Reason Magazine - Contributors

Hungry for the Next Fix

info@reason.com (Stanton Peele) — Wed, 01 May 2002 00:00:00 EDT

As director of the National Institute on Drug Abuse (NIDA), Alan Leshner toured the country with a PowerPoint presentation featuring brain scans. The show was a slightly more sophisticated version of the Partnership for a Drug-Free America's famous ad showing an egg frying in a pan. As he flashed magnetic resonance images (MRIs) on a screen, Leshner would say, in effect, "This is your brain on drugs."

Leshner's message was threefold. First, certain drugs are inherently addictive. Second, scientists have discovered the neurochemical processes through which these drugs cause addiction. Third, that understanding will make it possible to develop drugs that cure or prevent addiction. Leshner's traveling PowerPoint show epitomized NIDA's reductionist approach to drug abuse: Take a brain, add a chemical, and voilà, you've got substance dependence.

Leshner left NIDA at the end of November. Coincidentally, Enoch Gordis, head of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) since 1986, retired around the same time. Like Leshner, Gordis sees addiction as a biological problem with a pharmaceutical solution. He believes scientists have "the ability based on new knowledge from neuroscience research to develop pharmacologic treatments that act on brain mechanisms involved in alcohol dependence."

The view of addiction espoused by Leshner and Gordis is at odds with what we know about the actual behavior of drug users and drinkers -- including evidence from government-sponsored research. These studies indicate that treatment is neither necessary nor sufficient for overcoming addiction. The main factor in successful resolution of a drug or alcohol problem is the ability to find rewards in ordinary existence and to form caring relationships with people who are not addicts. By looking instead for a magical elixir just over the horizon, NIDA and the NIAAA give short shrift to the individual circumstances that are crucial to understanding why some people abuse drugs.

'A Medical Illness'

NIDA's official mission is, in its own words, "to lead the Nation in bringing the power of science to bear on drug abuse and addiction." Leshner, who has a Ph.D. in physiological psychology, took the agency's helm in 1994. During his tenure NIDA's budget doubled to $781 million, money devoted mainly to biological research that approaches addiction as a disease.

Although drug use "begins with a voluntary behavior," Leshner said in a 2001 interview with The Journal of the American Medical Association, it ceases to be voluntary after it repeatedly affects the "pathway deep within the brain" common to all drug addiction. "There's no question it's a medical illness," he said, "and once you have it, it mandates treatment. It's a myth that millions of people get better by themselves."

Leshner's model of addiction emphasizes the special power of drugs. After all, he did not travel around the country with MRI images showing how shopping, gambling, or eating potato chips affects the brain. Thus it was startling to see him concede that drug abuse may be fundamentally similar to excessive involvements with other activities that give pleasure or relieve stress. "Over the past 6 months," he said in the November 2 issue of Science, "more and more people have been thinking that, contrary to earlier views, there is a commonality between substance addictions and other compulsions." Some of us have been making this point for years, and it does not fit very well with the idea that drugs create addicts by transforming their brains.

As evidence for this view, Leshner would point to MRI scans of experienced drug users, which he claimed differed in characteristic ways from images of ordinary brains. He also cited studies of drug-induced brain changes in animals. He liked to display a map -- reminiscent of a phrenology chart -- showing which areas of the brain are involved in drug use and addiction.

But Leshner's seemingly scientific claims have never jibed with reality. Consider what the sociologist Lee Robins and the psychiatrist John Helzer found when they headed a team that interviewed veterans who had been addicted to heroin in Vietnam. Only one in eight became readdicted at any time during the three years after they came home. This was not because the rest were abstinent: Six in 10 used a narcotic after returning to the U.S., and a quarter of the previously addicted men used heroin regularly.

Yet only one in five of those who used a narcotic after they got home, including only half of those who used heroin regularly, became readdicted.

The Vietnam situation, of course, was unique. Young men were torn from their homes, sent to a strange and dangerous environment, and offered easy access to heroin. Then they returned to normal life. Still, the results surprised Robins and her associates, who commented: "It is uncomfortable presenting results that differ so much from clinical experience with addicts in treatment. But one should not too readily assume that differences are due to our special sample. After all, when veterans used heroin in the United States...only one in six came to treatment." In other words, looking only at addicts who are treated provides a skewed view of addiction. Indeed, the vets who were treated after they got home actually were more likely to pick up the habit again.

Rats vs. People

Any doubts about the relevance of the Vietnam veterans study are allayed by findings from long-term studies of drug users in the U.S. Long-term cocaine users, for example, generally do not become addicts. And when they do go through periods of abuse, they typically cut back or quit on their own. They may not do so as rapidly as others (and they themselves) wish they would. But addicts act very much like other human beings:

They pursue pleasure or relief, and most will change their behavior when it causes them serious harm, so long as they have reasonable alternatives.

According to the National Household Survey on Drug Abuse (overseen by the Substance Abuse and Mental Health Services Administration), about 3 million Americans have used heroin. Of these, one in 10 report using the drug in the last year, and one in 20 say they've used it in the past month. The percentages for cocaine are similar. In both cases, daily use is so rare that the government does not provide figures for it. These findings indicate that the vast majority of heroin and cocaine users either never become addicted or, if they do, soon manage to moderate their use or abstain.

This pattern has been confirmed again and again by government-sponsored research. At NIDA, however, studies of human behavior have taken a back seat to research involving brain scans, special breeds of rats, and monkeys tethered to drug-dispensing catheters.

Given NIDA's biological orientation, it may seem odd that the main form of treatment the agency advocates (pending development of a wonder drug for addiction) involves adopting a new set of quasi-religious beliefs and meeting regularly with like-minded individuals. But NIDA's take on addiction has much in common with the view promoted by Alcoholics Anonymous (A.A.) and its imitators. Both see addiction as a disease involving loss of control that can be overcome only through abstinence.

NIDA's support for drug treatment based on A.A.-like principles, the dominant approach in the United States, flies in the face of its avowed commitment to rigorous science -- a conflict illustrated in the last issue of NIDA's newsletter published under Leshner. A front-page article announced the disastrous long-term consequences of heroin use, based on a study that followed a group of addicts for more than 30 years. "The death rate among the members of the group is 50 to 100 times the rate among the general population of men in the same age range," the article said.

"Even among surviving members of the group," the lead researcher added, "severe consequences such as high levels of health problems, criminal behavior and incarceration, and public assistance were

associated with long-term heroin use."

Yet the subjects of this study were criminal offenders in California who were forced to attend abstinence-oriented, A.A.-style group sessions between 1962 and 1964. In other words, they benefited from just the sort of treatment NIDA advocates. Undaunted, Leshner began his column in the same issue of the newsletter with the cheery news that "NIDA's quarter century of research has produced a basic unequivocal message -- drug addiction is a treatable brain disease." Yet today's preferred treatment is indistinguishable from the programs those California convicts attended in the 1960s.

Sugar: The Miracle Cure

If Leshner and Gordis are right, A.A.-style therapy will ultimately be replaced, or at least supplemented, by drugs that block addiction. The leading candidate so far is naltrexone, which is reputed to curb the urge for both heroin and alcohol. Naltrexone has been approved for treatment of alcohol dependence, and Gordis, an M.D., promoted the drug as the first in the pharmacopoeia he envisioned for alcoholism.

A study published in December made that prospect seem unlikely. The researchers divided 600 alcoholics into three groups: One received naltrexone for a year, another was given naltrexone for three months followed by nine months of sugar pills, and the third group took just the placebo. The subjects began the study drinking, on average, on two out of every three days, 13 drinks on each occasion. One year after their treatment began, these men were drinking one-quarter as frequently and consuming somewhat less when they did drink. But the reduction was about the same for the men who took the fake pills as it was for those who were given naltrexone.

Announced in The New England Journal of Medicine, these findings were incomprehensible to anyone who accepts the view of alcoholism promoted by the NIAAA. Aside from the evidence against naltrexone's effectiveness, it was stunning that sugar pills enabled severe alcoholics to reduce their drinking without abstaining completely, which alcoholism experts in the United States teach is impossible. Yet every major study of alcoholism carried out during Gordis' tenure at the NIAAA yielded the same sort of results. It's just that Gordis spent much of his energy denying what his own agency had found.

In 1992 the NIAAA surveyed more than 42,000 randomly selected Americans in the National Longitudinal Alcohol Epidemiologic Survey. Census Bureau interviewers questioned each respondent about his or her lifetime drug and alcohol use. Of special interest were 4,585 respondents who at some time in their lives were "alcohol dependent" (what most people call alcoholic). Of this group, only about a quarter were ever treated for alcoholism (including A.A. as treatment). But the treated group was no more likely to have improved, as measured by either abstinence or drinking without abuse. In fact, more treated (33 percent) than untreated alcoholics (28 percent) were continuing to abuse alcohol.

One reason untreated alcoholics did better was that many more of them reduced their drinking without abstaining. Among people who at some point in their lives had qualified as alcohol dependent but were never treated, nearly "6 in 10" or "more than half" (58 percent) in the untreated group were drinking without a diagnosable problem. Including all the treated and untreated alcoholics in this random sample of Americans, half were drinking without abusing alcohol.

Driven Not to Drink

The NIAAA sponsored another ambitious study -- the largest trial of psychotherapy ever conducted. Completed in 1996, the study was known as Project MATCH because it was aimed at determining whether different treatments could be "matched" to specific types of alcoholics to produce optimum results. One of the therapies, based on A.A.'s 12 steps, was called "12-step facilitation." A second was dubbed "coping skills therapy." The third was "motivational enhancement therapy." Nearly half of the 1,700 or so subjects underwent hospital treatment first; the rest entered the MATCH treatments directly.

All the therapies performed equally well, but one was considerably simpler than the others: Motivational enhancement involved four sessions with each alcoholic, compared to 12 for the two other types of therapy (although, on average, subjects attended only two-thirds of the sessions scheduled for any of the therapies). Motivational enhancement brings into focus and strengthens the individual's own drive for sobriety, but it leaves the mechanics of sobriety to the alcoholics themselves.

Although the Project MATCH subjects had few counseling sessions (especially in motivational enhancement therapy), their drinking was periodically assessed following treatment. These interactions with the project, intended solely for research purposes, seem to have had the effect of keeping alcoholics focused on controlling their drinking.

Whatever treatment alcoholics received in Project MATCH, few abstained for even a year. Gordis and his colleagues instead emphasized dramatic reductions in drinking by the subjects. Whereas they averaged 25 days of drinking a month prior to treatment, after a year they were drinking only six days out of the month. Moreover, the average number of drinks they consumed each time they drank dropped from 15 to three.

In all three of these prominent studies -- the naltrexone trial, the NIAAA's national survey, and Project MATCH -- the results were essentially the same. Even with clinical alcoholics, minimal treatments were as successful as more elaborate ones, and the best indicator of success was the alcoholics' ability to cut back their drinking rather than quit altogether. But how can sugar pills or a few sessions of motivational enhancement help alcoholics control their drinking? The basic ingredients for successful treatment are 1) identifying a problem with the agreement of the addict, 2) believing change is possible, 3) placing primary responsibility on the addict for carrying out the change, 4) accepting reductions in use as well as abstinence, and 5) following up to let addicts know someone cares and wants to make sure they stay on course.

Beyond Abstinence

In the face of studies that cast doubt on traditional notions about alcoholism, Gordis seemed to consider it his duty to explain why they actually confirmed the conventional wisdom. Project MATCH in particular presented a serious P.R. problem for the NIAAA: It spent more than $30 million without fulfilling its purpose of identifying principles for matching alcoholics to treatments. This is how Gordis spun the results: "The good news is that treatment works. All three treatments...produced excellent overall outcomes."

Although Gordis relied on reduced drinking as a measure of success to put the best gloss on Project MATCH, he has always quashed any revision of the abstinence-oriented goals that characterize virtually all American alcoholism treatment. Responding to a 1997 U.S. News and World Report story on Moderation Management, a program for reducing alcohol consumption among problem drinkers, Gordis sternly warned that "current evidence supports abstinence as the appropriate goal for persons with the medical disorder 'alcohol dependence' (alcoholism)."

While abstinence may be a desirable goal for these individuals, not many accomplish it. Project MATCH engaged the top clinical practitioners and researchers in the United States in designing and supervising treatment for alcoholics. As a result of this attentive, sophisticated care, which is unlikely to be matched by any program an alcoholic could find in the real world, about a quarter of the subjects abstained for as long as a year.

Gordis' attitude seems to be: "Most alcoholics won't abstain after treatment, but they should! And we are not going to accept anything less than this worthy, if unreachable, goal." His attitude is especially disturbing since Project MATCH found that reductions in drinking were beneficial. The subjects' liver functioning typically improved, and they displayed fewer problems associated with drinking. Surely, better health and less destructive behavior are worthy goals.

Since Gordis spoke for the U.S. alcohol treatment establishment, his rigidity condemned American alcoholics to limp along, most continuing to drink, with little chance of finding assistance in limiting their drinking or reducing its negative consequences. We will never eliminate drinking and drug use. But we might be able to reduce the harm they sometimes cause if we could eliminate the pseudoscientific moralism dispensed by the likes of Leshner and Gordis.

Drunk with Power

info@reason.com (Stanton Peele) — Tue, 01 May 2001 00:00:00 EDT

In 1990, a landscaper named Robert Warner pled guilty in a Woodbury, New York, court to drunken driving charges, his third such conviction in a little over a year. Judge David Levinson, following the recommendation of the Orange County Department of Probation, sentenced Warner to attend Alcoholics Anonymous meetings for three years. In fact, OCDP specified AA participation in all its alcohol-related cases.

Warner soon objected to the AA meetings, but his probation officer ordered him back to AA. After almost two years, Warner filed a claim in federal court against the probation department. Warner, an atheist, said that it was unconstitutional for him to be sentenced to attend the 12-step program, which relied on God and a "higher power" as its method of addressing alcoholism, and at which prayer was a regular feature. In 1994, the federal District Court for Southern New York ruled for Warner, finding that "sending probationers to rehabilitation programs which engage in the functional equivalent of religious exercise is an action which tends to establish a state religious faith." The 2nd Circuit Court of Appeals affirmed the decision in 1996.

Warner's was the first in a series of successful challenges to the widespread practice of coercing defendants to participate in AA or in treatment programs based on its 12 steps. Since then, three other appeals courts have ruled against the practice; these are two state Supreme Courts (New York and Tennessee) and the federal 7th Circuit Court in Wisconsin. These courts have based their decisions on the Constitution's Establishment Clause, which prohibits government-established religion. The U.S. Supreme Court has ruled that no government body can require religious participation of any sort.

Recently, Oklahoma's conservative Gov. Frank Keating harshly criticized such decisions. Writing last December 13 for National Review Online, Keating complained bitterly that, "Apparently it wasn't enough to ban classroom prayer and remove Christmas displays from city parks; now the federal judiciary is after Alcoholics Anonymous, which has had the audacity -- for two-thirds of a century -- to mention God's name as it saved millions of lives." Other prominent politicians have derided these decisions, but only Keating has fully laid out the arguments in favor of compulsory 12-step participation, thus summarizing the resistance to the recent court decisions.

Keating's argument is filled with factual errors. For example, he writes as though the decisions about AA had just occurred, "66 years" after a vision that co-founder Bill Wilson had in 1934. Keating further asserts that these decisions were made by "federal circuit courts...in Wisconsin and California." In fact, the four appellate courts that have ruled against the state imposition of AA or 12-step treatment did so in 1996-1997, and none of them was in California. Keating has apparently confused the Orange County, New York, of the Warner case with Orange County, California. In 1994, the federal District Court for Central California did rule on an Orange County, California, requirement that DUI offenders attend a self-help group, generally meaning AA. But in that case, the court upheld the local court's reliance on AA as the main referral for convicted drunken drivers. Of critical importance for the court was that the law permitted the plaintiff to select a non-AA program, or to devise his own self-help program, to be approved by the county.

In Wisconsin, the 7th Circuit Court found that Oakhill Prison warden Catherine Farrey wrongfully compelled James Karr to participate in Narcotics Anonymous. If he refused, Karr faced being shipped to a tougher prison, while being denied parole. Considering that Karr was decided in 1996, Keating is not very convincing when he claims that this decision endangers "the widespread and growing practice of mandating AA involvement" for inmates and parolees. And, despite the Warner decision, as Keating himself notes, "AA meetings and some form of AA-based counseling or treatment have become almost standard conditions for probation" for DUI offenders.

Indeed, that development is precisely the problem. The decisions of the mid-1990s have been widely ignored by courts, prisons, and probation departments, partly because the U.S. Supreme Court has not ruled on the issue. Of course, the Supreme Court's refusal to hear a case does not necessarily mean that it accepts a lower court's decision, and the Court could uphold mandatory 12-step sentencing in the future.

One appeal the U.S. Supreme Court refused to hear was from a state decision against New York's Department of Corrections. New York's highest court ruled against the department in 1996 when the latter made inmate David Griffin's entry into a prison family reunion program contingent on his participation in the department's 12-step substance abuse program.

In the absence of a definitive national precedent, similar cases will continue to percolate up through the courts. Meanwhile, in reaction to Griffin, New York prison officials designed new legal strategies to compel inmates to participate in the state corrections treatment program. Prison officials argued in the District Court for Northern New York that Troy Alexander's repeated objections to participating in the 12-step program were not based on genuine conviction. But last September, the court rejected this argument because it required the state to evaluate people's religious beliefs (or lack thereof), which the First Amendment was designed to avoid in the first place.

Defendants who are accused of 12-step coercion invariably claim that AA is a spiritual, not a religious, program. Keating defends this notion at length. Yet "God," or "Him," or a "higher power," is mentioned in half of the 12 steps. Keating singles out as essential "AA's elegant third step: 'Came to believe that a power greater than ourselves could restore us to sanity.'" (Note to Keating: This is actually AA's second step.) Like other AA defenders, Keating says that this higher power can be anything, "a dead ancestor, a tall tree, or the group itself."

But does Keating really mean that belief in trees can "restore sanity"? For their part, the courts have rejected such arguments. As is the case with many AA groups, those that Robert Warner attended in 1990 began with a religious invocation and ended with a Christian prayer. More basically, New York's highest court pointed out in its decision in Griffin that "a fair reading of the fundamental A.A. doctrinal writings discloses that their dominant theme is unequivocally religious....While A.A. literature declares an openness and tolerance for each participant's personal vision of God,...the writings demonstrably express an aspiration that each member of the movement will ultimately commit to a belief in the existence of a Supreme Being of independent higher reality than humankind."

Although Keating was on George W. Bush's short list for attorney general, he apparently cannot distinguish religious from secular. He details from AA's "Big Book" -- which records stories about AA's early members and outlines the group's principles -- how a desperate Bill Wilson "asked God to intervene, saw a brilliant burst of light, and felt immense peace." But New York's high court used this story as evidence that AA is religious: "'Bill's Story' describes the spiritual transformation of one of the co-founders of A.A., in which he finally achieved salvation from his alcoholism by 'enter[ing] upon a new relationship with my Creator.'" Although Keating claims all religions can embrace the 12 steps, the American Jewish Congress filed a friend-of-the-court brief in support of Griffin.

The courts have not forbidden 12-step treatment in prisons or DUI programs. As Keating recognizes, "The courts said Twelve Step involvement could not be mandated; they did suggest that courts and parole authorities could continue to require involvement in some form of treatment or recovery program as long as there is a secular, 'non-religious' alternative." It is true that the courts in these cases have made clear that the absence of an alternative was the deciding factor. Keating instead devises this non sequitur: "Pluck out all the references to God or spiritual elements, the rulings said, and you'll be fine. As a result, hundreds of court and prison system bureaucrats across America are busily engaged in sad and ludicrous efforts to rewrite Bill Wilson's Twelve Steps."

According to Keating, the court is attacking practices that "promise potential reductions in the national crime rate of up to 50 percent!" But this claim confronts a difficult reality. AA has grown exponentially, from 100 members in 1939 to 1.16 million members currently, according to the AA Web site. (Keating puts this figure at more than 2 million people.) At the same time, a 1997 survey conducted at the University of Georgia found that more than 90 percent of private treatment programs are based on AA's 12 steps. Why, then, is our prison population at record levels, and why is so much of this crime associated with substance abuse? Keating approvingly refers to a Department of Justice finding that most criminals are substance abusers, including a "staggering 83 percent of state inmates."

Keating cites several studies that have found that inmates who complete treatment and continue to attend AA have better records than untreated prisoners and parolees. However, studies that include dropouts from treatment groups in their calculations have reported different results. For instance, a 1999 study of Texas' correctional substance abuse treatment programs found that those who participated in an in-prison program had the same recidivism rates as non-participants. Although those who completed the program did better than untreated offenders, those who entered but did not complete the program did worse. Moreover, probationers enrolled in treatment in Texas had an overall higher recidivism rate than non-participants.

Two explanations could account for such findings. One possibility is that, while treatment and non-treatment groups are equally likely to be recidivist, those who quit treatment are those who were more likely to relapse anyway. Thus, counting only those who remain in treatment and aftercare is cherry-picking those most likely to succeed in the first place. The other possibility, which would scandalize AA zealots like Keating, is that those who have a negative reaction to AA and its 12-step approach are actually driven to relapse by the experience.

For Keating, AA is singularly and extraordinarily effective: "The hard truth is that in the thousands of years before AA, there was no effective treatment for alcoholism....In 2000, as in 1935, if you're a drunk and you want to get sober, you go to AA or to a treatment program based on AA's Twelve Steps. ...It's still the only game in town...." Orange County's attorney, Richard Golden, asserted this after the Warner decision: "There are alternatives out there. Do the probation officials think they are satisfactory? Absolutely not." Indeed, New York's highest court accepted the claim that "A.A. practices and precepts have proven to be the most effective method for preventing relapse...."

In fact, in clinical trials in which alcoholics are randomly assigned to different treatments, neither 12-step treatment in general nor AA in particular has ever been found superior to a tested alternative treatment. Indeed, in most cases, the reverse has been true. In 1991, Diana Walsh and her colleagues at the Harvard School of Public Health assigned employee assistance program referrals for alcohol abuse either to a treatment program or to AA, or gave them a choice of treatments. Sixty-three percent of the AA assignees required additional treatment, compared with 38 percent of the choice group and 23 percent sent to a treatment program.

In 1997, the National Institute on Alcohol Abuse and Alcoholism completed its massive Project MATCH -- at over $30 million the largest clinical trial of psychotherapy ever conducted. Three treatments were compared: (1) skills training, which teaches alcoholics to cope with feelings and stress without drinking; (2) motivational enhancement, which leads alcoholics to balance their other values against the need for continued drinking; and (3) "12-step facilitation." Neither skills training nor motivational enhancement refers to a "higher power." In MATCH, leading clinicians wrote handbooks, trained professional counselors, and monitored videotapes of therapy sessions. Under these ideal conditions (unlike anything an inmate or drunken driver will experience), 12-step treatment merely did as well as the other two therapies. Nonetheless, since it required 12 sessions, while motivational enhancement took only four, the latter would be the most cost-effective therapy for alcoholism according to usual medical standards.

AA members often assert that these negative findings result from forcing individuals into treatment. Yet coercion -- the most common path into AA -- is exactly what Keating and many treatment advocates espouse. As Keating writes, "People rarely walk voluntarily through the door and ask for help; most of them arrive unwillingly, forced to AA and treatment by circumstances that have increasingly included orders by courts or parole officers."With drunkies and junkies, you usually need a hammer."

Although it has been adjudicated only in relation to prison and probation programs, AA coercion by state agencies and representatives extends well beyond these populations. Government-licensed professional organizations -- including pilots, attorneys, and health professionals -- public assistance programs, and family courts all regularly assign Americans to 12-step programs. Most people recognize that imposing Christianity is un-American, even if those who adopt Christianity have fewer drug and alcohol problems. Yet many people readily accept the government's imposition of AA and 12-step treatment.

Even if AA and 12-step treatment were better than available alternatives, and even if the courts found that the powerlessness that each AA member must admit to in Step 1, the higher power each has to subscribe to in Step 2, and the "decision to turn our will and our lives over to the care of God as we understood Him" in Step 3 were as nonspecific as Keating claims, forcing people into AA would still violate their personal integrity. Do Keating and other advocates of compulsory 12-step treatment really believe that the state has the right to tamper with a citizen's inner beliefs in this way?

After the Crash

info@reason.com (Stanton Peele) — Wed, 01 Nov 2000 00:00:00 EST

At 6 p.m. on March 25, Audrey Kishline was driving west on the eastbound side of Interstate 90 near Seattle when her Ford pickup truck collided head-on with a Dodge coupe occupied by Richard Davis, 38, and his 12-year-old daughter, LaSchell, killing both of them. Kishline had a half-empty vodka bottle on the seat beside her when police found her, unconscious, in her truck. Her blood-alcohol level was 0.26 percent, more than three times Washington’s legal limit for drivers. Three months later, she pleaded guilty to two counts of vehicular homicide in Kittitas County Superior Court.

The crash, however tragic and avoidable, would have been no more newsworthy than the thousands of other drunk driving accidents in which Americans are killed each year were it not for the fact that Kishline is the author of the 1994 book Moderate Drinking and founder of Moderation Management, an organization aimed at helping problem drinkers control their alcohol consumption. (I wrote an introduction to the book and served as an adviser to M.M.) To longtime critics of the "controlled drinking" Kishline espoused as an alternative to the abstinence urged by Alcoholics Anonymous and its imitators, the crash was a vindication. The National Council on Alcohol and Drug Dependence (NCADD)–a private group that, like A.A., considers alcoholism a disease that can be controlled only through abstinence–gloated in a press release that Kishline’s crash taught a "harsh lesson for all of society, particularly those individuals who collude with the media to continually question abstinence-based treatment for problems related to alcohol and other drugs."

Yet Kishline’s one brief statement to the press revealed some facts that ran counter to the NCADD’s interpretation. "Two months before the crash," The Seattle Times reported, "she dropped out of the [M.M.] program and joined Alcoholics Anonymous. But it wasn’t long before she was consuming so much wine at night she would drink herself to sleep." In other words, Kishline, who belonged to A.A. before founding M.M., had returned. Only then, it appears, did her drinking veer out of control.

Of course, it is as unfair to blame A.A. for the Kishline tragedy as it is to blame M.M. She was apparently experiencing family and financial difficulties that had thrown her life off kilter after seven years of moderate drinking. While M.M. attracted media attention, it had never provided a reliable source of income. Kishline’s husband was an itinerant businessman, and she had moved with him four times in the previous seven years. They and their two young daughters ended up living with her in-laws in a small town outside Seattle. But whatever the circumstances of Kishline’s relapse, it is a mark of ideological intransigence and intellectual dishonesty that critics such as the NCADD do not note that she was regularly attending A.A. at the time of the crash.

Kishline’s story is not just a tale of personal despair and failure. It embodies centuries of American conflict over alcohol in which teetotalers have repeatedly clashed with advocates of moderation. Having failed to impose their vision on the rest of the nation through Prohibition, the forces of abstinence nowadays focus mainly on problem drinkers, insisting that they renounce alcohol rather than try to use it more responsibly. This stubborn position overlooks substantial evidence that the sort of moderation training once advocated by Kishline can succeed where abstinence fails.

The A.A.-style abstinence approach dominates American treatment programs. A 1997 survey of private treatment centers found that 93 percent followed A.A.’s 12 steps (which include admitting that one is "powerless over alcohol") and 99 percent insisted upon abstinence. The belief that alcoholics must abstain is so ensconced in American folklore that contrary research findings tend to produce angry responses.

In 1976, a RAND Corp. study found that 22 percent of alcoholics were drinking without problems 18 months following treatment, compared to 24 percent who were abstaining. Luther Cloud, board member of the National Council on Alcoholism (the NCADD’s forerunner), claimed the RAND study would lead to "death and brain damage" among alcoholics. Yet in a four-year follow-up study, the RAND investigators found that many alcoholics continued to drink without problems. Indeed, for some categories of alcoholics, abstainers were at greater risk of relapse than moderate drinkers.

The RAND researchers simply reported on patients in federal alcohol treatment centers, all of which were abstinence-oriented. But in the early 1970s two psychologists, Mark and Linda Sobell, had published research showing that alcoholics they treated with moderation techniques fared better than alcoholics treated in a standard hospital abstinence program. In 1982 three researchers, led by psychologist Mary Pendery, published a rebuttal of the Sobells’ work in the prestigious journal Science, charging that the Sobells had misreported their data and that subjects trained to drink moderately often relapsed. The Pendery group’s accusations led to a series of investigations by the Canadian Addition Research Foundation, the U.S. Alcohol, Drug Abuse, and Mental Health Administration, and a congressional subcommittee, all of which exonerated the Sobells of wrongdoing. As a result of the investigations, the Sobells’ finding that the abstinence-trained alcoholics had more relapses was actually reinforced.

In a disturbing postscript to this episode, Mary Pendery was shot to death in 1994 by an extremely intoxicated lover who had been treated by the hospital program where Pendery had worked. This incident, which on the face of it did not reflect well on the abstinence approach, did not get anything like the attention attracted by Kishline’s crash, which was widely cited as evidence that alcoholics cannot learn to moderate their drinking and so must abstain. A closer look reveals a more complicated story.

At 43, Audrey Kishline had had a drinking problem for years. After treatment with two inpatient alcohol programs, a series of counselors, and A.A., she concluded that there was a better way. In the summer of 1993, she contacted me and several other nontraditionalists in the alcoholism field for assistance in creating her own support group.

The psychologists whose work Kishline consulted contended that there were two groups of alcohol abusers: alcoholics who display the full array of symptoms, including tolerance and withdrawal, and less severely afflicted "problem drinkers," who encounter personal, family, social, work, or legal problems due to drinking. Moderation Management was explicitly presented as a support group for "problem drinkers" who wanted to reduce their drinking to safe levels (quite low ones of, at most, nine drinks weekly for women and 14 for men). In the aftermath of the RAND and Sobell controversies, it was only with such drinkers that behavioral psychologists would dare to attempt moderation therapy, since using that approach with drinkers identified as alcoholics would have invited intense professional criticism and raised the possibility of legal liability. Even so, such psychologists deviate significantly from the disease model, which holds that even a taste of booze sets off a craving in an alcoholic that inevitably leads to excess. Instead, they view problem drinking as a learned response to stressful situations and negative feelings.

You wouldn’t think that traditional, 12-step alcoholism counselors would object to moderation for problem drinkers, since they themselves maintain that it is only real alcoholics who need to abstain. But this seeming agreement masks longstanding conflicts, because both sides say it is impossible to know for sure, before the fact, which drinkers need to abstain and which can learn to drink moderately. Thus when Sally Satel, an anti—disease-theory psychiatrist, defended moderation training in The New York Times after Kishline’s guilty plea, she undermined her own argument by saying, "The distinction between the problem drinker and the alcoholic, while not razor sharp, exists." Since the line is hard to draw, 12-step advocates argue, therapists should err on the side of caution by urging everyone with a drinking problem to abstain.

When Caroline Knapp wrote about the Kishline case for Salon, she was certain that alcoholics can never moderate, because she had tried and failed. Knapp–author of Drinking: A Love Story, which details her alcoholic degradation and redemption through A.A.–cited no research to support her claim. But what was most remarkable was how similar her language was to Satel’s. "If an individual has crossed the line, admittedly fuzzy, into alcoholism," Satel had written, "then the risks of allowing someone to have an occasional drink or two become too high." Knapp wrote, "The line between problem drinking and full-fledged alcoholism may be blurry and difficult to discern–certainly it’s difficult for the drinker to accept–but once you’ve passed a certain point in your abuse, moderation simply ceases to be an option."

The problem drinker/alcoholic dichotomy is a vague approximation of reality. Although the American Psychiatric Association classifies alcohol disorders as either "alcohol abuse" (i.e., problem drinking) or "alcohol dependence," most investigators and clinicians (especially those outside the U.S.) prefer to place drinkers along a scale, based on a combination of social problems (e.g., arrests, fights) and medical symptoms (e.g., withdrawal-induced "shakes"). According to this incremental view, the more severely dependent the drinker, the less likely moderation is–at least without the passage of substantial time.

Even that formulation is overly reductive: Several teams of researchers in the United Kingdom, for example, have found that problem drinkers’ beliefs–whether they see themselves as "powerless," for example, or whether they think a single drink will set off a relapse–influence whether abstinence or controlled drinking is the more attainable goal. In other words, the very subjective elements that American alcoholism treatment derides as "denial" can improve the chances of recovery: It is easier to achieve what you believe.

The point is not that moderation training is always better than abstinence. But even if abstinence was the right goal for Audrey Kishline, she didn’t manage it. Therapists, whatever their orientation, are reluctant to admit that most alcohol abusers relapse, and that they need training to avoid harming themselves and others when they do. For example, people can learn in therapy to call their spouse when they get drunk to make sure they don’t drive while intoxicated. By failing to develop such fallback positions, therapists and support groups are saying, in effect, "If you make a mistake, you might as well give up all restraint–taking a drink, getting drunk, and driving drunk are all equivalent."

When Kishline repopularized the idea that some people could return to nonproblematic drinking, she aroused the ire of the NCADD, which denounced the idea in a July 1995 press release. "Millions of Americans," it said, "have recently seen life-threatening stories in the media that people with alcohol problems don’t have to stop drinking completely to get better." In perhaps the high point of national media attention Moderation Management was to receive, U.S. News & World Report featured controlled drinking and M.M. in a July 1997 cover story. The article focused on problem drinkers, who it indicated were a solid majority of those with alcohol problems. Nonetheless, the director of the government's National Institute on Alcohol Abuse and Alcoholism (NIAAA), Enoch Gordis, wrote a letter to the magazine emphasizing that "persons with the medical disorder ‘alcohol dependence’" need to abstain.

The NIAAA’s own research has contradicted that position. Project MATCH was the largest trial of alcoholism treatment ever conducted. Completed in 1996, less than a fifth of the 952 alcoholics who underwent only outpatient treatment, and a little more than a third of the 774 alcoholics who had hospital treatment followed by outpatient treatment, abstained for as long as a year. So the NIAAA used a different standard of success: It emphasized that the subjects entered treatment drinking, on average, 25 days per month and 15 drinks per occasion; after treatment they drank, on average, five to six days a month and three drinks per occasion. The NIAAA in this case seemed to be endorsing controlled drinking.

In 1992 the NIAAA conducted face-to-face interviews with a representative sample of nearly 43,000 Americans, asking them about their current and past drinking practices. Of the more than 4,500 who had been alcohol dependent at some point in their lives according to the current psychiatric definition, about a quarter had entered treatment as a result. A third of those who had been treated were drinking abusively at the time of the survey, compared to a quarter of those who hadn’t been treated. Untreated alcoholics were less likely to be abusing alcohol, but they were twice as likely to be drinking without qualifying as problem drinkers or alcoholics. Abstinence was more common among alcoholics who had been in treatment, but still only a minority (39 percent) were abstaining, while 28 percent were drinking without diagnosable problems. Those who had been treated did, on average, have worse problems to begin with. But all of the drinkers in the analysis had at one time qualified for the diagnosis of alcohol dependence and would certainly have been considered in need of treatment. A plausible explanation for the finding that treated alcoholics were more likely to be drinking abusively is the all-or-nothing message taught by A.A.-style programs: When people who have undergone traditional treatment fall off the wagon, they’re convinced that it marks the beginning of a binge, which then becomes a self-fulfilling prophecy.

Thus, federal research whose size and comprehensiveness will not readily be equaled gives the lie to the principal claims of America’s treatment establishment: that alcoholics can’t recover without treatment; that alcoholics can’t reduce their drinking to nonproblematic levels; and that alcoholism treatment reliably produces abstinence.

Ignoring this evidence, abstinence-only advocates are using the Kishline case to close the small cracks that have appeared in the 12-step monolith.

This year, under medical director Alexander DeLuca, the Smithers Center in New York–founded by the late R. Brinkley Smithers, a wealthy recovering alcoholic and A.A. supporter–began to make referrals to M.M. DeLuca did not himself offer moderation treatment at Smithers. Rather, in keeping with the ethical and legal requirement of informed consent, he thought it proper to discuss alternatives such as controlled drinking with patients who were not fully committed to quitting. DeLuca still hoped such patients would ultimately decide to abstain.

Despite these nuances, in July the board of the Smithers Foundation, headed by Brinkley Smithers’ widow, Adele Smithers-Fornaci, took out a full-page ad in The New York Times attacking the reconstituted Smithers program (with which her family is no longer associated). "The seductive appeal of controlled drinking to the alcoholic will cause needless loss of life and destruction of families," the ad warned. "This is no more sadly illustrated than in the tragically ironic case of the founder of the Moderation Management program, Audrey Kishline.…Using the Smithers name in conjunction with this type of treatment is an abomination, an insult and a disgrace to the memory of R. Brinkley Smithers." Within days of the ad’s appearance, the Smithers Center accepted DeLuca’s resignation.

Bottle Battle

info@reason.com (Stanton Peele) — Fri, 01 Oct 1999 00:00:00 EDT

Since 1989, every bottle of beer, wine, and liquor sold in the United States has carried a two-part government warning that is by now almost as familiar as the bar code: "(1) According to the surgeon general, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. (2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems."

Soon you may start to notice a new sort of label on wine bottles. "To learn the health effects of wine consumption," the proposed label says, "send for the Federal Government's Dietary Guidelines for Americans." If you like to be lectured, or you simply can't get enough of the thrilling prose generated by government-appointed committees, you can get a look at the guidelines by writing to the U.S. Department of Agriculture's Center for Nutrition Policy and Promotion or by visiting its Web site; addresses for both are helpfully provided.

But Strom Thurmond would prefer that you didn't. In fact, the Republican senator from South Carolina, who sponsored the legislation that brought us the surgeon general's warnings about drinking and pregnancy, drinking and driving, and drinking and health, was said to be "absolutely furious" when he heard that the Bureau of Alcohol, Tobacco, and Firearms (BATF) planned to let wineries mention the Dietary Guidelines on their labels.

What is so subversive about the federal government's own nutritional advice? Thurmond objects to two sentences in a discussion of alcohol that is otherwise unrelentingly negative: 1) "Alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history." 2) "Current evidence suggests that moderate drinking is associated with a lower risk for coronary heart disease in some individuals."

Although both of those statements are verifiably true, Thurmond worries that acknowledging any positive aspect to drinking will contribute to alcoholism. It's the sort of attitude you might expect from a Southern teetotaler who is old enough to be a paleoprohibitionist. What's surprising is that Thurmond's position is echoed by so many people who claim to speak in the name of science and public health.

Public health may be blind to the plea-sure that people get from drinking, but a discipline aimed at minimizing morbidity and mortality has to take into account the large body of evidence that moderate alcohol consumption reduces the risk of heart disease and prolongs life. Beginning in the 1980s with the famous Framingham study, epidemiologists discovered that alcohol is good for the cardiovascular system. It combats atherosclerotic buildup in the blood vessels, which eventually results in the blockage characteristic of coronary artery disease--by far the leading killer of both men and women in this country. Because they are less prone to coronary artery disease, moderate drinkers live longer than abstainers.

Despite this discovery, public health information about alcohol in the United States continues to be almost uniformly negative. As a result, having learned about alcohol from grade school on, American students still don't appreciate the difference between hazardous and beneficial drinking. Seven in 10 high school seniors disapprove of adults having "one or two drinks nearly every day." Yet this is just the sort of drinking that is associated with greater longevity in the epidemiological studies. (Such a pattern also avoids the dangerous aspects of the drinking binges that are typical among high school and college students.)

The Dietary Guidelines for Americans, which are produced jointly by the Department of Agriculture and the Department of Health and Human Services (HHS), originally reflected the federal government's general tendency to portray drinking as something to be avoided. The 1990 edition, for example, said drinking alcoholic beverages "has no net health benefit, is linked with many health problems, is the cause of many accidents, and can lead to addiction. Their consumption is not recommended." But by 1995 (the guidelines are revised every five years), the evidence of alcohol's health benefits had become so strong that it could no longer be ignored. After considerable debate, the committee of scientists appointed to revise the guidelines decided to include the two sentences that so upset Thurmond.

Committee member Marion Nestle, chairwoman of the Department of Nutrition and Food Studies at New York University, seemed amazed that she and her allies had managed to add some balance to the discussion of alcohol. "It's a miracle, a miracle," she told The New York Times. "It is a triumph of science and reason over politics. The committee process was very contentious, but the outcome makes the fuss seem worthwhile."

Philip Lee, assistant secretary for health at HHS and a wine drinker whose father owned a vineyard, was also pleased. "In my personal view," he said, "wine with meals in moderation is beneficial. There was a significant bias in the past against drinking. To move from anti-alcohol to health benefits is a big change." Elisabeth Holmgren, director of research and education at the Wine Institute, the vintners' trade group, pronounced herself "full of joy."

For all the celebrating, the section on alcohol in the Dietary Guidelines remained daunting. It said up front that alcohol "has effects that are harmful when consumed in excess. These effects of alcohol may alter judgment and can lead to dependency and a great many other serious health problems," including increases in "high blood pressure, stroke, heart disease, certain cancers, accidents, violence, suicides, birth defects, and overall mortality." Hence the guidelines urged moderation for those who choose to drink, meaning "no more than one drink per day for women and no more than two drinks per day for men." Finally, considerable space was devoted to specifying who should not drink, including alcoholics, children and adolescents, women who are pregnant or trying to conceive, and people using prescription drugs or operating machinery.

Still, from the perspective of vintners who were eager to counter the surgeon general's warnings on their products with something positive, the new guidelines presented an opportunity. In June 1996, the Wine Institute proposed a label similar to the one that was ultimately approved. The only difference was that the Wine Institute originally referred to "the health benefits of moderate wine consumption," which the BATF thought should be changed to "the health effects of wine consumption," lest it sound like a reason to drink.

Even though the label, especially as edited by the BATF, amounted to little more than a plug for the Dietary Guidelines, a coalition of 20 health organizations attacked the Wine Institute's request. The coalition included HHS, co-author of the very document cited on the label. In July 1997, John M. Eisenberg, acting secretary for health (Philip Lee had left HHS by then), told the BATF he was "deeply concerned" that the label "would be construed by the public as encouraging the consumption of alcoholic beverages." Surgeon General David Satcher warned that it would send "mixed messages."

Seeing the labeling request as part of a general campaign by vintners to make hay over reports of health benefits from alcohol, the Center for Science in the Public Interest issued a report in October 1997 entitled "Vintage Deception: The Wine Institute's Manipulation of Scientific Research to Promote Wine Consumption." The CSPI warned that publicizing alcohol's health benefits would encourage people to drink, resulting in more alcohol-related disease and social problems.

Given its longstanding resistance to anything that could be construed as a health claim for alcoholic beverages, the BATF was probably sympathetic to this argument. But as then-Treasury Secretary Robert Rubin noted in a March 1998 letter to Thurmond, the bureau simply does not have the legal or constitutional authority to reject a label statement that is neither false nor misleading. So last February, almost two years after the initial proposal, the BATF finally approved the Wine Institute's language, along with a label from California's Laurel Glen Winery that urged consumers to "consult your family doctor about the health effects of wine consumption."

The National Council on Alcoholism called the decision "potentially disastrous." Thurmond immediately proposed legislation that would overturn the BATF's decision and transfer authority for alcohol labels to HHS. The senator considers the bureau too cozy with the industry, and he seems to believe that HHS could use stricter criteria in reviewing labels, taking into account broader health issues associated with alcohol.

But the fate of the Wine Institute's label may not matter if anti-alcohol forces are successful in deleting the positive statements about moderate drinking from the 2000 edition of the Dietary Guidelines. Many of the submissions received by the committee that is working on the guidelines offer the sort of one-sided treatment that typifies a public health establishment preoccupied with alcoholism.

Consider the recommendations of Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a subdivision of HHS. After the standard opening sentence, "Alcoholic beverages supply calories but few or no nutrients and can be addictive," Gordis proposes the line, "Individuals who do not now consume alcohol, for religious or any other reasons, should not begin to drink." Is it the government's role to advise people about religious matters? If a nondrinker changes his religious beliefs, and decides he wants to consume alcohol, why is that the government's business?

Tellingly, Gordis does not offer similar words of support for individuals whose religions condone the moderate consumption of alcoholic beverages. Indeed, he would delete from the 2000 edition of the Dietary Guidelines the seemingly noncontroversial statement that "alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history." (Though this sentence has been interpreted as a kind of endorsement, one of the scientists who worked on the 1995 pamphlet told The New York Times "it was written into the guidelines merely to justify having any language about alcohol in the first place.")

Turning to the benefits of alcohol, Gordis tries hard to minimize them. He says the coronary effects of moderate drinking are "primarily seen in men over 45 and post-menopausal women." These two groups are at the highest risk of death from heart disease, so it is not surprising that they are the two groups in which epidemiological studies find the biggest decreases in mortality. But since alcohol is believed to reduce the risk of heart disease by increasing production of HDL (the "good cholesterol"), it stands to reason that moderate drinking earlier in life would help prevent the accumulation of fatty deposits, although the impact of this effect would not be notable until later on, when people are prone to heart attacks.

Gordis also fails to note that all women with risk factors for heart disease--overweight, smoking, diabetes, high blood pressure, or high cholesterol--can reduce their chance of death by consuming alcohol. The Harvard Nurses' Health Study, the major study of the connection between drinking and mortality among women, found that about three-quarters of all subjects had at least one such risk factor and were likely to live longer if they drank moderately.

Gordis emphasizes what he calls ambiguities and contradictions in the research on the coronary benefits of alcohol. He notes that some research shows benefits from drinking can be gained from having as little as one drink every other day. And he goes on to cite dangers not only from heavier drinking but also from moderate drinking (breast cancer, for example).

Neither Gordis nor the Dietary Guidelines ever explain that a large body of persuasive evidence shows that people who drink moderately live longer. The main exception is premenopausal women with a family history of breast cancer, who should abstain or drink only very lightly. That is, when all of alcohol's potential effects are combined, alcohol is beneficial for most individuals. This would seem to be a relevant piece of information for people weighing the costs and benefits of drinking.

At a June meeting of epidemiologists in Montreal, several prestigious research organizations confirmed the link between moderate drinking and increased longevity. One of them was the Alcohol Research Group, the epidemiology center funded by Gordis's NIAAA. The group's study found that men who drank two to four drinks daily had the lowest mortality rate. If it is relevant for Gordis to tell Americans the minimum level of drinking that has been associated with prolonged life, surely it is also relevant to cite the maximum level at which benefits have been measured.

Another study finding a significant reduction in mortality, for both men and women, came from a source even closer to Gordis--the NIAAA's own epidemiology division. NIAAA researcher Deborah Dawson reported that drinkers who were not alcoholics had a significantly lower mortality rate than abstainers.

Epidemiological research is complex and evolving, but it is by now nearly indisputable that alcohol protects against death from heart disease. A large number of Americans do not follow the drinking practices most likely to help them live longer, but this more often involves abstaining than drinking too much. According to surveys, half of Americans have not had a single drink in the last month.

Yet Gordis and like-minded public health officials wish to present what we know about alcohol in the most negative light possible, rather than offering straightforward scientific information. This is consistent with a longstanding anti-alcohol tradition in America, one whose advocates once spoke in the name of religion and morality but now wear the mantle of science. The battle over how to portray alcohol in the Dietary Guidelines and whether to allow wineries to publicize, even obliquely, the benefits of moderate drinking is a battle between those who portray alcohol as an unmitigated evil and those who have a more nuanced view.

Recall that the main objection to the Wine Institute label was based on the expectation that it would foster excessive drinking. In response to that concern, HHS commissioned a survey aimed at assessing how wine drinkers would react to the proposed label language. Only 3 percent of respondents said they would be inclined to drink more. The researchers concluded that "the risk of alcohol abuse resulting from the directional labels is negligible because they will not encourage a change in consumption patterns."

If so, you may wonder, what is the point of the label? Whether or not it actually sells more wine, the industry sees it as an important public relations victory. As Wine Institute President John De Luca puts it, "the label is an essential educational component of our public policy mission to counter efforts in some quarters to mischaracterize wine as a `gateway drug' and a `sin' that warrants higher taxes, trade limitations, and advertising restrictions." It is, in other words, part of the ongoing war over alcohol's place in our society, a war that did not end with Prohibition or its repeal.

Getting Wetter?

info@reason.com (Stanton Peele) — Mon, 01 Apr 1996 00:00:00 EST

A traditional anecdote tells of a congressman who answered a constituent's inquiry about his position on whiskey: "If you mean the demon drink that poisons the mind, pollutes the body, desecrates family life and inflames sinners, then I'm against it. But if you mean the elixir of Christmas cheer, the shield against winter chill,...then I'm for it. This is my position and I will not compromise!"

Unlike this apocryphal congressman, Americans and their government have staked out strong positions on alcohol. But these positions have fluctuated wildly from era to era.

There are signs that, after several decades of anti-alcohol crusading, the United States is swinging back toward a more positive attitude. The most conspicuous indicator of this shift was the federal government's acknowledgment in its 1995 dietary guidelines that alcohol has beneficial effects. Long overdue, this recognition marks a significant change from previous government decrees on the subject. Other signs of a thawing in attitudes toward alcohol are still preliminary: Several small pilot programs in the United States are challenging the dominant approach to alcohol problems, which offers abstinence as the only cure for the "disease" of alcoholism. And leading researchers, noting that the risks of fetal alcohol syndrome have been greatly exaggerated, are questioning conventional advice about drinking during pregnancy.

These positive signs should be regarded with caution. America's ambivalence about "demon rum" is deeply imbedded in our culture. For two centuries, we have fought about the role alcohol should play in our lives. Just as we turn in one direction, forces are set in motion that pull us back the opposite way.

The colonial era was the golden age of American drinking. Americans consumed three to four times as much alcohol (mostly beer and cider) as they do today, with few social problems. Legislators drank while in session; communion wine was part of Protestant services; the tavern was a family-oriented gathering place; and tavern keepers were highly respected members of the community. There was no anti-alcohol movement in pre-revolutionary America. There were drunkards, but responsibility for excessive drinking was laid at their feet and not blamed on alcohol. The distinguished Puritan cleric Increase Mather warned against drinking too much but in the same breath referred to alcohol as "God's Good Creature."

Drinking became less benign following expansion of the United States after the War of Independence. Industrialization and the institution of regular work hours made heavy drinking less compatible with daily obligations. At the same time, the social forces that kept drinking under control in colonial America began to wane. In the fabled saloons and dance halls of the West, unlike in the family tavern, the only women present were prostitutes; drunken unruliness, fist fights, and gunplay were commonplace.

The temperance movement arose in the 19th century in response to growing problems related to drinking. Despite its name, the movement rejected the idea of moderation, maintaining that any drinking inevitably progressed to excess and ruin. Several states enacted--and repealed--alcohol prohibition. At the national level, the war between the "drys" and the "wets" translated into regional and group conflict--the South and Midwest versus the West and urban East, Protestants versus Catholics, native-born Americans versus new European immigrants.

When the nation embarked on "the Noble Experiment" of Prohibition in 1920, reactions were mixed, but there was little organized opposition to the 18th Amendment. Thirteen years later, wets and drys alike had become so disenchanted with Prohibition that few opposed repeal. The temperance promise that sin and poverty would be eliminated along with booze was simply not borne out, and the attempt to suppress alcohol consumption had brought a host of unintended costs. In the aftermath of Prohibition, drinking became acceptable once again.

But the feelings that gave rise to Prohibition remained just beneath the surface of the American psyche, and in the 1970s a new temperance movement emerged, manifested in the rapid growth of the recovery movement and Alcoholics Anonymous, of private alcoholism treatment à la the Betty Ford Center, and of government efforts to limit alcohol consumption. The United States quadrupled its hospital beds for alcoholics between 1978 and 1984, placed warning labels for pregnant women on alcoholic beverages, and made anti-alcohol education programs a staple not only for high school students but for children as young as six. Banners proclaiming that "alcohol is a liquid drug" appeared in schools nationwide, while "Just Say No" became a national slogan.

But the seeds of an opposing trend were being sown just as the new anti-alcohol movement flowered. Medical epidemiologists tracking health outcomes in large groups of people repeatedly found that abstainers suffered more heart disease than moderate and light drinkers. Since heart disease is by far America's leading cause of death, moderate drinkers had lower overall mortality rates (although mortality rates among excessive drinkers were higher than average). Such findings, which began appearing in medical journals by the 1980s, presented public health officials with a dilemma: How was it possible to tell children drinking was bad but that people who drank lived longer?

Despite much evidence to the contrary, in 1990 the dietary guidelines compiled by the U.S. Department of Health and Human Services in conjunction with the Department of Agriculture asserted that "drinking has no net health benefit." But the government faced increasing difficulty sustaining its blanket condemnation of alcohol, and the latest dietary guidelines, issued in January, announced that drinking could be beneficial. The report even went so far as to note that "alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history." The change occurred in part because additional scientific evidence appeared after the 1990 report. But the real obstacle had been cultural resistance. According to Assistant Secretary of Health Philip Lee, "There was a significant bias in the past against drinking." Marion Nestle, a guidelines committee member and chair of New York University's nutrition and food science department, said the change represented "a triumph of science and reason over politics."

Still, the revision does not represent a flip to Mediterranean-style attitudes. For one thing, the recommended daily consumption limits--one drink for women and two for men--are quite low. In Britain (hardly a Mediterranean culture), the government's "sensible drinking" limits are about twice the American levels: two to three drinks daily for women and three to four for men. Furthermore, the U.S. guidelines emphasize that children should not consume alcohol. This is far from a universal belief. In Spain, children of any age may drink beer or wine with a parent at a cafe. This is also true in New Zealand, provided a meal is being eaten. In Switzerland, children may drink on their own at 16, and in some cantons at 14. No industrial nation other than the United States restricts drinking to people 21 and older.

Forbidding drinking by children does not seem to reduce alcohol abuse. Psychiatrist George Vaillant, who tracked a group of Boston adolescents for four decades, found that Irish-Americans were seven times as likely to become alcoholic as were Italians, Greeks, and Jews. Yet the latter groups typically introduce children to alcohol, while in Irish culture children traditionally do not drink in the home.

Despite a legal drinking age of 21, youthful overdrinking is a common feature of American life. In national surveys, about half of male high school seniors and college students say they have consumed at least five drinks at a sitting in the previous two weeks. More than a third of female students say they've had four or more drinks at a time. The figure for sorority and fraternity members is 80 percent or higher. It stands to reason that teenagers who learn to drink with friends are less likely to acquire responsible habits than teenagers who learn to drink at home in a family setting.

Among other anomalous features of Irish drinking, Vaillant's Boston study found that there were more abstainers in this group as well as more alcoholics. One reason for this dichotomy was that many excessive drinkers had sworn off drinking altogether. The Italians, on the other hand, were more likely to react to a drinking problem by cutting down.

This cultural difference reflects a larger battle in American alcoholism treatment. For many years, behavioral psychologists have claimed considerable success in teaching problem drinkers to reduce their intake. A.A. members and others who subscribe to the medical model of alcoholism, including the staffs of innumerable private treatment centers, insisted that this was impossible. But in 1992, the World Health Organization announced the results of an international study of "brief interventions" in both developed and Third World countries. Brief interventions are carried out in a general health care setting, rather than at alcohol treatment centers. A physician or other health care worker inquires about a patient's level of drinking, then informs heavy drinkers about healthy levels of drinking. In subsequent visits, the doctor asks about the patient's progress in reducing his or her drinking. The WHO study found that brief interventions are substantially more effective than standard alcoholism treatment of the kind practiced in the United States. They reach more drinkers with less folderol, and they avoid the conflicts associated with reformers-cum-therapists accusing heavy drinkers of being alcoholics in denial.

Despite these promising results and some success at offering controlled drinking as an alternative in pilot programs at several American universities, the U.S. alcoholism treatment industry is not likely to wither away any time soon. For the foreseeable future, recovering alcoholics and expensive private hospitals will continue to hold sway over how Americans deal with problem drinkers.

Another manifestation of temperance-movement thinking is the advice given to women about drinking during pregnancy. Predictably, the 1995 U.S. dietary guidelines confirm the instruction that appears on every bottle of beer, wine, and liquor: "According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects."

Americans started hearing about the dangers of fetal alcohol syndrome (FAS) beginning in the 1980s. But subsequent investigations have revealed that FAS is exceedingly rare, even among alcoholic women. In 1995, Ernest Abel, a pioneering FAS researcher at Wright State University, performed a meta-analysis of 59 studies in various countries that looked at the relationship between maternal drinking and birth weight. Not only was there no evidence that light drinking harmed the fetus, but mothers who consumed up to one drink per day actually had heavier babies than mothers who abstained. (However, pregnant women who average two drinks a day tend to have lighter babies.) Those findings led Abel to question the wisdom of public health efforts to discourage all women from drinking during pregnancy. Once again, the evidence does not support an official U.S. health proclamation about alcohol.

American attitudes toward alcohol are aberrant even when compared to those of cultures, such as Britain and Scandinavia, that share elements of the temperance tradition. Consider: Among the NATO soldiers in Bosnia, only the Americans are forbidden to drink. According to TheNew York Times, "the Norwegian soldiers here can drink in moderation, as can the French, the Danes, and the British." Apparently, other nations accept the logic that adults who are allowed to fly large aircraft and fire heavy artillery can also be trusted to consume alcohol moderately. We do not. But then, the Danes, French, British, and Norwegians have never enacted national prohibition.