalization of misery compounded by a sudden increase of spurious conditions potentially treated by prescription dependency.
Tellingly, by the middle of the Twentieth century, the emerging orthodoxy was that addiction could be relieved by talk therapy, maintained or replaced by a bewildering range of psychotropic drugs, with or without a psychological interpretation of its underlying cause and physiological effects. This was at the point when psychiatry evolved under a new flag of convenience, exchanging the introspective fad of Freud for the insidiousness of Big Pharma as its principle raison d’etre.
Apo’ on the other hand sprang from an entirely different premise; that sufferers of addiction would be best served by a non-addictive and short neuropharmacological intervention that repaired the damaged bio-chemical structure of the brain to relieve anxiety, withdrawal and the compulsion to seek and use. In today’s context of drugs like Acamprosate and Naltrexone for drinking and remedies like Champix for smoking Apo’ can therefore be seen as similar in concept if not in terms of the detail of its neural mechanism.
Furthermore, Apo’ was demonstrably successful as an adjunct to support and follow-up psychotherapy by doctors close to the patient’s own community and in a variety of clinical settings and countries. This is particularly ironic in light of the National Institute for Clinical Excellence’s (NICE) recent impotent and facile policy termed the “brief intervention”, a short consultation whereby doctors might get to the point with their patient where a few home truths about their drinking might reduce the burden of a problem which currently costs society more than £12 billion a year. Superficially the “brief intervention” might appear to be a good idea but practically isn’t it a bit rich to expect the modern patient with his expectation of ‘short fixes’ to suddenly accept that wholesale changes are required?
Additionally, how on earth can it be practical in this “pill a day” culture against a background of depersonalised high streets, pharmacies, betting shops and fast food outlets to ask the modern G.P. to resurrect what politicians and bureaucrats, aided and abetted by the pharmaceutical industry, happily dismantled all those years ago: the deeply respected patrician physician? Back in the day that was the norm and curiously one of that breed also used Apo’ for addiction.
This is that story.
(What follows is a greatly abbreviated biography which refers to events that had a bearing on one man’s pioneering and profoundly ethical efforts to understand and treat addiction and how this evolved into a successful and systematic treatment using Apo’ that did not preclude other approaches.)