Saturday, December 26, 2020


From Aviation-Medical Bulletin October 2020

You know full well that all kinds of soda — diet or not —  aren’t exactly good for you. But, thanks to a growing pile of damning evidence, it’s becoming increasingly clear that sugar-sweetened and diet sodas are about the worst things you can put in your body. While soda sales have slipped over the past decade, total consumption of sugar-sweetened sodas is still double what it was in the 1980s, with half of all Americans today drinking them regularly.

Here are a few reasons that are such a frightening statistic.

Your Body Thinks It's Water

A 20-ounce Coke has 240 empty calories, slightly more than a whole pack of Skittles. Both are horrible for you, but you’re better off eating the candy because at least your body will register that you’ve eaten. When you chew food, it takes time, and your body and brain acknowledge the act of eating. But, you can drink a whole meal’s worth of calories and your body won’t even realize it.

It’s like it never happened.

In fact, your body will just assume you’ve guzzled water. If you drink a soda right now, your body will treat it like water, and 30 minutes later you’ll be just as hungry as if you hadn’t consumed all those calories.

It Puts You on the Fast Track for Diabetes

One soda a day is all it takes to crank up your Type-2 diabetes risk by 26 percent. Each additional sugary drink you consume can increase your odds by another 18 percent. When such large amounts of glucose and fructose are absorbed so quickly, the glucose tells the body to secrete insulin to buffer the blood-sugar surge. If you drink soda daily, your pancreas will eventually wear out. Meanwhile, the fructose from soda gets stored in the liver as fat. The combination of overworking your pancreas and slowly developing fatty liver disease contributes directly to diabetes, as well as heart disease.

Here’s more incentive to kick the can: By replacing your daily vice with water, coffee, or unsweetened tea, you can lower your diabetes risk by 14 percent.

Nothing Is Worse for Your Teeth

Besides supplying loads of sugar for cavity-causing bacteria to feast on, soda is laced with acid, which erodes tooth enamel. That, in turn, causes cavities and decay.

Death by Sugar

Earlier this year, researchers singled out sugar-sweetened beverages as the likely culprit in a huge number of chronic disease-related deaths worldwide. They estimate that in 2010, sugary drinks may have led to 133,000 deaths from diabetes, 45,000 from heart disease, and 6,450 from cancer — a total of 184,000 deaths.

It Ages You as Much as Smoking

Swigging one 20-ounce bottle of sugary soda a day can age you an additional 4.6 years — the same as smoking cigarettes. A recent study revealed that, regardless of their actual age, daily soda drinkers had older white blood cells than people who occasionally or never consumed soda. This type of accelerated cell aging has been tied to shorter lifespans and chronic diseases like diabetes and cancer.

It's Easier to Find (and Cheaper) Than Just About Any Food

Adjusting for inflation, fruits and veggies cost 35 percent more today than 30 years ago. Soda, on the other hand, costs 35 percent less. And, with a “steal of a deal” like a 64-ounce Big Gulp, you’re talking pennies in 2015, even compared to those 6.5-ounce glass bottles served at diners decades ago. Besides being cheap, soda is now everywhere. What used to be gas stations are now junk food outlets with walls of soda.

You see soda at every store checkout, all throughout the airport, and in parking structures. The world we live in today is constantly giving us cues to drink more and more of this garbage.

Diet Soda Is No Better for You

Even though diet soda has zero calories, it’s really no better for you than regular soft drinks.

People who drink diet in hopes of losing weight will not, and we see more diabetes and obesity among diet soda drinkers than people who don’t drink it. The million-dollar question is why.

Experts are still wrestling over whether artificial sweeteners trick your body into thinking they’re sugar so it processes them the same way, or if the cloying taste of these faux sugars makes you crave more sweet stuff later. Another thought is that diet soda drinkers, thinking they can afford the calories, are more likely to order fries than a side salad.

Monday, November 30, 2020

Keeping Male Bodies Out of Women’s Rugby

Linda Blade, ChPC, PhD Kinesiology, is a sport performance coach. She tweets at @coachblade.
September27, 2020

From November 2015 until February 2020, World Rugby, rugby’s global governing body, incorporated guidelines established by the International Olympic Committee (IOC) on transgender participation in sports. According to these rules, males who wish to self-identify into women’s rugby could do so if they committed to reducing their testosterone levels to 10 nmol per liter or lower for at least 12 months. (The average level for men is about seven times that level.)

During this period, instances of biological males playing in the women’s game increased, and some participants began to express alarm. One rugby referee posted on the website Fair Play for Women, for instance, that “being forced to prioritize hurt feelings over broken bones exposes me to personal litigation from female players who have been harmed by players who are biologically male. This is driving female players and referees out of the game.” Another wrote, “I volunteer my time to officiate matches because I love my sport. But I won’t continue much longer if I have stay quiet about the unfairness I see on the pitch or risk abuse by getting called transphobic if I turned a player away.” A chairperson of one UK rugby club expressed shock upon discovering that, as she reported, “If anyone suspects someone on the opposing team might have an advantage because they are transgender, ‘they must not ask.’ They must simply accept that all teams will be ‘complying with the rules.’”

In some cases, female rugby players and their coaches would show up to matches to discover that there was a biologically male athlete playing on the opposing team. As one player put it, “I have to play or forfeit my place even when I know it’s unsafe for me.” Those who enjoyed the advantage of having a trans-identifying player on their team, on the other hand, were sometimes found to be lacking in sympathy. On one occasion, a team captain was quotedas saying that their male-bodied player had “folded an opponent like a deck chair.”

With worries mounting about safety—especially concussions—and financial liability, World Rugby undertook a review of its transgender policy in February 2020. This might seem to be a common-sense step. Yet among global sports federations, it was actually seen as a ground-breaking moment. World Rugby turned out be the first sport to bring to the table experts on all sides of the eligibility issue, including sociologists, biologists, kinesiologists (my own specialty), and those with a background in human rights. The consultation is reported to have been respectful and thorough. All relevant opinions were heard.

The dominant view that emerged from this summit was that World Rugby would have to amend its policy. It was simply too risky to continue to allow male bodies into the women’s game. The decision-makers relied on data that had been published by the renowned Karolinska Institute (Sweden) in September 2019. Even after a full year of hormonal reduction in accordance with IOC guidelines, the researchers concluded, there was no appreciable loss of mass, muscle mass, or strength in transitioning males. In physical terms, it was just a man playing with women.

World Rugby had to come to terms with reality: Irrespective of hormonal intervention, male athletes are, on average, 40 percent heavier, 15 percent faster, 30 percent more powerful, and 25–50 percent stronger than their female counterparts. And these differences pose obvious risks for female players in full-contact rugby. World Rugby’s new policy document has not yet been made public. But according to those who’ve seen it (and the various media leaks), the organization is proposing a comprehensive ban on biological men in the women’s sport—though these recommendations won’t become official policy until they are reviewed and voted upon by the World Rugby Council later this year.

Women’s rugby isn’t a particularly popular mass-participation sport. But because World Rugby’s proposal, if enacted, would represent one of the first big cracks in the dam for those who insist trans-identified males should be allowed to compete with women, the case has attracted plenty of lobbying. The Canadian Women’s Sex-Based Rights group (CaWsbar), for instance, sent a letter to CEO Brett Gosper, thanking World Rugby for becoming “the first world sports federation to have undertaken a thorough and balanced review of the 2015 International Olympics Committee consensus.” Social-media commentary has been abundant. Even my own little August 20th tweet urging readers to send their appreciation to World Rugby generated (what was for me) unprecedented public support (and, notably, scant pushback).

Activist groups opposed to any reconsideration of the IOC’s rules, on the other hand, put out statements—many of them picked up by the press—with headlines suggesting that World Rugby was implementing a “ban” on trans athletes. In fact, no one would be “banned” under the proposal. Athletes would simply be required to compete with athletes of their own sex, as had been the case in rugby, and numerous other sports, until very recently.

Some observers may be tempted to conflate World Rugby’s proposal with the controversy surrounding elite runner Caster Semenya, which was the subject of a recent decision by Switzerland’s Federal Supreme Court. Under World Athletics guidelines introduced in 2019, which were subsequently upheld by the Court of Arbitration for Sport, Semenya would be allowed to compete in long-distance running events only if she agreed to take testosterone-reducing drugs, a condition that Semenya opposes. But that case is distinct, because Semenya is one of a small number of people who exhibit differences of sexual development (DSD)—“a group of congenital conditions associated with atypical development of internal and external genital structures,” as experts define it. The trans rugby players who seek to participate in women’s leagues, on the other hand, are simply biological males who have changed their pronouns and social identity.

Nevertheless, both situations highlight the tension that exists between biological determinants and human-rights claims when it comes to access to women’s sports. And in both cases, there are at least two clear lessons: (1) sports federations should assert their authority to set their own eligibility guidelines; and (2) the sooner a governing body asserts such boundaries, the better. Once opportunists have taken advantage of a lax regulatory regime, they will do everything in their power to resist change. And they will have the media on their side, because they will be able to present themselves as victims.

A decade ago, prevarication and a lack of corporate discipline by World Athletics—then known as the International Amateur Athletic Federation (IAAF)—resulted in a decade of unnecessary upheaval in the sport of athletics (which includes a broad range of pursuits, including track and field). Semenya had only recently broken onto the scene as a junior athlete, and already had demonstrated performance levels that were raising eyebrows. After failing to make the 800m finals at the 2008 World Junior Championships (with a time slower than 2:04), Semenya finished the 2009 season as reigning World Champion in the senior women’s division, with a time that was almost nine seconds faster. This kind of quantum-leap improvement isn’t normal, and the IAAF had no choice but to investigate.

Notoriously, this included a humiliating sex-verification test. It was supposed to be private, but somehow the information leaked. In the ensuing uproar, the IAAF chose to clear Semenya in 2010 without really dealing coherently with the results of the test. In one statement, it was announced that, “The IAAF accepts the conclusion of a panel of medical experts that she can compete with immediate effect.” In another, the general secretary said: “She is a woman but maybe not 100 percent.” Needless to say, this sort of comment set off lurid speculation about Semenya’s biology. So while Semenya continued to run, accumulate accolades, and win races, there was a cloud of suspicion that affected spectators and fellow runners. This is exactly the sort of protracted and degrading process that World Rugby can avoid by acting decisively.

What saddens me as a Canadian, someone who has long worked within the sports sector as both coach and provincial sport-association president, is the official response from Rugby Canada, which I had hoped would have endorsed the commitment made by World Rugby to “work with relevant groups to explore appropriate participation pathways for transgender athletes.” Placing male athletes in with female players for full-contact rugby isn’t the only option available for trans rugby players. There could very well be safer alternatives, if organizations such as Rugby Canada were interested in exploring them.

Instead, Rugby Canada used its voice to channel the opinions of one-note gender activists. Its official statement, released in early September, declared that the proposed new World Rugby rules “are not policy that can or will be adopted should they move forward.” Rugby participation in Canada, the organization said, would continue to be guided by the existing Trans Inclusion Policy, which states that players “should be able to participate as the gender with which they identify and not be subject to requirements for disclosure of personal information beyond those required of cisgender athletes. Nor should there be any requirement for hormonal therapy or surgery.” That’s right: The policy is pure, no-questions-asked self-identification. The only reference to safety in the entire document relates to the suggestion that someone might not feel “safe” if his “gender identity and gender expression” weren’t respected.

It seems to me that Rugby Canada can ill afford to posture against biological reality. It was only two years ago that a young man named Brodie McCarthy died as a result of a head injury suffered in a rugby tournament. Five years before that, it was a women’s team captain, Rowan Stringer, a 17-year-old from Ottawa, who died from a blow to the head during a game. In response, Ontario passed Rowan’s Law, requiring all youth sports, whether at the club or school level, to observe strict safety protocols pertaining to head injury and concussions. Canada’s federal government extended the movement nationally by developing its own public health advisory on the dangers of concussion. The advisory specifically identifies rugby as one of three especially dangerous sports: “Ice hockey, rugby and ringette are the sports with the highest proportion of brain injuries among children and youth 5–19 years of age, ranging from 27 percent to 44 percent of all injuries that happened while playing these sports.” Now imagine how much more dangerous it is for women who face men on the rugby pitch.

This month, British trans activist groups have been scrambling to update their policies to accord with new British government rules that prohibit schools from using materials that encourage children to question whether they are in the “wrong body.” These groups are doing this because failing to do so will now have legal and financial implications. Gender clinics, moreover, are now starting to get sued for recklessly transitioning children on the basis of flimsy or non-existing health science. And rightly so: Those who put women, children, and other vulnerable populations at risk for ideological reasons must face the legal consequences. One can only hope that Rugby Canada, and its counterparts all over the world, come to understand this before someone gets hurt—or goes bankrupt.

Friday, November 27, 2020

Association between physical exercise and mental health

Chekroud, Sammi R, Ralitza Gueorguieva, Amanda B Zheutlin, Martin Paulus, Harlan M Krumholz, John H Krystal, Adam M Chekroud. Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross-sectional study. The Lancet:Volume 5. September 2018.


Background Exercise is known to be associated with reduced risk of all-cause mortality, cardiovascular disease, stroke, and diabetes, but its association with mental health remains unclear. We aimed to examine the association between exercise and mental health burden in a large sample and to better understand the influence of exercise type, duration, and intensity.



In this cross-sectional study, we analyzed data from 1,237,194 people aged 18 years or older in the USA from the 2011, 2013, and 2015 Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System survey. We compared the number of days of bad self-reported mental health between individuals who exercised and those who did not, using an exact non-parametric matching procedure to balance the two groups in terms of age, race, gender, marital status, income, education level, body-mass index category, self-reported physical health, and previous diagnosis of depression. We examined the effects of exercise type, duration, frequency, and intensity using regression methods adjusted for potential confounders, and did multiple sensitivity analyses.



Individuals who exercised had 1.49 (43·2%) fewer days of poor mental health in the past month than individuals who did not exercise but were otherwise matched for several physical and sociodemographic characteristics (W=7.42 ×10¹⁰, p<2.2 × 10–¹⁶). All exercise types were associated with a lower mental health burden (minimum reduction of 11.8% and maximum reduction of 22.3%) than not exercising (p<2.2 × 10¹⁶ for all exercise types). The largest associations were seen for popular team sports (22.3% lower), cycling (21.6% lower), and aerobic and gym activities (20.1% lower), as well as durations of 45 min and frequencies of three to five times per week. 



In a large US sample, physical exercise was significantly and meaningfully associated with self-reported mental health burden in the past month. More exercise was not always better. Differences as a function of exercise were large relative to other demographic variables such as education and income. Specific types, durations, and frequencies of exercise might be more effective clinical targets than others for reducing mental health burden, and merit interventional study.

Friday, November 13, 2020

How’s this Sound?

We’re putting together a new program designed to grow our participation and audiences. Over the span of the next several weeks, I’m going to run some ideas up the flag pole. 

While in Irving last month, I had a lot of quality time with many of the WCXXIX attendees. Here’s the first idea: The Significant Other Tandem. 

This concept has been kicked around in past few years. Now’s the time to formalize the event. I spoke with some of our competitors who were very enthusiastic about the idea. 

What we need is a protocol. Exactly what does this look like? We want to integrate the wives and/or girlfriends; but exactly how. Perhaps they do the hose advance?

A lot of these women have called themselves “Challenge Widows.” But why not raise the ante and give them a shot at getting out on the course. 

What is critical to our success is raising the entertainment level and thereby keeping more people in the seats. The Relay category, by far, is the most entertaining of all the races. Especially in the last heats. Bob Ramsey, our venerable long-term announcer from the ESPN days says “I can call a race between two turtles and make it exciting as long as it’s close.”

I’d like to see us as an attractive entertainment event at major functions such as fairs and festivals. This may take on the form of an “audition” or qualification, clinic, or trials first day, followed by the Main Event, or the Big Show on the second day. 

Following this paradigm, the Relay categories could be sorted into multiple Flights, based upon finish time. In a recent luncheon meeting with one of the legacy teams, they remarked that they were just getting to the dummy when the opposing team was turning in their Air-Paks. “It’s humiliating.” 

I’d like to hear from you; via email or phone call. 

You can leave a message on my 24hr Voice Mail: 301.421.4433 x 104. 

Or, send me an email to

Friday, November 6, 2020

COVID-19 reveals how obesity harms the body in real time, not just over a lifetime

Cate Varney 
November 6, 2020, 8.31am EST 

The COVID-19 pandemic has thrust the obesity epidemic once again into the spotlight, revealing that obesity is no longer a disease that harms just in the long run but one that can have acutely devastating effects. New studies and information confirm doctors’ suspicion that this virus takes advantage of a disease that our current U.S. health care system is unable to get under control. 

In most recent news, the Centers for Disease Control and Prevention reports that 73% of nurses who have been hospitalized from COVID-19 had obesity. In addition, a recent study found that obesity could interfere with the effectiveness of a COVID-19 vaccine. 

I am an obesity specialist and clinical physician working on the front lines of obesity in primary care at the University of Virginia Health System. In the past, I often found myself warning my patients that obesity could take years off their life. Now, more than ever, this warning has become verifiable. 

More damage than believed 
Initially, physicians believed that having obesity increased only your risk of getting sicker from COVID-19, not your chance of being infected in the first place. Now, newer analysis shows that not only does obesity increase your risk of being sicker and dying from COVID-19; obesity increases your risk of getting infected in the first place. 

In March 2020, observational studies noted hypertension, diabetes, and coronary artery disease as the most common other conditions – or co-morbidities – in patients with more severe COVID-19 disease. But it was the editors of Obesity journal who first raised the alarm on April 1, 2020, that obesity would likely prove to be an independent risk factor for more severe effects of COVID-19 infection. Additionally, two studies including nearly 10,000 patients have shown that patients who have both COVID-19 and obesity have a higher risk of death at days 21 and 45 compared to patients with a normal body mass index, or BMI. And a study published in September 2020 reported higher rates of obesity in COVID-19 patients who are critically ill and require intubation. 

It is becoming overwhelmingly evident from these studies and others that those with obesity are facing a clear and present danger. 

Stigma and lack of understanding 
Obesity is an interesting disease. It is one that many physicians talk about, often in frustration that their patients cannot prevent or reverse it with the oversimplified treatment plan that we have been taught in our initial training; “Eat less and exercise more.” 

It is also a disease that causes problems physically, such as sleep apnea and joint pain. It also affects one’s mind and spirit due to societal and medical professionals’ bias against those with obesity. It can even adversely affect the size of your paycheck. 

Can you imagine the outcry if the headline read “Patients with high blood pressure earn less”? We doctors and researchers have understood for quite some time the long-term consequences of excess weight and obesity. We currently recognize that obesity is associated with at least 236 medical diagnoses, including 13 types of cancer. 

Obesity can decrease one’s lifespan by up to eight years. Despite knowing this, U.S. physicians are not prepared to prevent and reverse obesity. In a recently published survey, only 10% of medical school deans and curriculum experts feel that their students were “very prepared” in regards to obesity management. Half of the medical schools responded that expanding obesity education was a low priority or not a priority. An average of 10 hours total was reported as dedicated to obesity education during their entire training in medical school. And doctors sometimes don’t know how or when to prescribe medications for patients with obesity. 

For example, eight FDA-approved weight loss medications are on the market, but only 2% of eligible patients receive prescriptions for them from their physicians. 

What goes on in the body 
So, here we are, with a collision of the obesity epidemic and the COVID-19 pandemic. And a question I find patients asking me more and more: How does obesity create more severe disease and complications from COVID-19 infection? 

There are many answers; let's start with structure. Excess adipose tissue, which stores fat, creates a mechanical compression in patients with obesity. This limits their ability to take in and completely release a full breath of air. Breathing takes more work in a patient with obesity. It creates restrictive lung disease, and in the more serious cases, lead to hypoventilation syndrome, which can cause a person to have too little oxygen in their blood. And then there is function. 

Obesity results in an excess of adipose tissue, or what we colloquially call “fat.” Over the years, scientists have learned that adipose tissue is harmful in and of itself. One may say that adipose tissue acts as an endocrine organ all its own. It releases multiple hormones and molecules that lead to a chronic state of inflammation in patients with obesity. When the body is in a constant state of low-grade inflammation, it releases cytokines, proteins that fight inflammation. They keep the body on guard, simmering and ready to fight disease. That’s all well and good when they are kept in check by other systems and cells. When they are chronically released, however, an imbalance can occur that causes injury to the body. 

Think of it like a small but contained wildfire. It’s dangerous, but it’s not burning the entire forest. COVID-19 causes the body to create another cytokine wildfire. When a person who is obese has COVID-19, two small cytokine wildfires come together, leading to the raging fire of inflammation that damages the lungs even more so than patients with normal BMI. Additionally, this chronic state of inflammation can lead to something called endothelial dysfunction. In this condition, instead of opening up, blood vessels close down and constrict, further decreasing oxygen to the tissues. 

In addition, increased adipose tissue may have more ACE-2, the enzyme that allows the coronavirus to invade cells and begin to damage them. A recent study has shown an association of increased ACE-2 in adipose tissue rather than lung tissue. This finding further strengthens the hypothesis that obesity plays a major role in more serious COVID-19 infections. So in theory, if you have more adipose tissue, the virus can bind to and invade more cells, causing higher viral loads that stay around longer, which can make the infection more severe and prolong recovery. 

ACE-2 can be helpful in counteracting inflammation, but if it otherwise bound to COVID-19, it cannot assist with this. 

The novel SARS COVID-19 virus has forced the medical profession to face the reality that many U.S. physicians inherently know. When it comes to prevention of chronic diseases such as obesity, the U.S. health care system is not performing well. Many insurers reward physicians by meeting metrics of treating the effects of obesity rather than preventing it or treating the disease itself. 

Physicians are reimbursed, for example, for helping patients with Type 2 diabetes to attain a certain A1C level, or a set blood pressure goal. I believe is time to educate physicians and provide them with resources to combat obesity. Physicians can no longer deny that obesity, one of the strongest predictors for COVID-19 and at least 236 other medical conditions, must become public enemy number one.

Incase You Missed Irving This Year

This a year that we’ll long remember, but hope to forget. The YouTube webcast gave you a bird’s eye view. But, here’s a special feature, done by the City of Irving that capsulates capsulated the shortened, four days of competition.

Saturday, October 24, 2020

You Sorta Have to be Here...World Challenge XXIX

Day 1 with Sunshine
This has been a weird year- to say it mildly: it sucked. 

But the light at the end of the tunnel was never brighter than the parking lot of the Dallas Light Rail terminal in Irving. 

Hard to capture the buoyancy of a bunch of incredible fire-athletes whose bravery need not be shown in any other way. Going in harm’s way for the past 9 months, this incredible crew of First Responders has cheated death many times over.

Virtually every man and woman have dug deep into their personal finances to be here. Best characterized as a family reunion that’s taking place at a sports event, old and new friends share the common bond of doing what is hard and dangerous, faster, safer, and better. 

A 40°F temperature drop and gale-forced winds created minor damage but had absolutely no diminution in the spirit of our athletes.  

The public needs to see this and express thanks for this incredible cohort who respond without hesitation; who don’t ask for your credit card before turning out to help fix a day that’s not exactly going well. You call, we come, no questions asked but “where.”

A heart-felt to all of our sponsors, without their support this event would not be possible.

If you’re reading this as the event is taking place, (Thursday, Oct 21 through Sunday, Oct 24) go to www.FFCC.TV and click on Live.

Tuesday, October 20, 2020

The Early Days of Fitness in the Fire Service (circa 1976)

Rare Photo of Rule in Uniform
When I read the biography for Charley Rule, in the class of 2021 (Hall of Legends) I thought as perhaps one of his living contemporaries there needed to be more content. In 1976, I was a faculty member at the University of Maryland’s Sports Medicine Center. We had just finished a major research project where the City of Alexandria had made a significant contribution by supporting our efforts with career firefighters who were participants in a work-simulation and laboratory-based fitness assessment. It was Chief Rule who saw the value and took it two steps further. 

Alexandria would be the first fire department outside of Los Angles to organize a structured fitness program for all uniformed personnel. Prior to the kickoff, Chief Rule and I traveled to every battalion and conducted briefings, and took questions from members of the department. Right from the horse’s mouth, he tamped down the paranoia that this was not a program to get people fired, but rather to live long and longer, collecting your length-of-service pension. 

The Fitness Coordinator for the program was Lt. Jack Beam (who would later rise to the Fire Chief’s position). Jack had studied the early-retirement data and found everyone was a smoker. “Wouldn’t it make sense to require firefighters not to use tobacco?“ 

Virginia, a tobacco state- well you could imagine the push back from the Tobacco Institute, just 90 miles down I-95. Charley was convinced this was the right thing to do. We met with the City Attorney and he concurred. 

James Califano, the then Secretary of HEW, conducted a press conference at City Hall. The Washington Post covered the event under the headline: Rules’s Rule. Today, no smokers can be found in any of the fire departments in the greater Washington DC area. 

Charley was a non-uniform wearing, (perhaps the only phot of Charley in uniform: see link above) cerebral kind of guy who shunned a lot of traditions. During the discussion and planning phase of the rollout of the new program, he asked me about pipe smoking, I told him that he was fooling himself if he thought that he was reducing his cancer risk. He quit cold turkey. 

Our UoM staff conducted individual fitness assessments on every uniformed member of AFD. Each firefighter was provided a “Fitness Report Card” with bar charts showing their scores for aerobic fitness, muscular strength and endurance, and body composition. We would interpret the data and make recommendations for improvement. Jack Beam was patiently explaining to one firefighter how he could bring some of his sagging scores up to meet the demands of the job. 

When Jack was attempting to garner support, the guy looked at him and said, “That’s easy for you to say, you work out.”

Saturday, October 17, 2020

The Irrationality of Alcoholics Anonymous

(THIS is a long article, but one of the best on the subject of alcohol dependence. You might want to share this with others interested in the topic. The original link is: Atlantic 

The Irrationality of Alcoholics Anonymous
Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked central tenets of AA doctrine and found dozens of other treatments more effective.

Gabrielle Glaser is the author of Her Best-Kept Secret: Why Women Drink—And How They Can Regain Control.
Dan Saelinger

J.G. is a lawyer in his early 30s. He’s a fast talker and has the lean, sinewy build of a distance runner. His choice of profession seems preordained, as he speaks in fully formed paragraphs, his thoughts organized by topic sentences. He’s also a worrier—a big one—who for years used alcohol to soothe his anxiety.

J.G. started drinking at 15, when he and a friend experimented in his parents’ liquor cabinet. He favored gin and whiskey but drank whatever he thought his parents would miss the least. He discovered beer, too, and loved the earthy, bitter taste on his tongue when he took his first cold sip.

His drinking increased through college and into law school. He could, and occasionally did, pull back, going cold turkey for weeks at a time. But nothing quieted his anxious mind like booze, and when he didn’t drink, he didn’t sleep. After four or six weeks dry, he’d be back at the liquor store.

By the time he was a practicing defense attorney, J.G. (who asked to be identified only by his initials) sometimes drank almost a liter of Jameson in a day. He often started drinking after his first morning court appearance, and he says he would have loved to drink even more, had his schedule allowed it. He defended clients who had been charged with driving while intoxicated, and he bought his own Breathalyzer to avoid landing in court on drunk-driving charges himself.

In the spring of 2012, J.G. decided to seek help. He lived in Minnesota—the Land of 10,000 Rehabs, people there like to say—and he knew what to do: check himself into a facility. He spent a month at a center where the treatment consisted of little more than attending Alcoholics Anonymous meetings. He tried to dedicate himself to the program even though, as an atheist, he was put off by the faith-based approach of the 12 steps, five of which mention God. Everyone there warned him that he had a chronic, progressive disease and that if he listened to the cunning internal whisper promising that he could have just one drink, he would be off on a bender.

J.G. says it was this message—that there were no small missteps, and one drink might as well be 100—that set him on a cycle of bingeing and abstinence. He went back to rehab once more and later sought help at an outpatient center. Each time he got sober, he’d spend months white-knuckling his days in court and his nights at home. Evening would fall and his heart would race as he thought ahead to another sleepless night. “So I’d have one drink,” he says, “and the first thing on my mind was: I feel better now, but I’m screwed. I’m going right back to where I was. I might as well drink as much as I possibly can for the next three days.”

He felt utterly defeated. And according to AA doctrine, the failure was his alone. When the 12 steps don’t work for someone like J.G., Alcoholics Anonymous says that person must be deeply flawed. The Big Book, AA’s bible, states:
Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way.

J.G.’s despair was only heightened by his seeming lack of options. “Every person I spoke with told me there was no other way,” he says.

The 12 steps are so deeply ingrained in the United States that many people, including doctors and therapists, believe attending meetings, earning one’s sobriety chips, and never taking another sip of alcohol is the only way to get better. Hospitals, outpatient clinics, and rehab centers use the 12 steps as the basis for treatment. But although few people seem to realize it, there are alternatives, including prescription drugs and therapies that aim to help patients learn to drink in moderation. Unlike Alcoholics Anonymous, these methods are based on modern science and have been proved, in randomized, controlled studies, to work.

For J.G., it took years of trying to “work the program,” pulling himself back onto the wagon only to fall off again, before he finally realized that Alcoholics Anonymous was not his only, or even his best, hope for recovery. But in a sense, he was lucky: many others never make that discovery at all.

The debate over the efficacy of 12-step programs has been quietly bubbling for decades among addiction specialists. But it has taken on new urgency with the passage of the Affordable Care Act, which requires all insurers and state Medicaid programs to pay for alcohol- and substance-abuse treatment, extending coverage to 32 million Americans who did not previously have it and providing a higher level of coverage for an additional 30 million.

Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools. The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists. (The Columbia report notes that there may be additional doctors who have a subspecialty in addiction.) Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED. Many counselors are in recovery themselves. The report stated: “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

Alcoholics Anonymous was established in 1935, when knowledge of the brain was in its infancy. It offers a single path to recovery: lifelong abstinence from alcohol. The program instructs members to surrender their ego, accept that they are “powerless” over booze, make amends to those they’ve wronged, and pray.

Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works. In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

The Big Book includes an assertion first made in the second edition, which was published in 1955: that AA has worked for 75 percent of people who have gone to meetings and “really tried.” It says that 50 percent got sober right away, and another 25 percent struggled for a while but eventually recovered. According to AA, these figures are based on members’ experiences.

In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.

I spent three years researching a book about women and alcohol, Her Best-Kept Secret: Why Women Drink—And How They Can Regain Control, which was published in 2013. During that time, I encountered disbelief from doctors and psychiatrists every time I mentioned that the Alcoholics Anonymous success rate appears to hover in the single digits. We’ve grown so accustomed to testimonials from those who say AA saved their life that we take the program’s efficacy as an article of faith. Rarely do we hear from those for whom 12-step treatment doesn’t work. But think about it: How many celebrities can you name who bounced in and out of rehab without ever getting better? Why do we assume they failed the program, rather than that the program failed them?

When my book came out, dozens of Alcoholics Anonymous members said that because I had challenged AA’s claim of a 75 percent success rate, I would hurt or even kill people by discouraging attendance at meetings. A few insisted that I must be an “alcoholic in denial.” But most of the people I heard from were desperate to tell me about their experiences in the American treatment industry. Amy Lee Coy, the author of the memoir From Death Do I Part: How I Freed Myself From Addiction, told me about her eight trips to rehab, starting at age 13. “It’s like getting the same antibiotic for a resistant infection—eight times,” she told me. “Does that make sense?”

“I honestly thought AA was the only way anyone could ever get sober, but I learned that I was wrong.”

She and countless others had put their faith in a system they had been led to believe was effective—even though finding treatment centers’ success rates is next to impossible: facilities rarely publish their data or even track their patients after discharging them. “Many will tell you that those who complete the program have a ‘great success rate,’ meaning that most are abstaining from drugs and alcohol while enrolled there,” says Bankole Johnson, an alcohol researcher and the chair of the psychiatry department at the University of Maryland School of Medicine. “Well, no kidding.”

Alcoholics Anonymous has more than 2 million members worldwide, and the structure and support it offers have helped many people. But it is not enough for everyone. The history of AA is the story of how one approach to treatment took root before other options existed, inscribing itself on the national consciousness and crowding out dozens of newer methods that have since been shown to work better.

A meticulous analysis of treatments, published more than a decade ago in The Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods. At the top of the list are brief interventions by a medical professional; motivational enhancement, a form of counseling that aims to help people see the need to change; and acamprosate, a drug that eases cravings. (An oft-cited 1996 study found 12-step facilitation—a form of individual therapy that aims to get the patient to attend AA meetings—as effective as cognitive behavioral therapy and motivational interviewing. But that study, called Project Match, was widely criticized for scientific failings, including the lack of a control group.)

As an organization, Alcoholics Anonymous has no real central authority—each AA meeting functions more or less autonomously—and it declines to take positions on issues beyond the scope of the 12 steps. (When I asked to speak with someone from the General Service Office, AA’s administrative headquarters, regarding AA’s stance on other treatment methods, I received an e-mail stating: “Alcoholics Anonymous neither endorses nor opposes other approaches, and we cooperate widely with the medical profession.” The office also declined to comment on whether AA’s efficacy has been proved.) But many in AA and the rehab industry insist the 12 steps are the only answer and frown on using the prescription drugs that have been shown to help people reduce their drinking.

People with alcohol problems also suffer from higher-than-normal rates of mental-health issues, and research has shown that treating depression and anxiety with medication can reduce drinking. But AA is not equipped to address these issues—it is a support group whose leaders lack professional training—and some meetings are more accepting than others of the idea that members may need therapy and/or medication in addition to the group’s help.

AA truisms have so infiltrated our culture that many people believe heavy drinkers cannot recover before they “hit bottom.” Researchers I’ve talked with say that’s akin to offering antidepressants only to those who have attempted suicide, or prescribing insulin only after a patient has lapsed into a diabetic coma. “You might as well tell a guy who weighs 250 pounds and has untreated hypertension and cholesterol of 300, ‘Don’t exercise, keep eating fast food, and we’ll give you a triple bypass when you have a heart attack,’ ” Mark Willenbring, a psychiatrist in St. Paul and a former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism, told me. He threw up his hands. “Absurd.”

Part of the problem is our one-size-fits-all approach. Alcoholics Anonymous was originally intended for chronic, severe drinkers—those who may, indeed, be powerless over alcohol—but its program has since been applied much more broadly. Today, for instance, judges routinely require people to attend meetings after a DUI arrest; fully 12 percent of AA members are there by court order.

Whereas AA teaches that alcoholism is a progressive disease that follows an inevitable trajectory, data from a federally funded survey called the National Epidemiological Survey on Alcohol and Related Conditions show that nearly one-fifth of those who have had alcohol dependence go on to drink at low-risk levels with no symptoms of abuse. And a recent survey of nearly 140,000 adults by the Centers for Disease Control and Prevention found that nine out of 10 heavy drinkers are not dependent on alcohol and, with the help of a medical professional’s brief intervention, can change unhealthy habits.

We once thought about drinking problems in binary terms—you either had control or you didn’t; you were an alcoholic or you weren’t—but experts now describe a spectrum. An estimated 18 million Americans suffer from alcohol-use disorder, as the DSM-5, the latest edition of the American Psychiatric Association’s diagnostic manual, calls it. (The new term replaces the older alcohol abuse and the much more dated alcoholism, which has been out of favor with researchers for decades.) Only about 15 percent of those with alcohol-use disorder are at the severe end of the spectrum. The rest fall somewhere in the mild-to-moderate range, but they have been largely ignored by researchers and clinicians. Both groups—the hard-core abusers and the more moderate overdrinkers—need more-individualized treatment options.

“We cling to this one-size-fits-all theory even when a person has a small problem.”

The United States already spends about $35 billion a year on alcohol- and substance-abuse treatment, yet heavy drinking causes 88,000 deaths a year—including deaths from car accidents and diseases linked to alcohol. It also costs the country hundreds of billions of dollars in expenses related to health care, criminal justice, motor-vehicle crashes, and lost workplace productivity, according to the CDC. With the Affordable Care Act’s expansion of coverage, it’s time to ask some important questions: Which treatments should we be willing to pay for? Have they been proved effective? And for whom—only those at the extreme end of the spectrum? Or also those in the vast, long-overlooked middle?

For a glimpse of how treatment works elsewhere, I traveled to Finland, a country that shares with the United States a history of prohibition (inspired by the American temperance movement, the Finns outlawed alcohol from 1919 to 1932) and a culture of heavy drinking.

Finland’s treatment model is based in large part on the work of an American neuroscientist named John David Sinclair. I met with Sinclair in Helsinki in early July. He was battling late-stage prostate cancer, and his thick white hair was cropped short in preparation for chemotherapy. Sinclair has researched alcohol’s effects on the brain since his days as an undergraduate at the University of Cincinnati, where he experimented with rats that had been given alcohol for an extended period. Sinclair expected that after several weeks without booze, the rats would lose their desire for it. Instead, when he gave them alcohol again, they went on week-long benders, drinking far more than they ever had before—more, he says, than any rat had ever been shown to drink.

Sinclair called this the alcohol-deprivation effect, and his laboratory results, which have since been confirmed by many other studies, suggested a fundamental flaw in abstinence-based treatment: going cold turkey only intensifies cravings. This discovery helped explain why relapses are common. Sinclair published his findings in a handful of journals and in the early 1970s moved to Finland, drawn by the chance to work in what he considered the best alcohol-research lab in the world, complete with special rats that had been bred to prefer alcohol to water. He spent the next decade researching alcohol and the brain.

Sinclair came to believe that people develop drinking problems through a chemical process: each time they drink, the endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person is to think about, and eventually crave, alcohol—until almost anything can trigger a thirst for booze, and drinking becomes compulsive.

Sinclair theorized that if you could stop the endorphins from reaching their target, the brain’s opiate receptors, you could gradually weaken the synapses, and the cravings would subside. To test this hypothesis, he administered opioid antagonists—drugs that block opiate receptors—to the specially bred alcohol-loving rats. He found that if the rats took the medication each time they were given alcohol, they gradually drank less and less. He published his findings in peer-reviewed journals beginning in the 1980s.

Subsequent studies found that an opioid antagonist called naltrexone was safe and effective for humans, and Sinclair began working with clinicians in Finland. He suggested prescribing naltrexone for patients to take an hour before drinking. As their cravings subsided, they could then learn to control their consumption. Numerous clinical trials have confirmed that the method is effective, and in 2001 Sinclair published a paper in the journal Alcohol and Alcoholism reporting a 78 percent success rate in helping patients reduce their drinking to about 10 drinks a week. Some stopped drinking entirely.

I visited one of three private treatment centers, called the Contral Clinics, that Sinclair co-founded in Finland. (There’s an additional one in Spain.) In the past 18 years, more than 5,000 Finns have gone to the Contral Clinics for help with a drinking problem. Seventy-five percent of them have had success reducing their consumption to a safe level.

The Finns are famously private, so I had to go early in the morning, before any patients arrived, to meet Jukka Keski-Pukkila, the CEO. He poured coffee and showed me around the clinic, in downtown Helsinki. The most common course of treatment involves six months of cognitive behavioral therapy, a goal-oriented form of therapy, with a clinical psychologist. Treatment typically also includes a physical exam, blood work, and a prescription for naltrexone or nalmefene, a newer opioid antagonist approved in more than two dozen countries. When I asked how much all of this cost, Keski-Pukkila looked uneasy. “Well,” he told me, “it’s 2,000 euros.” That’s about $2,500—a fraction of the cost of inpatient rehab in the United States, which routinely runs in the tens of thousands of dollars for a 28-day stay.

When I told Keski-Pukkila this, his eyes grew wide. “What are they doing for that money?” he asked. I listed some of the treatments offered at top-of-the-line rehab centers: equine therapy, art therapy, mindfulness mazes in the desert. “That doesn’t sound scientific,” he said, perplexed. I didn’t mention that some bare-bones facilities charge as much as $40,000 a month and offer no treatment beyond AA sessions led by minimally qualified counselors.

As I researched this article, I wondered what it would be like to try naltrexone, which the U.S. Food and Drug Administration approved for alcohol-abuse treatment in 1994. I asked my doctor whether he would write me a prescription. Not surprisingly, he shook his head no. I don’t have a drinking problem, and he said he couldn’t offer medication for an “experiment.” So that left the Internet, which was easy enough. I ordered some naltrexone online and received a foil-wrapped package of 10 pills about a week later. The cost was $39
Dan Saelinger

The first night, I took a pill at 6:30. An hour later, I sipped a glass of wine and felt almost nothing—no calming effect, none of the warm contentment that usually signals the end of my workday and the beginning of a relaxing evening. I finished the glass and poured a second. By the end of dinner, I looked up to see that I had barely touched it. I had never found wine so uninteresting. Was this a placebo effect? Possibly. But so it went. On the third night, at a restaurant where my husband and I split a bottle of wine, the waitress came to refill his glass twice; mine, not once. That had never happened before, except when I was pregnant. At the end of 10 days, I found I no longer looked forward to a glass of wine with dinner. (Interestingly, I also found myself feeling full much quicker than normal, and I lost two pounds. In Europe, an opioid antagonist is being tested on binge eaters.)

I was an n of one, of course. My experiment was driven by personal curiosity, not scientific inquiry. But it certainly felt as if I were unlearning something—the pleasure of that first glass? The desire for it? Both? I can’t really say.

Patients on naltrexone have to be motivated to keep taking the pill. But Sari Castrén, a psychologist at the Contral Clinic I visited in Helsinki, told me that when patients come in for treatment, they’re desperate to change the role alcohol has assumed in their lives. They’ve tried not drinking, and controlling their drinking, without success—their cravings are too strong. But with naltrexone or nalmefene, they’re able to drink less, and the benefits soon become apparent: They sleep better. They have more energy and less guilt. They feel proud. They’re able to read or watch movies or play with their children during the time they would have been drinking.

In therapy sessions, Castrén asks patients to weigh the pleasure of drinking against their enjoyment of these new activities, helping them to see the value of change. Still, the combination of naltrexone and therapy doesn’t work for everyone. Some clients opt to take Antabuse, a medication that triggers nausea, dizziness, and other uncomfortable reactions when combined with drinking. And some patients are unable to learn how to drink without losing control. In those cases (about 10 percent of patients), Castrén recommends total abstinence from alcohol, but she leaves that choice to patients. “Sobriety is their decision, based on their own discovery,” she told me.

Claudia Christian, an actress who lives in Los Angeles (she’s best known for appearing in the 1990s science-fiction TV show Babylon 5), discovered naltrexone when she came across a flier for Vivitrol, an injectable form of the drug, at a detox center in California in 2009. She had tried Alcoholics Anonymous and traditional rehab without success. She researched the medication online, got a doctor to prescribe it, and began taking a dose about an hour before she planned to drink, as Sinclair recommends. She says the effect was like flipping a switch. For the first time in many years, she was able to have a single drink and then stop. She plans to keep taking naltrexone indefinitely, and has become an advocate for Sinclair’s method: she set up a nonprofit organization for people seeking information about it and made a documentary called One Little Pill.

In the United States, doctors generally prescribe naltrexone for daily use and tell patients to avoid alcohol, instead of instructing them to take the drug anytime they plan to drink, as Sinclair would advise. There is disagreement among experts about which approach is better—Sinclair is adamant that American doctors are missing the drug’s full potential—but both seem to work: naltrexone has been found to reduce drinking in more than a dozen clinical trials, including a large-scale one funded by the National Institute on Alcohol Abuse and Alcoholism that was published in JAMA in 2006. The results have been largely overlooked. Less than 1 percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug shown to help control drinking.

To understand why, you have to first understand the history.

The American approach to treatment for drinking problems has roots in the country’s long-standing love-hate relationship with booze. The first settlers arrived with a great thirst for whiskey and hard cider, and in the early days of the republic, alcohol was one of the few beverages that was reliably safe from contamination. (It was also cheaper than coffee or tea.) The historian W. J. Rorabaugh has estimated that between the 1770s and 1830s, the average American over age 15 consumed at least five gallons of pure alcohol a year—the rough equivalent of three shots of hard liquor a day.

Religious fervor, aided by the introduction of public water-filtration systems, helped galvanize the temperance movement, which culminated in 1920 with Prohibition. That experiment ended after 14 years, but the drinking culture it fostered—secrecy and frenzied bingeing—persists.

In 1934, just after Prohibition’s repeal, a failed stockbroker named Bill Wilson staggered into a Manhattan hospital. Wilson was known to drink two quarts of whiskey a day, a habit he’d attempted to kick many times. He was given the hallucinogen belladonna, an experimental treatment for addictions, and from his hospital bed he called out to God to loosen alcohol’s grip. He reported seeing a flash of light and feeling a serenity he had never before experienced. He quit booze for good. The next year, he co-founded Alcoholics Anonymous. He based its principles on the beliefs of the evangelical Oxford Group, which taught that people were sinners who, through confession and God’s help, could right their paths.

AA filled a vacuum in the medical world, which at the time had few answers for heavy drinkers. In 1956, the American Medical Association named alcoholism a disease, but doctors continued to offer little beyond the standard treatment that had been around for decades: detoxification in state psychiatric wards or private sanatoriums. As Alcoholics Anonymous grew, hospitals began creating “alcoholism wards,” where patients detoxed but were given no other medical treatment. Instead, AA members—who, as part of the 12 steps, pledge to help other alcoholics—appeared at bedsides and invited the newly sober to meetings.

A public-relations specialist and early AA member named Marty Mann worked to disseminate the group’s main tenet: that alcoholics had an illness that rendered them powerless over booze. Their drinking was a disease, in other words, not a moral failing. Paradoxically, the prescription for this medical condition was a set of spiritual steps that required accepting a higher power, taking a “fearless moral inventory,” admitting “the exact nature of our wrongs,” and asking God to remove all character defects.

Mann helped ensure that these ideas made their way to Hollywood. In 1945’s The Lost Weekend, a struggling novelist tries to loosen his writer’s block with booze, to devastating effect. In Days of Wine and Roses, released in 1962, Jack Lemmon slides into alcoholism along with his wife, played by Lee Remick. He finds help through AA, but she rejects the group and loses her family.

Mann also collaborated with a physiologist named E. M. Jellinek. Mann was eager to bolster the scientific claims behind AA, and Jellinek wanted to make a name for himself in the growing field of alcohol research. In 1946, Jellinek published the results of a survey mailed to 1,600 AA members. Only 158 were returned. Jellinek and Mann jettisoned 45 that had been improperly completed and another 15 filled out by women, whose responses were so unlike the men’s that they risked complicating the results. From this small sample—98 men—Jellinek drew sweeping conclusions about the “phases of alcoholism,” which included an unavoidable succession of binges that led to blackouts, “indefinable fears,” and hitting bottom. Though the paper was filled with caveats about its lack of scientific rigor, it became AA gospel.

Jellinek, however, later tried to distance himself from this work, and from Alcoholics Anonymous. His ideas came to be illustrated by a chart showing how alcoholics progressed from occasionally drinking for relief, to sneaking drinks, to guilt, and so on until they hit bottom (“complete defeat admitted”) and then recovered. If you could locate yourself even early in the downward trajectory on that curve, you could see where your drinking was headed. In 1952, Jellinek noted that the word alcoholic had been adopted to describe anyone who drank excessively. He warned that overuse of that word would undermine the disease concept. He later beseeched AA to stay out of the way of scientists trying to do objective research.

But AA supporters worked to make sure their approach remained central. Marty Mann joined prominent Americans including Susan Anthony, the grandniece of Susan B. Anthony; Jan Clayton, the mom from Lassie; and decorated military officers in testifying before Congress. John D. Rockefeller Jr., a lifelong teetotaler, was an early booster of the group.

In 1970, Senator Harold Hughes of Iowa, a member of AA, persuaded Congress to pass the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act. It called for the establishment of the National Institute on Alcohol Abuse and Alcoholism, and dedicated funding for the study and treatment of alcoholism. The NIAAA, in turn, funded Marty Mann’s nonprofit advocacy group, the National Council on Alcoholism, to educate the public. The nonprofit became a mouthpiece for AA’s beliefs, especially the importance of abstinence, and has at times worked to quash research that challenges those beliefs.

In 1976, for instance, the Rand Corporation released a study of more than 2,000 men who had been patients at 44 different NIAAA-funded treatment centers. The report noted that 18 months after treatment, 22 percent of the men were drinking moderately. The authors concluded that it was possible for some alcohol-dependent men to return to controlled drinking. Researchers at the National Council on Alcoholism charged that the news would lead alcoholics to falsely believe they could drink safely. The NIAAA, which had funded the research, repudiated it. Rand repeated the study, this time looking over a four-year period. The results were similar.

After the Hughes Act was passed, insurers began to recognize alcoholism as a disease and pay for treatment. For-profit rehab facilities sprouted across the country, the beginnings of what would become a multibillion-dollar industry. (Hughes became a treatment entrepreneur himself, after retiring from the Senate.) If Betty Ford and Elizabeth Taylor could declare that they were alcoholics and seek help, so too could ordinary people who struggled with drinking. Today there are more than 13,000 rehab facilities in the United States, and 70 to 80 percent of them hew to the 12 steps, according to Anne M. Fletcher, the author of Inside Rehab, a 2013 book investigating the treatment industry.

The problem is that nothing about the 12-step approach draws on modern science: not the character building, not the tough love, not even the standard 28-day rehab stay.

Marvin D. Seppala, the chief medical officer at the Hazelden Betty Ford Foundation in Minnesota, one of the oldest inpatient rehab facilities in the country, described for me how 28 days became the norm: “In 1949, the founders found that it took about a week to get detoxed, another week to come around so [the patients] knew what they were up to, and after a couple of weeks they were doing well, and stable. That’s how it turned out to be 28 days. There’s no magic in it.
Dan Saelinger

Tom McLellan, a psychology professor at the University of Pennsylvania School of Medicine who has served as a deputy U.S. drug czar and is an adviser to the World Health Organization, says that while AA and other programs that focus on behavioral change have value, they don’t address what we now know about the biology of drinking.

Alcohol acts on many parts of the brain, making it in some ways more complex than drugs like cocaine and heroin, which target just one area of the brain. Among other effects, alcohol increases the amount of GABA (gamma-aminobutyric acid), a chemical that slows down activity in the nervous system, and decreases the flow of glutamate, which activates the nervous system. (This is why drinking can make you relax, shed inhibitions, and forget your worries.) Alcohol also prompts the brain to release dopamine, a chemical associated with pleasure.

Over time, though, the brain of a heavy drinker adjusts to the steady flow of alcohol by producing less GABA and more glutamate, resulting in anxiety and irritability. Dopamine production also slows, and the person gets less pleasure out of everyday things. Combined, these changes gradually bring about a crucial shift: instead of drinking to feel good, the person ends up drinking to avoid feeling bad. Alcohol also damages the prefrontal cortex, which is responsible for judging risks and regulating behavior—one reason some people keep drinking even as they realize that the habit is destroying their lives. The good news is that the damage can be undone if they’re able to get their consumption under control.

Studies of twins and adopted children suggest that about half of a person’s vulnerability to alcohol-use disorder is hereditary, and that anxiety, depression, and environment—all considered “outside issues” by many in Alcoholics Anonymous and the rehab industry—also play a role. Still, science can’t yet fully explain why some heavy drinkers become physiologically dependent on alcohol and others don’t, or why some recover while others flounder. We don’t know how much drinking it takes to cause major changes in the brain, or whether the brains of alcohol-dependent people are in some ways different from “normal” brains to begin with. What we do know, McLellan says, is that “the brains of the alcohol-addicted aren’t like those of the non-alcohol-dependent.”

Bill Wilson, AA’s founding father, was right when he insisted, 80 years ago, that alcohol dependence is an illness, not a moral failing. Why, then, do we so rarely treat it medically? It’s a question I’ve heard many times from researchers and clinicians. “Alcohol- and substance-use disorders are the realm of medicine,” McLellan says. “This is not the realm of priests.”

When the Hazelden treatment center opened in 1949, it espoused five goals for its patients: behave responsibly, attend lectures on the 12 steps, make your bed, stay sober, and talk with other patients. Even today, Hazelden’s Web site states:
People addicted to alcohol can be secretive, self-centered, and filled with resentment. In response, Hazelden’s founders insisted that patients attend to the details of daily life, tell their stories, and listen to each other … This led to a heartening discovery, one that’s become a cornerstone of the Minnesota Model: Alcoholics and addicts can help each other.

That may be heartening, but it’s not science. As the rehab industry began expanding in the 1970s, its profit motives dovetailed nicely with AA’s view that counseling could be delivered by people who had themselves struggled with addiction, rather than by highly trained (and highly paid) doctors and mental-health professionals. No other area of medicine or counseling makes such allowances.

There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol- and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever—not even a GED or an introductory training course was necessary—and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery.

Fourteen states had no license requirements for addiction counselors—not even a GED or an introductory course.

Mark Willenbring, the St. Paul psychiatrist, winced when I mentioned this. “What’s wrong,” he asked me rhetorically, “with people with no qualifications or talents—other than being recovering alcoholics—being licensed as professionals with decision-making authority over whether you are imprisoned or lose your medical license?

“The history—and current state—is really, really dismal,” Willenbring said.

Perhaps even worse is the pace of research on drugs to treat alcohol-use disorder. The FDA has approved just three: Antabuse, the drug that induces nausea and dizziness when taken with alcohol; acamprosate, which has been shown to be helpful in quelling cravings; and naltrexone. (There is also Vivitrol, the injectable form of naltrexone.)

Reid K. Hester, a psychologist and the director of research at Behavior Therapy Associates, an organization of psychologists in Albuquerque, says there has long been resistance in the United States to the idea that alcohol-use disorder can be treated with drugs. For a brief period, DuPont, which held the patent for naltrexone when the FDA approved it for alcohol-abuse treatment in 1994, paid Hester to speak about the drug at medical conferences. “The reaction was always ‘How can you be giving alcoholics drugs?’ ” he recalls.

Hester says this attitude dates to the 1950s and ’60s, when psychiatrists regularly prescribed heavy drinkers Valium and other sedatives with great potential for abuse. Many patients wound up dependent on both booze and benzodiazepines. “They’d look at me like I was promoting Valley of the Dolls 2.0,” Hester says.

There has been some progress: the Hazelden center began prescribing naltrexone and acamprosate to patients in 2003. But this makes Hazelden a pioneer among rehab centers. “Everyone has a bias,” Marvin Seppala, the chief medical officer, told me. “I honestly thought AA was the only way anyone could ever get sober, but I learned that I was wrong.”

Stephanie O’Malley, a clinical researcher in psychiatry at Yale who has studied the use of naltrexone and other drugs for alcohol-use disorder for more than two decades, says naltrexone’s limited use is “baffling.”

“There was never any campaign for this medication that said, ‘Ask your doctor,’ ” she says. “There was never any attempt to reach consumers.” Few doctors accepted that it was possible to treat alcohol-use disorder with a pill. And now that naltrexone is available in an inexpensive generic form, pharmaceutical companies have little incentive to promote it.

In one recent study, O’Malley found naltrexone to be effective in limiting consumption among college-age drinkers. The drug helped subjects keep from going over the legal threshold for intoxication, a blood alcohol content of 0.08 percent. Naltrexone is not a silver bullet, though. We don’t yet know for whom it works best. Other drugs could help fill in the gaps. O’Malley and other researchers have found, for example, that the smoking-cessation medication varenicline has shown promise in reducing drinking. So, too, have topirimate, a seizure medication, and baclofen, a muscle relaxant. “Some of these drugs should be considered in primary-care offices,” O’Malley says. “And they’re just not.”

In late August, I visited Alltyr, a clinic that Willenbring founded in St. Paul. It was here that J.G. finally found help.

After his stays in rehab, J.G. kept searching for alternatives to 12-step programs. He read about baclofen and how it might ease both anxiety and cravings for alcohol, but his doctor wouldn’t prescribe it. In his desperation, J.G. turned to a Chicago psychiatrist who wrote him a prescription for baclofen without ever meeting him in person and eventually had his license suspended. Then, in late 2013, J.G.’s wife came across Alltyr’s Web site and discovered, 20 minutes from his law office, a nationally known expert in treating alcohol- and substance-use disorders.

J.G. now sees Willenbring once every 12 weeks. During those sessions, Willenbring checks on J.G.’s sleep patterns and refills his prescription for baclofen (Willenbring was familiar with the studies on baclofen and alcohol, and agreed it was a viable treatment option), and occasionally prescribes Valium for his anxiety. J.G. doesn’t drink at all these days, though he doesn’t rule out the possibility of having a beer every now and then in the future.

I also talked with another Alltyr patient, Jean, a Minnesota floral designer in her late 50s who at the time was seeing Willenbring three or four times a month but has since cut back to once every few months. “I actually look forward to going,” she told me. At age 50, Jean (who asked to be identified by her middle name) went through a difficult move and a career change, and she began soothing her regrets with a bottle of red wine a day. When Jean confessed her habit to her doctor last year, she was referred to an addiction counselor. At the end of the first session, the counselor gave Jean a diagnosis: “You’re a drunk,” he told her, and suggested she attend AA.

The whole idea made Jean uncomfortable. How did people get better by recounting the worst moments of their lives to strangers? Still, she went. Each member’s story seemed worse than the last: One man had crashed his car into a telephone pole. Another described his abusive blackouts. One woman carried the guilt of having a child with fetal alcohol syndrome. “Everybody talked about their ‘alcoholic brain’ and how their ‘disease’ made them act,” Jean told me. She couldn’t relate. She didn’t believe her affection for pinot noir was a disease, and she bristled at the lines people read from the Big Book: “We thought we could find a softer, easier way,” they recited. “But we could not.”

Surely, Jean thought, modern medicine had to offer a more current form of help.

Then she found Willenbring. During her sessions with him, she talks about troubling memories that she believes helped ratchet up her drinking. She has occasionally had a drink; Willenbring calls this “research,” not “a relapse.” “There’s no belittling, no labels, no judgment, no book to carry around, no taking away your ‘medal,’ ” Jean says, a reference to the chips that AA members earn when they reach certain sobriety milestones.

In his treatment, Willenbring uses a mix of behavioral approaches and medication. Moderate drinking is not a possibility for every patient, and he weighs many factors when deciding whether to recommend lifelong abstinence. He is unlikely to consider moderation as a goal for patients with severe alcohol-use disorder. (According to the DSM‑5, patients in the severe range have six or more symptoms of the disorder, such as frequently drinking more than intended, increased tolerance, unsuccessful attempts to cut back, cravings, missing obligations due to drinking, and continuing to drink despite negative personal or social consequences.) Nor is he apt to suggest moderation for patients who have mood, anxiety, or personality disorders; chronic pain; or a lack of social support. “We can provide treatment based on the stage where patients are,” Willenbring said. It’s a radical departure from issuing the same prescription to everyone.

The difficulty of determining which patients are good candidates for moderation is an important cautionary note. But promoting abstinence as the only valid goal of treatment likely deters people with mild or moderate alcohol-use disorder from seeking help. The prospect of never taking another sip is daunting, to say the least. It comes with social costs and may even be worse for one’s health than moderate drinking: research has found that having a drink or two a day could reduce the risk of heart disease, dementia, and diabetes.

To many, though, the idea of non-abstinent recovery is anathema.

No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence. Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely. (Both groups were given a standard hospital treatment, which included group therapy, AA meetings, and medications.) The Sobells published their findings in peer-reviewed journals.

In 1980, the University of Toronto recruited the couple to conduct research at its prestigious Addiction Research Foundation. “We didn’t set out to challenge tradition,” Mark Sobell told me. “We just set out to do good research.” Not everyone saw it that way. In 1982, abstinence-only proponents attacked the Sobells in the journal Science; one of the writers, a UCLA psychologist named Irving Maltzman, later accused them of faking their results. The Science article received widespread attention, including a story in The New York Times and a segment on 60 Minutes.

Over the next several years, four panels of investigators in the United States and Canada cleared the couple of the accusations. Their studies were accurate. But the exonerations had scant impact, Mark Sobell said: “Maybe a paragraph on page 14” of the newspaper.

America spends $35 billion a year on substance-abuse treatments, yet heavy drinking causes 88,000 deaths a year.

The late G. Alan Marlatt, a respected addiction researcher at the University of Washington, commented on the controversy in a 1983 article in American Psychologist. “Despite the fact that the basic tenets of [AA’s] disease model have yet to be verified scientifically,” Marlatt wrote, “advocates of the disease model continue to insist that alcoholism is a unitary disorder, a progressive disease that can only be arrested temporarily by total abstention.”

What’s stunning, 32 years later, is how little has changed.

The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University, in Fort Lauderdale, Florida. They also run a clinic. Like Willenbring in Minnesota, they are among a small number of researchers and clinicians, mostly in large cities, who help some patients learn to drink in moderation.

“We cling to this one-size-fits-all theory even when a person has a small problem,” Mark Sobell told me. “The idea is ‘Well, this may be the person you are now, but this is where this is going, and there’s only one way to fix it.’ ” Sobell paused. “But we have 50 years of research saying that, chances are, that’s not the way it’s going. We can change the course.”

During my visit to Finland, I interviewed P., a former Contral Clinic patient who asked me to use only his last initial in order to protect his privacy. He told me that for years he had drunk to excess, sometimes having as many as 20 drinks at a time. A 38-year-old doctor and university researcher, he describes himself as mild-mannered while sober. When drunk, though, “it was as if some primitive human took over.”

His wife found a Contral Clinic online, and P. agreed to go. From his first dose of naltrexone, he felt different—in control of his consumption for the first time. P. plans to use naltrexone for the rest of his life. He drinks two, maybe three, times a month. By American standards, these episodes count as binges, since he sometimes downs more than five drinks in one sitting. But that’s a steep decline from the 80 drinks a month he consumed before he began the treatment—and in Finnish eyes, it’s a success.

Sari Castrén, the psychologist I met at Contral, says such trajectories are the rule among her patients. “Helping them find this path is so rewarding,” she says. “This is a softer way to look at addiction. It doesn’t have to be so black and white.”

J.G. agrees. He feels much more confident and stable, he says, than he did when he was drinking. He has successfully drunk in moderation on occasion, without any loss of control or desire to consume more the next day. But for the time being, he’s content not drinking. “It feels like a big risk,” he says. And he has more at stake now—his daughter was born in June 2013, about six months before he found Willenbring.

Could the Affordable Care Act’s expansion of coverage prompt us to rethink how we treat alcohol-use disorder? That remains to be seen. The Department of Health and Human Services, the primary administrator of the act, is currently evaluating treatments. But the legislation does not specify a process for deciding which methods should be approved, so states and insurance companies are setting their own rules. How they’ll make those decisions is a matter of ongoing discussion.

Still, many leaders in the field are hopeful—including Tom McLellan, the University of Pennsylvania psychologist. His optimism is particularly poignant: in 2008, he lost a son to a drug overdose. “If I didn’t know what to do for my kid, when I know this stuff and am surrounded by experts, how the hell is a schoolteacher or a construction worker going to know?” he asks. Americans need to demand better, McLellan says, just as they did with breast cancer, HIV, and mental illness. “This is going to be a mandated benefit, and insurance companies are going to want to pay for things that work,” he says. “Change is within reach.”