Arne Tallberg was an indefatigable spreader of the word; not only did he raise awareness in the Scandinavian world of apomorphine, but he documented the human day-to-day realities of working with addicted patients. His flexible approach, integrating both conventional and apomorphine treatment, presented an undogmatic and undramatic view of how such treatment could be incorporated into existing models of addiction therapy. Towards the end of his life he recorded a significant observation: alcoholic patients who smoked cigarettes stopped smoking following apomorphine treatment, suggesting that apomorphine might also be effective for nicotine addiction.
Tallberg was born in Stockholm in 1902. He started his medical career as a ship’s doctor in the Swedish Navy. He then became a medical officer for a collection of commercial shipping companies before taking on hospital postings in Northern Sweden. New responsibilities included looking after mental patients triggering, a life-long interest in psychiatry, and from the 1950s he was routinely treating alcoholics.[1]
In addition to being in demand as a doctor Tallberg was a prolific writer. His books, mostly medical, were published from the late 1920s.
Illustration from ‘Travel Without a Goal’ by Arne Tallberg, 1928.
In 1941 Tallberg married Ingrid Thorin. They had four children in quick succession, prompting their move from central Stockholm to Tyresö a small town 10 klm south east of the city.
From the 1950s Tallberg contributed regularly on medical matters to newspapers and respected periodicals. He was keen to equip readers with the knowledge to help themselves, and his articles made medical information more understandable.[2]
Tallberg’s writing widened his circle of influence and brought him into contact with many published authors, artists and movers and shakers operating in the cultural milieu of Stockholm. A number were alcoholics. The Tallbergs were able to help by welcoming them into their home and were circumspect and private about the treatment and support provided.[3]
Dust jacket for ‘We Discover Man’ by Arne Tallberg, 1957
In the 1950s Tallberg was introduced to the Danish doctor Oluf Martensen Larsen who was well known amongst the Swedish psychiatric community for developing the Antabuse treatment.[4] They became life-long friends and regular correspondents and throughout the 1960s Tallberg keenly follow Martensen Larsen’s investigations into apomorphine.
Tallberg was well connected and in 1969, with support from local politicians and senior members of the clergy, helped establish a publicly funded alcohol treatment clinic in Tyresö. Despite being 67 and retired, Tallberg was persuaded to take over the management of the clinic a year later in 1970.[5] Encouraged by Martensen Larsen’s success with apomorphine he introduced it to the clinic, finding it an effective treatment option.
Throughout the 1970s Tallberg supported Martensen Larson’s endeavours to improve both the method of giving apomorphine and its availability. In 1974 the British addiction doctor, Brian Hore, invited Tallberg to give a paper at a conference in Manchester describing his treatment regime at the Tyresö Clinic.[6.7] In this paper Tallberg was the first medical practitioner to record apomorphine’s effectiveness for reducing nicotine craving. His detailed account of his patient centred approach would be included in a published collection of papers on apomorphine by Hamburg doctor Hanswhillhem Beil in 1976.[8]
Arne Tallberg’s success with patients was enhanced by a small team of assistants including his wife, Ingrid, who helped manage the day to day running of the Tyresö Clinic. He was originally contracted to work 10 hours per week, increasing to 18 hours a week.[9] Because of his commitment to his patients’ welfare, and for no extra payment, he worked at least 12 hours a day.[10]
Throughout his eight year association with the clinic Tallberg chose not to publicise his methods in the press, preferring to protect the anonymity of his patients. The death of Ingrid in 1978 prompted Tallberg’s retirement from the clinic. His replacement phased out the use of apomorphine in favour of Antabuse.[11]
Tallberg died of cancer in 1985 aged 83.[4]
References
Email 17.05.13 Mats Tallberg to Antonia Rubinstein.
ibid.
ibid.
ibid.
ibid.
Telephone conversation, Dr Brian Hore with Antonia Rubinstein, 19.04.17.
Work and Results in a Minor Alcohol Clinic Outside Stockholm, 20th International Institute on the Prevention and Treatment of Alcoholism, Arne Tallberg, Manchester, England, 1974.
The Treatment of Multiple Drug Dependence And Alcoholism with Apomorphine, Hanswilhelm Beil, Hamburg, 1976.
ibid (5).
Email 10.06.13.
Email 22.05.13.
Work and Results in a Minor Alcohol Clinic Outside Stockholm by Dr. Arne Tallberg, 1974. Paper presented at the 20th International Institute on the Prevention and Treatment of Alcoholism in Manchester, UK, June 1974.
In 1969 the municipal authorities of Tyresö, a small municipality of about 30,000 inhabitants, 10 miles south of Stockholm, decided to start a local Outpatient Alcoholic Clinic on a voluntary basis, free of charge for the patients. The clinic opened in January 1970 and except for the first months I have been the medical leader of the work there. Being a retired psychiatrist and besides that a resident of Tyresö for about 25 years I have been able to devote practically all my time, my strength and my interest for the development of the alcohol clinic in Tyresö.
The site of the Tyresö Clinic
In 1970 we had 1,750 visits, in 1971 – 2,567, in 1972 – 2,371 and in 1973 – 2,968 visits. Hitherto, in 1974 we have had an average of more than 300 visits a month with a maximum so far in August with 363 visits.
When I started I was officially allowed 10 hours a week to deal with the alcohol problems in Tyresö. That had gradually been extended to 18 hours a week. In reality, however, it has become for my part full-time work. We have four hours consultation 4 days a week, but in reality the consultation often lasts 5 – 6 hours, and the work goes on practically all around the clock every day. The staff consists of myself, a nurse (Gun Willart) well trained in psychiatry and the treatment of alcoholics, a male therapy assistant, especially engaged of Apomorphine treatment, home visits and “field work” and my wife (Ingrid Tallberg) as a voluntary social worker and a secretary.
Since late last year we have a very good locality in a house of our own, specially altered and equipped according to our demands with good facilities for Apomorphine treatment, with four beds for that purpose during consultation hours. With the staff we have, we cannot house patients during the night. There is, however, a possibility for that at the Municipal Hostel for single, homeless male alcoholics. Our clinic is beautifully situated just in the centre of Bollmora, the administrative and economical centre of Tyresö with good communications to all parts of the municipality.
Our patients represent all classes of the society and all ages from 16 – 65 years. The average age of 35 – 36. Some have a bad criminal or social record, others are quite “clean”. Some – the majority – are working more or less regularly and satisfactorily, others have been unemployed for years. Some are novices in the field of alcoholism, others are greyed veterans in the misuse. But most of them have at least one thing in common: the vast majority of them are coming to us more or less by their own free will-on their own initiative or by the recommendation of relations, other patients, friends, fellow workers or social workers, actually seeking help which they get without the risk of getting into some sort of social register, as the Clinic works independently of the Social Board. I have to give information by request, only about the comparatively few patients sent to us more or less compulsorily by the Board or the courts. All the others are protected by the clinic´s discretion. Because of that I am sure that we are catching up with an increasing part of “hidden” alcoholism in the municipality, which is indicated by the increasing number of young girls, house-wives and other female patients on our roll.
In order to obtain satisfying results, the establishment of good and trustful contact with the patient is considered a necessary premise. One has to break through the patient´s often shown mistrust, negativism, hopelessness and feelings of inferiority and failure to family, work and society.
In order to reach that very personal contact and increase the patient´s self-respect. I try to meet him on equal terms. During the consultation I never wear a white coat. I am not sitting on a pedestal with the patient at a lower level, figuratively speaking, I aim to become a friend and advisor to my patients, as far as it is possible and my principal goal is to enable the patient to function satisfactorily in the family, at his work and in his relations to the society, which requires a considerable amount of interest-not to mention time-from the doctor in charge and his staff in order to get behind the masque and reach the background and most probable cause of the misuse of alcohol and there to get on the road to the most suitable and proper treatment in each particular case.
As I have the opinion that a very close personal contact between doctor and patient is very important, at least at the beginning of the cure, I tell my patients first to see me four times a week, then twice a week, later once a week, twice a month, once a month etc. I also tell them that they may phone me any time, day or night, when they feel in sore need of advice or actual help in form of a talk, comfort, encouragement, a tranquilizer or a sleeping pill. I think this arrangement is of the utmost importance to give the patient a sense of security, a feeling that there is a hand to grasp, an ear willing to listen in case of emergency. I mention this not to brag but to give you an idea of how very personally we work in my clinic. We do not sonly see the patients, we live with them, sharing their problems, their joy and sorrow.
Treatment During the first two years our Clinic was working we only used what I will call conservative treatment with Heminevrin, Antabuse, concentrated B-vitamin injections, tranquilizer and sleeping drugs. We still use that method in the treatment of many patients. We try, however, to use tranquiliser and sleeping drugs as little as possible, and they are chiefly used in the initial phase of the treatment. I often use a combination of an antihistamine and a sleeping drug, in order to reduce the dose of the later. During the last three years we have more and more turned to Apomorphine treatment –firstly on account of the limited resources for clinical detoxification in the County of Stockholm – later because we have found Apomorphine a very valuable asset in the treatment of Alcoholics.
The main thing to decide at the first interview with the new patient is whether he is a case for Apomorphine treatment or more suited for traditional treatment.
The choice between Apomorphine and conventional treatment depends:
1 whether the patient can be considered as cooperative and trustworthy and 2 if he for one reason or another refuses to take injection.
In my opinion treatment with Apomorphine without the patient’s cooperation is meaningless.
Naturally it may happen that during the cure we have to change from Apomorphine to traditional treatment or vice versa. That depends on the patient: how he acts and reacts, if he is sufficiently motivated or not and how reliable he is. In the latter part of the Apomorphine treatment we simply have to rely upon him that he uses the Apomorphine capsules prescribed.
Apomorphine is not a newly detected drug. It has been known for more than 100 years as a most potent nausea or vomiting provoking drug when used in high doses. In about 1900 it was recommended as a hypnotic and anxiolytic drug in the treatment of Alcoholics and in the early twenties and thirties Dent in England used it successfully in his treatment of Alcoholic patients. Around 1950 it was used as an emetic in the then actual aversion therapy of Alcoholics by producing conditioned reflexes against alcohol (among others by Professor Izikhowitz in Stockholm). But as results were uncertain and disputed, doctors abstained from using Apomorphine and it was left with a dubious reputation as a remedy in Alcoholic treatment. The renaissance during the last years in the use of Apomorphine in small doses by Feldmann in Geneva, Martensen Larsen in Copenhagen, Beil in Hamburg and others is based on the blocking effect of Apomorphine in the transformation of Dopamine into Noradrenaline, which is something quite different to the now abandoned aversion method.
In my clinic we use a concentration of 2 mg Apomorphine hydrochloride in 1 ml for injections. The gelatine capsules of the Parke-Davies – type we use are filled with 10 or 20 mg of Apomorphine together with 200 mg Ascorbic acid and 30mg of effervescent. As it has been shown that Apomorphine is absorbed in the upper part of the stomach, the effervescent is added to make the capsules “explode” when the float on the surface of the stomach content. Nontoxic colours as Riboflavin and Cocoa are added to make it possible to differ between the two strengths of capsules: 10 mg yellow and 20 mg brown. Naturally the capsules can be combined in different ways in order to get the dose required, ad libitum.
In the effect of Apomorphine on the patient one must differ between what I call the “acute” effect and the “long term” effect. If a practically comatose drunkard is brought to us, we can make him “physically” sober in 3 – 4 hours by a series of subcutaneous injections of small doses of Apomorphine, rising step by step from 0.4 mg to about 2mg. The effect is striking and almost unbelievable. After the time stated, the patient has cleaned up, left the bed, has taken a showed, combed his hair, is enjoying a cup of coffee, a couple of sandwiches and a cigarette and is able to talk and discuss his situation. Of course, he has still his promille in the blood and can´t be considered for instance to be capable to drive a car. But when we see him again the next day he is more manageable and treatable than the second day of detoxication after the conventional detoxication with Heminevrin etc. During the last months we have, however, tried a combination of Apomorphine and Heminevrin detoxication with still better results.
In the ordinary Apomorphine cure the first day is just like the one described above. We start with 0.4 mg of Apomorphine and go up by adding 0.2 – 0.4 mg to the preceding dose at intervals of 20 minutes,30 minutes or 45 minutes. It seems realistic to try to reach larger doses as soon as possible and thus make the intervals shorter at the beginning and longer later on. The patient has to lie down during the treatment, partly because Apomorphine causes a temporary decline of the blood pressure (10 to 30 mm)and partly because he becomes sleepy. After the last injection for the day he is told to rest about an hour before leaving the clinic for home.
If the patient experiences nausea and starts vomiting, the dose is temporarily reduced and then we may try again to push a little more upwards. As a rule we never pass 4-5 mg in a subcutaneous dose. During the following 11 – 17 days the patient gets 2 injections daily. Now the injections are combined with capsules in doses of 10 – 40 mg taken at home twice a day. The daily injections start with the last dose the previous day. At the end of the injections the patient is to take capsules of 20 mg or 40 mg 4 times a day. I try to spread the capsules over the 16 hours the patient normally is awake. As Apomorphine is metabolized in about 5 hours, I find that arrangement necessary in order to keep the patient´s body saturated with Apomorphine. The cure goes on as described for 2 , 3, 4 or 6 months, depending on the results and how secure the patient feels. When treating elderly, chronic alcoholics, I have found it good to combine the apomorphine capsules with 1+1 capsule of 0.3 mg Heminevrin. That has enabled the patient to stay calm and sober for a remarkably long time.
The most interesting thing with Apomorphine treatment is that it does not hinder the patient´s drinking like Antabuse; it takes away the desire, the compulsion, to drink. He simply does not want to drink anymore, and several of my patients have also stopped or reduced their smoking or coffee drinking.
They seem not to be in need of stimulants, they are calm, well balanced, active, eager to work and improve their actual situation which they can now look upon and discus in an objective and creative way.
The duration of the cure is hard to predict. I have had previously heavy drinkers who had stayed sober for 1 – 2 years; others have been very much improved with months between the relapses. Some have been able to go over to social drinking. Of course we have also had failures, when the patients have refused to cooperate properly. On the whole I think I can say that about 50 % of the patients treated with Apomorphine have been more or less made better. Should, however, a relapse occur, the patient is welcome to come back and we start again from the beginning.
A rough comparison between Apomorphine and the conventional treatment shows that Apomorphine is the best alternative when it can be used. The results of improvement in the group with what I have called conventional treatment is about 20%. One must also keep in mind that Apomorphine can´t be overdosed on account of the risk of vomiting; it is not habit-forming as the tolerance of Apomorphine is reduced by and by during a long period of treatment and it can´t produce a “kick” in the doses we use.
Finally, I can only hope that Apomorphine treatment in the modern form will generally (be) accepted as a routine method in suitable cases besides the other methods now in use all over the world. Of the old rule Nihil nocere will lead every medical doctor working with alcoholics to the method he prefers for obtaining the best results.
Reference Article reproduced from The Treatment of Multiple Drug Dependence and Alcoholism with Apomorphine, Zusammengestellt und herausgegeben von Hanswilhelm Beil, Hamburg 1976
Mats Tallberg remembers the work of his father, Arne Tallberg.
From about 1969 my father, (Arne Tallberg), started the alcoholic clinic in Tyresö inspired very much by Oluf Martensen-Larsen. The clinic was situated in a small yellow house opposite the centre of Tyresö at Bollmoravägen. The staff were Lars Thelin, Bengt Thelin, Gun Willart and a nurse called Aina.
My father met Martensen-Larsen in Copenhagen in the mid-1950s. He recognised that he was a thinker and had very good ideas on how to treat alcoholics.
My father became knowledgeable about apomorphine towards the end of the 1960s. It may have been Martensen-Larsen or Arvid Carlsson in Gothenburg who told him about it.
My father didn’t speak publicly about the clinic. He wanted to keep it confidential because of the patients. The lecture he gave in Manchester (1974) about the clinic and the treatment was the only speech I am aware he gave. My father chose not to have articles on his work at the clinic published in the local newspapers or on local radio because he wanted his patients’ anonymity protected.
Our parents always talked about their medical engagements. We were told to tell nobody when they mentioned their patients. Some patients visited our home in Trollbäcksvägen 33 so we were very used to seeing them. Our home become a kind of “hotel” for some authors and other cultural people the so-called ‘Clara-brother’. Some had problems with alcohol. They lived from day to day writing or hoping for a poem or novel to be published in the newspapers. My father or mother helped them as much as they could.
My father, like my mother, was always drinking strong tea without milk. He smoked his pipe and played patience, listening always to the radio or to what his patients had to tell him. Unlike my mother he thought it was acceptable to have an occasional drink, preferably whisky. He was employed for 10 hours a week at the clinic. But he worked 24 hours a day. He spent 12 hours a day at the clinic.
My father was in contact with some people of importance. For example: the chairman of the local Social Board: Yngve Lundell, a liberal and a member of the Sobrian International Organisation of Good Templars. He had common sense and liked my parents. He decided that the Alcoholic Bureau, even if it kept its patients secret to his Social Board, would be interesting and that it would
be free of charge for the patients because he could see this type of patient could not afford to pay anything. Lundell was very happy when he quickly learnt of the positive results from the clinic.
Another strong supporter of the clinic was a member of the Conservative Party, Harald Falk, and his wife. They believed it was essential that poor people should have quick help if needed. The local Labour Party were also supporters. My parents were members so knew people in the party.
Two or three clerks in the social board were essential to the success of the clinic, Bengt Thelin, Gösta Johansson, and a girl, a member of the Communist Party, who was socially minded.
As a family we belonged to the Church of Sweden, an evangelical-Lutheran variant which chiefly had similarities with the Presbyterians and the Church of England.
Then there existed Länkarna the Links, an organisation of Anonymous Alcoholics, who wanted to live if possible in a sobrian way. The chairman was Lindquist, a strict man working in the Church of Sweden´s local parish in Tyresö. He recommended some of his members to the clinic. Then the clergyman and deacons of the parish of the church of Sweden in Tyresö -perhaps through Lindquist – decided to recommend some of their members who needed social help to contact the clinic.
The Free-Baptists in Tyresö also believed the clinic was a good idea and sent some of their new members to it. They had a central office in the city, Levi Petrus Foundation, which might contact the clinic.
Sometimes the Mariapolikliniken (in Stockholm) which helped extremely acute alcoholics might call up my father or mother. This was how they received patients from this clinic. It was essential that these patients felt that their anonymity was protected. People were referred to the bureau by word of mouth – through an informal network. Chiefly the patients were poor and without money even if a few from the establishment might have used the services.
My father’s successor, Mrs Bagge, was more conventional in her attitudes to the patients, and in the mid 1980s, the municipality of Tyresö, decided to abolish the Bureau. I don’t think she used apomorphine too much, despite my father’s success, but preferred Antabuse.
Even if the Bureau was successful one has to remember that there was often a back-lash with some of the patients which means that despite the treatment they again became alcoholics especially after the Bureau was closed. Since that time the research has expanded in addiction treatment and maybe there exists today another good medicine instead of the apomorphine.
