The Stanton Peele Addiction Website, January 6, 2010.

When the Sheriff Gets Into Town

Loran Archer was co-director of the National Institute on Alcohol Abuse and Alcoholism when the Rand Reports were published in 1976 and 1980. The second, four-year Rand follow-up was particularly hard on disease advocates since it found that – among a highly dependent government-treated population – safe drinking resolutions were as stable as abstinence – more so for some sub-groups!

Archer and the NIAAA’s director, John DeLuca, set about reinterpreting the research. This provoked a response from the authors published in an article by Jane Brody in the NY Times (January 29, 1980), along with Archer and DeLuca’s rejoinders:

The directors of the alcohol institute ... readily acknowledged their 'honest differences' with the scientists in interpreting their findings. The Rand Researchers, in turn, have expressed dismay with what they see as a distorted interpretation of their findings ... Mr. Archer said that he was strongly committed to the philosophy that total abstinence was the only sure path to recovery from alcoholism. Mr. DeLuca questioned whether any alcoholic who could safely return to drinking had been an alcoholic to begin with.

Archer is still around, and participates on the Kettil Bruun Society Listserv. His axe nowadays is to reinterpret the NESARC research findings that the majority of alcohol-dependent Americans moderate their drinking, and that the number of down-and-out, AA-type alcoholics is fewer than 1% of the population, while about a quarter of Americans have different kinds of drinking problems, generally self-ameliorating.

Eventually, I got tired of Loran’s incessant blathering, and wrote the following:

When the sheriff gets into town

Dear Loran,

I have bad news (but who better to hear it from than me?). That old alcoholism rap we’ve been laying down for decades? – the one that never worked but which has become increasingly useless? – you need to get out of town before the sheriff catches you! (You remember what happened to the Duke and the Dauphin in Huckleberry Finn when they got caught pulling that Royal Nonesuch scam!)

Let’s return to the beginning. A bunch of guys sitting around in church basements found that they had all had similar experiences with alcohol. A guy named Jellinek wrote their shared experiences and vision of alcoholism down – et voilà! – a movement was born. For a lot of reasons, it grew like wildfire, and became imprinted on the nation’s consciousness.

But, from the start it had problems. After all, how many people end up in church basements – I mean of all of those who ever had a drinking problem? And these – let’s call them “indelicacies” - began to be evident when they started conducting systematic research on drinking problems beginning in the late 1960s and early 1970s.

But before getting into that, the binary model of alcoholism – this distinct thing called alcoholism that some people had and never lost, and that others just as clearly never had – you remember, like the old analogy to pregnancy? That was actually a failure from the start.

In the first place, it led to lousy policies. If alcohol problems were due to just a small minority of Americans who were alcoholics, then everyone else could drink freely, with no worries! But there was all that mayhem college students and sailors and other young men got into, there was drunk driving, there were accidents under the influence – you see how unhelpful an either-or concept of alcoholism was for handling these?

Then there was clinical practice. If there were alcoholics and everyone else, and you were born alcoholic and always stayed that way, and the only solution was to quit drinking permanently – well you missed people who had drinking problems but who didn’t qualify as alcoholics, you didn’t treat people’s life problems aside from their drinking, and – then – really all you had in your tool kit were exhortations to quit drinking and never to go back to it – and you know how well that worked! (Remember Huck’s Pap, who swore a holy vow never to drink again but snuck out in the middle of the night, got drunk, and nearly killed himself climbing back into the house?)

But it was those darn epidemiologists (you know, the ones who used to be called sociologists who did population or community studies) who really muddied the clear “either you is or you ain’t” picture we all loved so well. It began in Berkeley (what commies they had there!) with Cahalan and Room’s work with the Alcohol Research Group.

Why, those guys wouldn’t know an alcoholic if he sat bolt upright in front of them and bit them on their noses! They kept finding people shifting into and out of drinking problem periods. Thank goodness nobody understood what they were talking about or paid any attention to them! (Except for claiming however many people they said had drinking problems were actually alcoholic Americans.)

But then came those pesky Rand researchers. What a pain they were! Using government money to study alcoholics treated in public treatment centers, they painted pretty much the same picture as Cahalan and Room did! You know – in and out of “alcoholism” – with an overall trend towards improvement with time and age?

I know – you and DeLuca did everything in your power to stamp that stuff out before it caught on. Why, you simply referred everyone back to the old alcoholism model everyone already knew was true! As your dance partner DeLuca proclaimed – if they drank safely then they were never really alcoholics in the first place – even if they had a median drinking level of 17 drinks daily when they entered those treatment centers! You see, you’re either a lifetime alcoholic or you’re not – like we’ve already been over.

Well, that died down – although it took some quick thinking from you and John to douse it when they reappeared with the four-year follow-up study maintaining the same seesawing back and forth of alcoholism with general improvement and substantial controlled drinking.

I thought we were home safe when what does the stupid NIAAA do after you and John left for greener pastures? They conduct their own national survey of drinking histories, called it NLAES, whatever the heck that is, and darned if it doesn’t paint the same picture as Cahalan and Room and the Rand studies. Most alcohol dependent people get better over time – including a majority who don’t quit drinking!

Oh, I need to back up and explain that they used this classification system from something called DSM-IV. Why those fools didn’t even have the horse sense to call alcoholism “alcoholism.” No, they had to divvy problems into two categories – dependence and abuse. More than that, there were these dependence symptoms which could be totaled to rate people’s level of dependence. (Like you can be more or less pregnant, remember?)

Okay, back to NLAES. So among a massive random sample of Americans, most alcoholics (ahem, I mean people who were ever “alcohol dependent”) – about three-quarters – weren’t treated. And get this – most remitted not only without treatment – but without abstaining! If that don’t beat all!

But, once again, we beat that rap – I mean, how many people heard of or cared about NLAES? But then they repeated essentially the same study – called it NESARC – except they had additional follow-up to make sure that the still-drinking no-longer-alcohol-dependent people showed actual life improvements (they did, sometimes more than abstainers!). And still the same three-quarters were untreated, while the majority of remitters were drinking safely.

What is going on here! Because, for the first time, the NIAAA actually promoted the NESARC results, reported them loud and clear, said we needed to have a new understanding of alcoholism!

But not for you and me, Loran. Look, here’s the plan – whenever they claim that only a tiny minority of alcoholics look like those guys in the church basement, then you start hee-hawing like a donkey – you remember, like we did in the Royal Nonesuch – say it ain’t such a tiny minority – it’s a little minority.

And when they say that alcoholics can resume moderate drinking – here’s how we’ll foul them up. We’ll say, “Alcohol dependence ain’t alcoholism. Only some of those alcohol dependents are alcoholics” – which ones? – we’ll pull a DeLuca on them – the ones who couldn’t or didn’t reduce their drinking. (Did I ever tell you about that pregnancy line you can use?)

Now, here’s our gimmick. You can never draw a line through those dependence symptoms and just say, “Above this is alcoholics, below this is – well – non-alcoholics.” No, its just ain’t that simple. Sure, more dependent drinkers are less likely to become safe drinkers – but that rule’s got more exceptions to it than there are flies in a stable. I mean, it’s only a probabilistic model, and a multivariate one at that – where all other kinds of factors figure in. (Where the hell did I come up with that?)

But you’ll just wave your hands around like there is some hard line – you remember, like DeLuca used to do. You can handle it, Loran. Cause, as for me – well, I’ve been thinking of going over to other side. It ain’t so bad, really. Why, I can even spell “epidemiology” now, and “stochastic” modeling. How? Well let me get back to you on that.

But, in the meantime, you carry on. Just watch out for a guy wearing a badge asking to see where you draw the line, and how it’s really like back in the old days, when an alcoholic was an alcoholic, for all of that, and nobody dared question you when you jumped them ponies through their hoops and cracked your whip.

See you later, Loran.

[Note: no intoxicating substances – either licit or illicit – were used in the preparation of this post.]