The Back Story

The WHO created a worldwide impact by publishing its Global Burden of Disease study (GBD) in 2018, covering the years 1990-2016 and involving 195 countries. The international GBD consortium of researchers concluded that there was “no safe level” of alcohol consumption. This conclusion was ballyhooed around the world. Public health specialists in the US were especially receptive to this message, which was amplified throughout American media and health news outlets. Meanwhile, at its “Alcohol Facts” website, the WHO lists solely negative consequences of drinking alcohol.

But the WHO’s claims that alcohol’s effects are all bad have been contradicted by epidemiological studies in the US and other wealthy nations, which consistently find net longevity and cognitive gains resulting from 1-4 drinks daily.

One large-scale demonstration of this contrary result came from the Journal of the American College of Cardiology in 2017. Based on data from 13 waves of the National Health Interview Surveys linked to the National Death Index records, 333,247 Americans aged 18 and older were analyzed. The results: “Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes.”

This reduction in deaths was due primarily to reduced cardiovascular disease, the biggest killer in the United States. 

The New Global Burden Findings

Such evidence has continued to mount, and now comes from a source that will be inconvenient to the WHO. In July, GBD published a larger (200+ countries), more detailed, updated analysis of the impact of alcohol worldwide in the Lancet. Its published conclusion was: “Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.”

That’s a pretty unilluminating conclusion. The Lancet provided a slightly more digestible summary of the results:

For adults over age 40, health risks from alcohol consumption vary by age and region. Consuming a small amount of alcohol for people in this age group can provide some health benefits, such as reducing the risk of cardiovascular disease, stroke, and diabetes. [My emphasis.]

Could You Be More Specific?

Before turning to the actual results, there are a couple of relevant terms you should know: DALYs (disability adjusted life years) measure years lost through premature disability and death for each disease; NDE (non-drinker equivalent) is the alcohol consumption level at which the health risk is equivalent for drinkers to that of non-drinkers.

At what level of drinking do drinkers and abstainers have the same DALYs?

Alcohol benefits, computed worldwide, are standard for people aged 40 and over who drink moderately.

Among people aged 40-64, GBD found, “the global NDE in 2020 was 1.7 standard drinks per day among males and 1.8 standard drinks per day among females.”

More strikingly, for those 65 and older, average NDE nearly doubled—to 3.2 standard drinks per day for men and 3.5 standard drinks per day for women.

Most critically, any amount below the NDE level, but not abstaining, lowers a person’s relative risk for disability or death.

In GBD terminology, alcohol has a protective effect. Alcohol benefits, computed worldwide, are standard for people aged 40 and over who drink moderately. A typical 40-to-64-year-old who averages somewhere under two drinks daily will live longer, and without disability, than a typical person who abstains. At 65-plus, “drinking moderately,” as measured globally by GBD, extends to somewhat more than three drinks daily. A typical 65-year-old who has three or fewer drinks daily will live longer and more healthily than a typical abstainer.

GBD alcohol risk table for all subjects worldwide. (Relative risk is pegged to abstinence = 1.)

The other finding that’s hinted at in this global report is that there are distinct, identifiable groups for which drinking is beneficial around the world. These are primarily age groups. Results did not differ significantly between men and women.

These age differences are standard in alcohol health studies. Advantages are little noted in younger populations. Yet positive as well as negative effects are accumulating all along. These benefits start to appear in early middle age and are accentuated in later life. They are due to the substantial effect of alcohol on the atherosclerosis (blood artery clogging) that causes the major killers of heart disease and ischemic strokes, as well as for diabetes. These conditions, and alcohol’s mitigating effects on them, largely only begin to emerge around age 40. Their appearance accelerates around age 65 for both men and women.

The problem for the WHO now becomes how to spin the results.

But the GBD result was stunning! Even those whose research has identified benefits due to drinking must be impressed at such a clear-cut and substantial advantage for drinking, calculated globally for mature and older drinkers.

Even as a non-temperance advocate who has always noted alcohol’s benefits, I am somewhat surprised by these results indicating universal benefits from significant levels of drinking. I am surprised because I have emphasized cultural influences in causing addiction and alcohol-related mortality. Ironically, the pro-temperance alcohol epidemiology movement represented by WHO and its Global Burden of Disease study has vividly alerted me to alcohol’s direct medicinal properties.

Now What?

The problem for the WHO and the temperance nations that overwhelmingly dominate international alcohol epidemiology now becomes how to spin the results. They must go from “there is no safe level of drinking” to “there are clear and substantial health benefits from alcohol that appear at age 40 and increase the older one becomes.”

Again, these results show that alcohol has beneficial effects globally. Up to almost two drinks daily reduces mortality and disability for people over 40 around the world. These benefits extend to over three drinks daily after age 65.

Is this information worth knowing?

The WHO and US public health specialists would never baldly state this substantive finding. Instead, they dispense the bromide that alcohol may be beneficial, but that depends primarily on where you’re located and your age.

True, as it goes. But is this the best message for Americans and many others to receive? Is this the well-intentioned dissemination of useful public health information? Or is it the defensive posturing of an entrenched temperance worldview in long-term retreat?

Photograph by Marco Verch Professional Photographer via Flickr/Creative Commons 2.0

The post The WHO Finds Alcohol Is Beneficial: Who Knew? appeared first on Filter.

It’s a familiar tale. And our analysis of such behaviors pervades modern addiction theory⁠—raised once again by Evaluating the Brain Disease Model of Addiction, a monumental collective work published this month.

Non-substance addictions are important to understand and mitigate in their own right. But they are also central to the case against a reductive concept of drug addiction that hampers recovery and underpins the drug war.

Archie Brodsky and I first refuted what was then a heroin-centric, biological model of addiction in Love and Addiction in 1975. We then deduced:

If addiction is now known not to be primarily a matter of drug chemistry or body chemistry, and if we therefore have to broaden our conception of dependency-creating objects to include a wider range of drugs, then why stop with drugs? Why not look at the whole range of things, activities, and even people to which we can and do become addicted? We must, in fact, do this if addiction is to be made a viable concept once again.

Our model was built on people’s attachment to an experience that felt essential for them but became harmful. Such experiences were powerful and immediate, provided crucial though temporary feelings of wellness and relief, but eroded the person’s coping skills and other interests and outside relationships.

Obviously, if the characteristics of addiction are routinely exhibited with non-drug behaviors, the notion that addiction is a unique property of drugs doesn’t hold up.

In the years since, the “list” of addictive drugs according to various sources has been expanded piecemeal to include cigarettes, cocaine, methamphetamines, benzodiazepines, sleep medications including Ambien and others, painkillers, alcohol of course, marijuana and more.

Among the non-drug involvements now described as addictive by a range of sources are love, sex (including pornography), electronic media (games, iPhones), social media, gambling, eating, shopping and more.

Obviously, if the characteristics of addiction are routinely exhibited with non-drug behaviors, the notion that addiction is a unique property of drugs doesn’t hold up.

But basing “addiction” on something other than drugs’ properties is crucial to a string of developments in our field. Among these are the recognition of natural recovery (people usually believe that they can outgrow love addictions); harm reduction (people aren’t expected to abstain from love and sex and eating to recover from those addictions); and the central roles of cognition, coping skills, social resources and environmental factors—which are more obvious without the presence of drugs.

The recognition of non-substance addictions also underlies the mission of normalizing drug use.

Resistance to Expanding “Addiction” Beyond Drugs

Some opponents of the disease model oppose any model of addiction. If, as Brodsky and I noted, the key “truths” of addiction—use of opioids/drugs is inevitably addictive; addiction is irreversible and lifelong; external life factors and individual psychological dispositions don’t impact addiction—are false, why should we expand the concept? Instead, they argue, we should discard it entirely.

Dr. John Davies made this argument in The Myth of Addiction (1993). For Davies, addiction is misattributed to the object of addiction (drug use), rather than identifying the factors that are actually at work. These include psychological (personal attitudes), social (group beliefs), and situational (such as socio-economic) factors. Why, he reasoned, repeat such misattributions about non-drug activities and involvements?

Dr. Carl Hart may be a contemporary example of such thinking. Hart’s important highlighting of normalized drug use, outlined in Drug Use for Grown-Ups (2021), is that drugs don’t create negative consequences for most people. Rather, the opposite is true—people usually welcome and benefit from the drugs’ effects. That’s why people use drugs.

Hart’s work presenting a rational, scientific view of drugs is invaluable. But he has shown less interest in identifying and understanding compulsive non-drug behaviors. While agreeing with much of Davies’ and Hart’s reasoning, I have defended the reconceptualization of addiction⁠—in large part because it can create a critical link between drug use and non-drug behaviors.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) meanwhile eschews “addiction” in favor of “substance use disorders” (from mild to severe). To its credit, these are defined by negative life impacts, not types or quantities of drugs consumed. Yet the term deliberately separates drugs from other involvements. 

Establishing a Human Concept of Addiction

Dr. Bruce Alexander, whose famous “Rat Park” studies of the 1970s and ‘80s did much to inform the understanding of human involvements with drugs, wrote with me in The Meaning of Addiction (1985):

A successful addiction model must synthesize pharmacological, experiential, cultural, situational, and personality components in a fluid and seamless description of addictive motivation … The model must [also] make sense out of the essentially similar behavior that takes place with all compulsive involvements. 

Real-world examples demonstrate the truths of Rat Park with humans. As Zach Rhoads and I described in Outgrowing Addiction (2019) and in Filter, most of the US soldiers in Vietnam who used heroin did not become addicted. Well over 90 percent of those who reported being addicted in Vietnam ceased the addiction within a short period on their return, almost always without treatment, even though half used an opioid stateside. Those veterans who used heroin again were no more likely to use it addictively than those using any other drug. And the minority who remained addicted or became re-addicted were immersed in negative social environments.

The Vietnam heroin experience simply reiterated the general rules of human behavior.

The Vietnam experience demonstrated that people move past addiction when their surroundings improve, that they are no more likely to use one drug compulsively than any other, and that having fewer positive life options obstructs natural recovery.

These are not special features of drug use. They are operational keys to all human functioning. The Vietnam heroin experience simply reiterated the general rules of human behavior.

Where Are We in 2022?

In reviewing Evaluating the Brain Disease Model of Addiction, I wrote its senior editor, Nick Heather, about its focusing on drugs rather than establishing a general model of addiction. Heather explained that “the issue is not directly addressed but is implied in the more general criticism of the brain disease model.”

Actually, the argument goes the opposite way: The fact that addiction carries beyond drugs disproves the brain disease model of addiction (BDMA).

The brain disease model was developed in the service of establishing the inherent dangers of drug use. This is the motivating vision of the National Institute on Drug Abuse, embedded in its name. For NIDA to consider normal or positive drug use is impossible—to do so would defy its defined mission.

The Heather et al. volume reprints the views of the prior and current directors of NIDA. Neither they, nor other BDMA theorists, were willing to contribute any new writing. Since BDMA is the ruling paradigm, they didn’t need to bother.

Meanwhile, as indicated by its title, Evaluating defines itself in terms of the BDMA, which most of its contributors critique. (Bruce Alexander’s two chapters, including the final one, “Replacing the BDMA: a paradigm shift in the field of addiction,” stand out for their cultural-social-psychological-experiential portrayal of addiction.) In this way, it reflects the superior position the disease theory occupies.

The current epidemic of drug-related deaths, which has accelerated over the quarter century that BDMA has been dominant, should have finally discredited the disease theory, a belief in which has been shown to impede recovery from addiction. Instead, its opponents still are shouting into the wind.

The Way Forward

There can be no advancing addiction theory, treatment or policy without placing drug use and addiction within the firmament of all human behavior.

A group of European psychologists observed in a 2013 review titled “Motivation and Self-Regulation in Addiction: A Call for Convergence”:

[as] Peele (1985) summarized, ‘addiction may occur with any potent experience’ . . . Until recently, mainstream addiction research has greatly departed from this broad definition of addiction that can encompass any kind of behavior whatsoever. Instead, there has been a clear tendency to over-identify addiction with substance abuse and to distinguish drug addiction in particular as a unique phenomenon, quantitatively and qualitatively distinct from behaviors and habits of everyday life. However, recent evidence in psychology, behavioral economics, and neuroscience increasingly suggest that the qualitative dichotomy is unwarranted and that addiction to drugs shares essential commonalities with motivated or goal-directed behaviors in general.

We can note the change in the substance use disorders section in the fifth edition of the DSM (2013). DSM-5 labels no drugs, but only compulsive gambling, as “addictive” in the section titled “Substance Use Disorders and Behavioral Addictions.” Its first acceptance of the existence of a non-drug addiction was a step forward; its limiting of the category to gambling alone is nonsensical.

Other non-substance addictions will surely be added in time, however. In fact, DSM-5 placed sex addiction and (electronic) gaming addiction on hold for further consideration. Meanwhile, the 2019 edition of the World Health Organization’s International Classification of Diseases (ICD-11) included both conditions (without labeling them “addictions”).

DSM doesn’t deconstruct its diagnosis of Obsessive Compulsive Disorder (OCD) into separate categories for washing hands, checking locks, lining up shoes, etc. Instead, the disorder is identified by the severity of the negative consequences of these and similar activities.

For substance use disorders, DSM enumerates 10 types of drugs—alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics or anxiolytics; stimulants (amphetamines and cocaine); tobacco (i.e., nicotine); and “other or unknown substances.” It then uses 11 criteria for categorizing them as disorders, from mild to severe.

American psychiatry still feels obligated to specify which activities, as if their identities form the dominant component of the condition.

These criteria all contribute to a portrait. Per the DSM:

“If substance use causes significant problems in someone’s life, such as health issues, disability, and/or not meeting responsibilities at work, home, or school, the person may have a substance use disorder.”

Using the same criteria, we could say that any immersive activity can be addictive. Yet American psychiatry still feels obligated to specify which activities, as if their identities form the dominant component of the condition.

The 13-year-old boy at the beginning of this article was able⁠—like most children, and most people who experience addiction⁠—to move forward into a positive new phase of his life.

His counselor worked calmly with him to find out more about his concerns and interests. With the agreement of his school, the boy took on a new classroom role of sharing his computer skills with less tech-savvy classmates.

This built his confidence, helping him to become more popular with his peers. All of this made him happier, leading him naturally to end his addictive relationship with gaming and to engage more with his schoolwork and other areas of his life.

No drug or activity is inherently, unavoidably or inescapably “addictive.” Addiction is a negative state in which some people become enmeshed for shorter or longer periods. Recognizing this truth—with both drugs and other behaviors—is necessary in order not only to advance treatment and related societal changes, but to cease the demonization of drugs. 

Photograph via PxHere

Archie Brodsky is a member of the board of directors of The Influence Foundation, which operates Filter.

The post Non-Substance Addictions Are Key to Understanding What Drugs Don’t Do appeared first on Filter.

Cases of dementia are expected to double worldwide by 2050. But in the United States, no new medication had been approved for addressing Alzheimer’s—the disease that most often causes the decline in mental abilities for which dementia is a general term—in almost 20 years. In June the Food and Drug Administration (FDA) approved such a drug. Yet FDA’s own panel of external advisers said that the treatment wasn’t proven effective. Amid much controversy, some said it could “cause harm.”

Meanwhile, a number of large, rigorous studies continue to indicate alcohol’s potential to significantly mitigate cognitive decline.

In 2000, Archie Brodsky and I reviewed in Drug and Alcohol Dependence the research literature on the psychological benefits of moderate alcohol consumption. Aside from producing feelings of well being, pleasure and sociability, one positive quality of alcohol had been repeatedly discerned—its ability to foster “long-term cognitive functioning.”

Since our review at the turn of the century, more and more research has affirmed this cognitive benefit from drinking. One project that did so was the British Whitehall Studies. 

What Did Whitehall Demonstrate?

The Whitehall research investigated social determinants of cardiovascular disease and mortality among British civil servants. The Whitehall II Study, conducted originally from 1985 to 1988, examined the health of over 10,000 civil servants ages 35 to 55. Two thirds were men and one third women. Tracking of these subjects has continued.

The Whitehall Studies assessed alcohol use. A 2004 study of Whitehall II subjects found that, 11 years from baseline, “Those who consumed at least one drink in the past week, compared with those who did not, were significantly less likely to have poor cognitive function. The beneficial effect extended to those drinking more than 240 g per week (approximately 30 drinks or more). The effect was stronger for women than men. . . .  The relations were not explained by confounding by smoking and by physical and mental health.” (My emphasis.)

The researchers concluded with this remarkable assertion: “for middle-aged subjects, increasing levels of alcohol consumption were associated with better function regarding some aspects of cognition.”

Positive associations with drinking have repeatedly appeared over decades in diverse populations.

In 2018, a 23-year follow-up was more nuanced: “alcohol consumption trajectories from midlife to early old age showed long term abstinence, decrease in consumption, and long term consumption >14 units/week to be associated with a higher risk of dementia compared with long term consumption of 1-14 units/week.”

Association, of course, is not causation. FDA-model clinical trials require randomly assigning target populations to receive or not receive a treatment. For various reasons, this research model is unworkable with alcohol. Yet positive associations with drinking have repeatedly appeared over decades in diverse populations even while undergoing adjustments for other likely influential variables.

But if you believe the prestigious Whitehall study conducted with a “captive” middle-class population from middle to old age, you should drink up to two drinks daily to avoid dementia. In this regard, alcohol seemingly acts like a medication!

Drinkers Can’t Be Trusted

Of course, no such claim was made based on the research. The authors of the initial Whitehall alcohol-cognitive study cautioned, despite alcohol’s indicated benefits, that “it is not proposed that these findings be used to encourage increased alcohol consumption.”

The conclusion of the latter study focused on reducing drinking targets: “The risk of dementia was increased in people who abstained from alcohol in midlife or consumed >14 units/week. In several countries, guidelines define thresholds for harmful alcohol consumption much higher than 14 units/week. The present findings encourage the downward revision of such guidelines to promote cognitive health at older ages.”

Abstinence or decreased drinking, however, were associated with more dementia than was heavier drinking. The risk ratios for dementia relative to continuous moderate drinking were 1.74 for abstinence, 1.55 for reduced drinking, and 1.40 for heavier drinking—heavier drinking was the healthiest category other than moderation.

Withholding information about the benefits of drinking has been the traditional response to positive indicators about alcohol. The first systematic program to study people’s health over time in a community was the Framingham Study. This research was launched by the United States Public Health Service in 1948 to investigate the risk factors for cardiovascular disease.

Carl Seltzer, an anthropologist and epidemiologist involved in the study, described how he was prohibited from publishing the alcohol finding by the National Institutes of Health.

Drinkers in Framingham were found to have fewer heart attacks during 35,563 person-years of follow-up.  “In the community, alcohol consumption is not associated with increased risk for congestive heart failure, even among heavy drinkers (> or = 15 drinks/wk in men and > or = 8 drinks/wk in women). To the contrary, when consumed in moderation, alcohol appears to protect against congestive heart failure.” (My emphasis.)

But this result wasn’t permitted to see the light of publication until 2002—30 years after it was first discovered. In 1997, Carl Seltzer, an anthropologist and epidemiologist involved in the Framingham study, described how, in 1972, he was prohibited from publishing the alcohol finding by the National Institutes of Health (NIH). This would have been the earliest systematic report of such a result, which has since been widely replicated.

At the time it censored the publication of Selzer’s finding in 1972, the NIH felt obligated to explain its recalcitrance in a memorandum: 

An article which openly invites the encouragement of undertaking drinking with the implication of prevention of coronary heart disease would be scientifically misleading and socially undesirable in view of the major health problem of alcoholism that already exists in the country.

Yet even after the Framingham results were belatedly released, public health experts were far from eager to publicize this lifesaving information.

In 2007, PBS broadcast a highly heralded special, The Hidden Epidemic: Heart Disease in America. The program, hosted by Larry King, featured Framingham. King led a panel of experts in discussing the role of exercise, diet—even sex—in heart health.

Alcohol was never mentioned.

While it was exploring the effects of alcohol, the Framingham Study also found benefits for cognitive performance from drinking, even at high levels: “women who drank moderately (2-4 drinks/day) showed superior performance in many cognitive domains relative to abstainers. For men, superior performance was found within the range of 4-8 drinks/day, although fewer significant relations were observed. These results were confirmed by prospective analyses of 24-year drinking history.” (My emphasis.)

In summary, two pioneering epidemiological projects—the British Whitehall cohort and American Framingham community studies—found strong evidence for the cognitive benefits of alcohol. Both studies found that dementia is more likely to be associated with drinking too little than with drinking more than the norm.

Did you know about such findings? Do they surprise you?  Do you believe them? Why, or why not? 

Supposed Negatives Are Amplified

Any apparent findings of negative effects of alcohol are meanwhile shouted from the rooftops. The primary example in recent history was WHO Europe’s ballyhooed headline “There is no safe level of alcohol.”

“Zero alcohol consumption minimizes the overall risk of health loss,” warned the senior author of the Lancet study that the agency proclaimed.

As I have noted in Filter, this opinion was reached from indiscriminately melding the impact of alcohol in 195 societies, with wildly varying public health variables and levels of development. No actual drinkers were examined; rather coefficients representing the impact of alcohol on each disease were multiplied across the prevalence of the diseases in each country.

As I further pointed out, a host of other reputable research since then (including a contemporary study in the Lancet) reached a contrary conclusion—that alcohol consumption preserves and extends life. Are those results worth knowing?

In 2019 and 2020, two prominent studies of drinking’s positive effects on cognitive functioning and its endurance over the life cycle were published.

One is a “scoping review” of alcohol use and dementia research from the years 2000-2017. The chief investigator, Jürgen Rehm, is the primary organizer of the World Health Organization’s Global Burden of Disease and the Impact of Mental and Addictive Disorders study, the one that declared that there is no level at which drinking is safe, let alone beneficial.

The subsequent, 2019, Rehm et al. review assessed the results from 28 methodologically sound studies the investigators identified. These component studies measured actual drinking outcomes. They were, in fact, meta-analyses that combined results from outcome research involving large numbers of subjects, who were usually older.

Rehm and his colleagues determined, based on the most credible research since 2000 (most of the studies were published post-2010), that “Although causality could not be established, light to moderate alcohol use in middle to late adulthood was associated with a decreased risk of cognitive impairment and dementia.”

But heavy drinking was hazardous, the authors found: “Reducing heavy alcohol use may be an effective dementia prevention strategy.”

Paternalism and Infantilization

A further study of a cohort of older subjects was reported in 2020 in JAMA Network. It asked the question: “Does an association exist between current low to moderate alcohol drinking and cognitive function trajectories or rates of cognitive decline from middle to older age among US adults?”

Answer: “Our study suggested that low to moderate drinking was associated with better total cognitive function and better individual cognition domain results for word recall, mental status, and vocabulary among middle-aged or older men and women in the United States.” This included “lower rates of decline in each of these cognition domains”—i.e., less dementia.

Public health agencies continue to wish away the idea that alcohol can be beneficial.

The 2020 report was part of the Health and Retirement Study. HRS follows a panel comprising a representative sample of nearly 20,000 older Americans. It is conducted at the University of Michigan with funding by the National Institute of Aging (NIA) and the Social Security Administration.

The range, different eras, and diverse populations represented by the research recording such results make alcohol’s role as an anti-dementia agent hard to ignore.

Nonetheless, public health agencies continue to wish away the idea that alcohol can be beneficial.

The National Institute of Aging website features the following under the heading “Facts About Aging and Alcohol:”

Uncle George’s and Grandma Betty’s Stories

Anyone at any age can have a drinking problem. Uncle George always liked his liquor, so his family may not see that his drinking is getting worse as he gets older. Grandma Betty was a teetotaler all her life until she started having a drink each night to help her get to sleep after her husband died. Now, no one realizes that she needs a couple of drinks to get through each day.

These are common stories.

How “common” are George’s and Betty’s cases? Most drinkers in HRS (85 percent) are low-to-moderate drinkers, having up to seven drinks a week for women and 14 for men. But the majority of this population of older Americans abstains. Since, compared with never-drinkers, low-to-moderate drinkers scored better on cognitive tests throughout the study and experienced less cognitive decline with age, this majority might reconsider.

When it comes to alcohol, the US agency charged with the well-being of older Americans offers cultural stereotypes rather than presenting its own data. The National Institute of Aging discourages healthy drinking by seniors and attacks their personal agency. This recalls NIH’s refusal to tell Americans that alcohol prevents heart disease. It’s for their own good!

Of course anyone can choose not to drink. But isn’t public health’s role to provide real information about drugs, including alcohol, on which adults can make sensible decisions? Instead, American public health agencies practice paternalism and infantilization.

Photograph by Andres Haro Dominguez on Unsplash

Archie Brodsky is a member of the Board of Directors of The Influence Foundation, which operates Filter.

The post Alcohol and Dementia: Why the Evidence Has Been Suppressed   appeared first on Filter.

A 2016 book by Stanford addiction expert Dr. Anna Lembke—Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop—presented the hard-core, sinister case against drug companies. It’s a case firmly rooted in her view of opioid addiction as an irresistible, irreversible disease.

Meanwhile, the recent, high-profile Hulu series Dopesick is based on the 2018 bestseller by Beth Macy, a journalist who investigated the drug crisis in Appalachia. Macy’s book—Dopesick: Dealers, Doctors and the Drug Company that Addicted America—tells essentially the same story as Lembke’s. The company in question is (or rather, was) Purdue, run by the Sackler family.

The book and series maintain that Purdue/the Sacklers lied that OxyContin was rarely addictive. Instead, people frequently became hooked, and died, because addictiveness is an inherent property of opioids.

Hulu’s Dopesick aims for a feeling of authenticity by, for example, portraying a doctor who had been addicted to OxyContin.

Opponents of the disease model certainly don’t deny that many people become addicted to opioids and other drugs, as well as to powerful non-drug behaviors and experiences. Addiction is fundamental to human experience.

But pointing out the genuine addictive experiences of individuals like Dopesick’s doctor doesn’t shed light on the likelihood of becoming addicted to opioids.

Indeed, we know that likelihood is quite low.

Earlier this month, a court painstakingly ascertained just that, along with dispelling a litany of headline-grabbing claims about opioids 

A Court Rejects Lembke’s Arguments

Unlike Macy and Dopesick’s other producers, Lembke is highly credentialed—a psychiatrist, director of the addiction medicine clinic at Stanford University, and a TED speaker. She is thus deemed qualified to offer expert testimony in court.

On November 1, Judge Peter J. Wilson, in Orange County’s California Superior Court, issued a ruling in a case brought by four California jurisdictions against numerous opioid manufacturers over their alleged liability for causing addiction and many resulting deaths.

His ruling: “There is simply no evidence to show that the rise in prescriptions was not the result of the medically appropriate provision of pain medications to patients in need.”

The court rejected the plaintiffs’ claims, which were based primarily on Lembke’s testimony, finding her and the suing jurisdictions to be plainly wrong in four ways: overstating the incidence of prescription opioid addiction; ignoring the medical benefits of opioid pain relief; generalizing inappropriately from drug death “hot spots” to less severely affected jurisdictions; and failing to show that prescribing practices caused the crisis of opioid-related deaths.

Below are several illustrative quotes taken from an interview with drug manufacturers’ attorneys John Heuston and Moez Kaba, together with excerpts from the judge’s decision.

Hueston: “[The key factor] was Stanford professor Lembke. Dr. Lembke was presented as the lead voice by the plaintiffs for their case trying to establish [drug company] misstatements that drove the crisis in California.”

Kaba: “It’s an extraordinarily methodical order. He [the judge] goes through alleged statement after alleged statement and reaches the findings that these are not false statements …”

“The studies relied upon by Dr. Lembke for that conclusion are inadequate to support it.”

The judge, who regularly stopped the trial to hold detailed discussions about evidence, noted in his ruling that Lembke “testified that one in four patients prescribed opioids would become addicted.”

But, he continued, “as Defendants point out, the studies relied upon by Dr. Lembke for that conclusion are inadequate to support it … the more reliable data would suggest less than 5 percent, rather than 25 percent.” And even with that much lower figure, “addiction based solely on the patient having been prescribed opioids does not occur in ‘most of these patients.’”

Kaba: “One of the things that Dr. Lembke claimed, for example, was that it was false or misleading to suggest that opioids can improve the function of people who take them. And we had her admit very clearly, very plainly, that not just the FDA but the state of California itself in its own laws acknowledges that opioid medications when properly prescribed do, in fact, improve function.”

Defense attorneys were also at pains to contextualize the California jurisdictions’ claims. That is, opioid addiction and death rates are highly dependent on specific locales and social settings.

Defense attorney Hueston: “We certainly wanted to make sure that a case about the opioid epidemic in California actually related to California. And what we wanted to do was to anticipate and blunt the attack from plaintiffs that California is like Appalachia and Tennessee, or some of the other notorious hot spots.”

Kaba: “There’s another part of his order where he says that there’s no causation, which was another big part of our case. In the examination that [Heuston] did of our economist, we proved that there is no causation …”

Proving causation requires linking more prescriptions to greater addiction and death rates. In fact, while there has been a steady decline in painkiller prescriptions, by nearly half, from 2012 to 2020, drug deaths continued to achieve record levels over that period, more than doubling between 2015 and 2020 alone. Causality—if anything—seemingly flows in the opposite direction. That is, restricting painkiller prescriptions leads to negative outcomes.

An Assault on Chronic Pain Patients

The trial additionally highlighted patients’ right to pain relief, and how the disease theory of addiction attacks this right.

Organizations representing pain doctors have strongly objected to draconian limitations imposed on prescribing. The American Medical Association itself has passed “resolutions against the rash of laws and mandatory policies that limit or prevent patient access to opioid painkillers.” Beleaguered pain patients have organized themselves into a grassroots movement.

Heuston: “It was critical to our strategy to ensure that the voices that are in support of proper pain management were heard, that pain management doctors who could help describe the life crises of people who simply have inadequate treatment of pain … the judge’s opinion sets forth not only the understanding of that balance by the FDA and the federal government but how that is enshrined specifically in California in, for instance, the Patients’ Bill of Rights.”

Stanford Medical School and its hospitals, incidentally, subscribe to these rights, including that to opioid medication.

Little wonder that this month, a group representing people with arthritis and rheumatic disease, whose leadership had invited Lembke to present to it, rescinded its invitation: “We understand how some of Dr. Lembke’s previous work and comments can be problematic. Thank you for taking the time and energy to show us articles, interviews, and quotes from Dr. Lembke that are not in keeping with our mission at CreakyJoints.”

Drawing the Wrong Conclusions From Vietnam

The 2020 Netflix series The Pharmacist jumped from a drug-related murder in New Orleans to portray an overwhelming national epidemic of prescription-opioid overdoses due to addiction. This view is put forward in spite of the dominant roles in today’s unprecedented drug-deaths crisis of drug-mixing, of an illicit supply adulterated with fentanyl and its analogues, and of the policies that lead to these conditions. (Due to this toxic combination of factors, it is actually a misnomer to label the deaths simply as “overdoses.”)

Dr. Lembke was interviewed in the Netflix series. “This country has seen two prior opioid epidemics,” she said, citing the Civil War and “when soldiers were coming back from the Vietnam War.”

Most soldiers who used heroin didn’t become addicted, and the overwhelming majority of those who did quickly recovered stateside, without treatment.

But the Vietnam addiction story actually demolishes Lembke’s opioid disease model. As Zach Rhoads and I described in Filter, “Vietnam Vets Proved that Addiction is a Product of Life Circumstances.”

Most soldiers who used heroin didn’t become addicted, and the overwhelming majority of those who did (over 90 percent) quickly recovered stateside, without treatment. The small group whose addictions persisted were identified by their adverse social situations before and after the war.

In 2021, 50 years after Lee Robins’s iconic Vietnam research, science journalist Lauren Aguirre revisited “Lessons learned—and lost—from a Vietnam-era addiction study … It’s too bad this research has been largely forgotten because its lessons can be useful today.”

As Aguirre notes, “many people recover on their own from drug addictions … most of them did not receive formal treatment.”  Furthermore, “exposure to opioids doesn’t inevitably lead to a substance use disorder. Some people can use opioids occasionally without becoming addicted [this included veterans who had been addicted in Vietnam]. In fact, a recent analysis found that only about 3 percent of the tens of millions of people prescribed opioids become addicted.”

In this context, Netflix viewers were led to think that the Vietnam narrative supports Lembke’s (and Dopesick’s) underlying assumption of the inescapability of addiction. But their perspective—which dominates the popular and political discourse—is actually the reverse of the meaning we should have taken from the Vietnam opioid experience.

Media Boosting of the Disease Theory

Media of all kinds and all political stripes are typically stalwart presenters of the Dopesick/Lembke demonization of opioid painkillers. Joe Rogan (who interviewed Lembke*), PBS’s Christine Amanpour (who interviewed Macy), and MSNBC commentators (several of whom interviewed Dopesick producer Danny Strong and showed clips from the series) are just a few examples of the worshipful exposure media give to inaccurate suppositions about opioids.

Hulu promoted a clip from Dopesick in which a tearful Appalachian doctor says that most of his patients became addicted. MSNBC’s Joe Scarborough and Nicolle Wallace, to name two, eagerly endorsed this preposterous claim.

It is our obligation to firmly and finally reject the demonization of drugs—including portraying addiction as the inexorable, irreversible, unavoidable consequence of drug use.

Most media’s ignorance of drug issues has long been a given. More exasperating is when people who support drug policy reform implicitly endorse the disease theory. I recall one event in 2017, at which figures from New York government, public health and several harm reduction organizations celebrated successful efforts to reduce painkiller prescribing since 2012—while simultaneously depicting continually rising drug-related deaths over the same period.

It is our obligation instead to firmly and finally reject the demonization of drugs—including portraying addiction as the inexorable, irreversible, unavoidable consequence of opioid and other drug use.

Many harm reduction and reform advocates rightly focus on the critical role of the social, psychological and economic circumstances faced by people who experience drug-related harms. They understand that drug use is not an infection. It is both a normal behavior and a human response to distress. And they see drug use as a human right, and drug users as a constitutionally protected group.

We will never contain our epidemic of drug deaths until these anti-drug war, anti-disease realizations are more widely shared.

Photograph by Mike Mozart via Flickr/Creative Commons 2.0

*I discuss, in “The Dope on Dopamine,” Joe Rogan’s podcast with Lembke about her 2021 disease follow-up, Dopamine Nation, which implausibly reduces addiction to neurochemistry.

The post A Court Rejected the Disease Theory of Opioid Addiction. Will We Listen? appeared first on Filter.

That research was based on international consumption and health figures, bridged across 195 countries. But combining national data from all these countries is creating a nonexistent cake out of disparate ingredients. Health conditions in Burundi, Haiti and the Solomon Islands don’t match those in Paris, New York and Vancouver. As Walter Willett, professor of epidemiology and nutrition at the Harvard School of Public Health, pointed out in critiquing the WHO diagnosis: “Our decisions about drinking in the United States shouldn’t be influenced by what alcohol does to tuberculosis.”

And the WHO study didn’t actually examine individuals. Instead, it was deduced from a health economics statistical analysis. Yet the Global Burden study, as it was called, was not the only international study on drinking to appear in The Lancet in 2018. A meta-analysis of 83 prospective studies, which together tracked 600,000 individuals from “high-income countries,” also appeared. It found that, “compared to moderate drinkers, ‘never drinkers’ experienced 30 percent more heart disease and strokes, and a 20 percent higher overall death rate.”

A relentless parade of research and data tells us that alcohol, overall, enhances health and prolongs life.

The WHO warning has nonetheless inspired an onslaught of new anti-alcohol exhortations throughout US media: “America has a drinking problem” (The Atlantic), “Did drinking give me breast cancer?” (Mother Jones), “Happy? Sad? Stressed? How drinking became the answer to everything“ (New York Times).

So we shouldn’t have been surprised when, in February, it was announced:

According to the Centers for Disease Control, drinking alcohol of any kind can increase your risk for certain cancers. The National Toxicology Program lists consumption of alcohol as a known human carcinogen.

A group of health organizations is looking to get that message out loud and clear. In a Citizen Petition, the American Society of Clinical Oncology and the American Institute for Cancer Research, along with others, are asking for a new cancer warning label to be added on all alcoholic beverages.

What miscreant could possibly oppose such a noble project? 

Alcohol can, like many other things (such as cold cuts and perhaps lox), cause cancer, and people deserve to know that. But limiting messaging about beverage alcohol to its potential harms is an inexcusable public health disservice.

That’s because a relentless parade of research and data tells us that alcohol, overall, enhances health and prolongs life. Five major recent studies have clearly shown that people who drink alcohol moderately, relative to those who abstain, live significantly longer and better.

Of course, there are objections to the research—there always are. I will address the leading arguments that will be made against these studies after I describe their results. 

In the meantime, the utter inability of American health institutions to acknowledge the benefits of alcohol resembles nothing so much as anti-vaccination denialism. Here’s what contemporary epidemiological research reveals.

Five Important Studies Showing Alcohol’s Benefits

1. Alcohol consumption in later life and reaching longevity: The Netherlands Cohort Study (Age and Aging, 2020).

This was a prospective study of a cohort group, where people were identified as “young” seniors (ages 68-70) and followed for 20 or more years to compare who survived until 90 and who did not. There was a significant positive association between starting-point alcohol intake and the probability of reaching 90 years for both men and women. Overall, the highest probability of reaching 90 was found in those consuming 5 < 15 g/d alcohol (up to a drink daily), with RR = 1.36.

Translation: RR is your “relative risk.” You would be 1.36 times more likely to reach 90 if you drank compared to abstaining, based on a multivariate analysis in which smoking, body mass, physical activity, history of illnesses, and education and occupation were included and their impact separated out—i.e., the impact of drinking was isolated.

Even men who drank several drinks more and women having up to another drink daily outlived those who abstained.

2. Alcohol intake and cognitively healthy longevity in community-dwelling adults: The Rancho Bernardo Study (Journal of Alzheimer’s Disease, 2017).

Another prospective study involved a group of seniors living in an upscale American residential development. Alcohol intake was measured and analyzed against people’s likelihood of reaching 90 with their cognitive faculties intact over a 20-year period.

Among Americans, this California group of seniors was unusually likely to imbibe. Most participants (88 percent) reported some current alcohol intake. Almost half drank regularly (49 percent reported a moderate amount of alcohol intake, and 48 percent reported drinking near-daily). 

The study concluded: “Relative to nondrinkers, moderate and heavy drinkers (up to 3 drinks/day for women and for men 65 years and older, up to 4 drinks/day for men under 65 years) had significantly higher adjusted odds of survival to age 85 without cognitive impairment.”

3. The 90+ Study by the University of California Irvine’s Institute for Memory Impairments and Neurological Disorders (American Association for the Advancement of Science Conference, 2018).

Time magazine covered the results of the 90+ Study—which examines the habits of people who live to at least 90—as they were reported at the annual conference of the American Association for the Advancement of Science.

As the article noted of the findings: “Drinking about two glasses of wine or beer a day was linked to an 18% drop in a person’s risk of early death—an even stronger effect than the life-preserving practice of exercise, according to the researchers.” 

4. Harvard Nurses’ Health and Health Professionals Studies (Circulation, 2018).

Insider magazine reported the results of 30 years of data for 120,000 health professionals tracked by the Harvard School of Public Health. The article responded to a recent trend: Dry January, which polling had suggested was attempted by one in five Americans:

Researchers at the Harvard TH Chan School of Public Health studied 30 years of data on nearly 80,000 women and 40,000 men to understand how their lifestyle habits affected their lifespan. Aside from eating a balanced diet and avoiding cigarettes, they found that the healthiest people with the longest life expectancies also drank a few units of alcohol a week.

Women who reported drinking up to 15g of alcohol a day (roughly one drink), and men who had up to 30g a day were less likely to prematurely develop diabetes and heart disease than those who had avoided alcohol altogether or drank in excess, the study found. This was the case particularly if they also exercised regularly, didn’t smoke, and ate plenty of vegetables. [This report omits a fifth included health factor: body mass.]

Moderate drinking, it should be noted, reduces disease even for those with the other positive health indicators. Yet curiously, the Chan School of Public Health omits mentioning these benefits in its newsletter addressing prevention of heart disease. 

5. Consuming alcohol in moderation can lower mortality risks (Journal of the American College of Cardiology, 2017).

The press release accompanying this study published in the American College of Cardiology’s flagship journal describes:  

Men and women who engage in light-to-moderate alcohol consumption have a decreased risk of mortality from all-causes and cardiovascular disease …

Bo Xi, MD, et al., looked at the relationship between all-cause, cardiovascular disease and cancer mortality risks and current alcohol consumption patterns. The researchers used data from 333,247 participants obtained through the National Health Interview Surveys from 1997 to 2009.

In an accompanying editorial, Giovanni de Gaetano, MD, PhD, said that while younger adults should not expect considerable benefit from moderate drinking, “for most older persons, the overall benefits of light drinking, especially the reduced cardiovascular disease risk, clearly outweigh possible cancer risk.” 

A Public Health Messaging Imperative

The sheer regularity of such findings—compiled in long-term research projects by highly respected investigators with large and varied groups of subjects, published in leading journals and funded by international health bodies—means that rejection of these results is an irrational, knee-jerk cultural response.

All negative alcohol impacts simply don’t carry as much weight on the scale of life as alcohol’s cardiovascular benefits.

And what is the cost of such denial? On our way to answering that, let’s note some objections commonly raised to such research. 

1. The research is funded and promoted by the alcohol industry.

The Netherlands Cohort Study is funded by the Dutch Cancer Society, the World Cancer Research Fund, the European Union (EU), and the Netherlands Organisation for Health Research and Development.

The Rancho Bernardo Study of Healthy Aging is a half-century-old study of a retirement community near San Diego funded by the National Institutes of Health (NIH), administered through the University of California San Diego.

The 90+ Study is a similarly decades-long research project out of the University of California Irvine’s Institute for Memory Impairments and Neurological Disorders.

The Harvard Health Professionals and Nurses Health Studies are research tracking tens of thousands of American health professionals administered by the Harvard School of Public Health, funded by the National Cancer Institute. (The NCI, one of the National Institutes of Health, is not to be confused with the American Institute for Cancer Research that wants a warning label, which is a private professional association.)

The National Health Interview Survey (NHIS) whose results were reported by the American College of Cardiology is a massive federal study established by the NIH in 1957 to monitor Americans’ health through national surveys.

2. Research on alcohol intake doesn’t take into account other factors in people’s lives that may impact their health and longevity. 

All research of this caliber measures and assesses the impact of other influential factors in longevity. If there is a key missing variable, it has to have escaped the notice of an awful lot of keen scientific minds.

3. The research doesn’t recognize that people often quit drinking because they are ill (or addicted)—the “sick quitters” hypothesis.

Once again: Do you think all those researchers missed that? There are two ways in which research accounts for sick quitters: Comparing drinkers with lifetime abstainers, or (in prospective studies) assessing illness at baseline.

4. Alcohol may reduce heart disease. But this is more than made up for by drinkers’ incidence of cancer, particularly for women.

No, it isn’t. Longevity is a net measure of survival. And the alcohol loading for impacted cancers (about 5 percent) is significantly lower than the coefficient for its cardiovascular benefits: The Lancet study examining subjects in wealthier countries found a 30 percent reduction in coronary artery disease, yielding a 20 percent reduction in overall mortality.

Alongside this, coronary artery diseases are the largest killer of women as well as men in the US, exceeding all forms of cancer. Moreover, lung cancer, which has not been shown to be affected by moderate drinking, is by far the most common cause of cancer death, outpacing breast, digestive tract and liver cancers.

All negative alcohol impacts that can potentially be noted—and will be, for instance by the ever-vigilant Times—simply don’t carry as much weight on the scale of life as alcohol’s cardiovascular benefits.

5. There’s no cost to simply telling people not to drink.

Yes, there is. People are welcome to abstain for whatever reasons they want. But reliable research tells us that most people reduce their likelihood of illness and death by drinking.

A public health message that conveys the dangers of alcohol, but ignores the benefits of drinking, is therefore loading the dice against most people.

And all these health considerations don’t even account for pleasure. 

Photograph by Ominae via Wikimedia Commons/Creative Commons 4.0

The post Warn That Alcohol Causes Cancer? Add That Drinkers Live Longer. appeared first on Filter.

From the ‘50s through the ‘70s, alcohol consumption and intoxication were unselfconsciously portrayed on television. In Gunsmoke, a CBS mainstay from 1955 to 1975, the key figures in the series (Marshall Matt Dillon, played by TV icon James Arness, saloon hostess Kitty, Doc, and sidekicks Chester and Festus) regularly drank together. They didn’t become drunk. They drank beer usually, and on special occasions spirits.

Negative behaviors associated with alcohol use could be contained through a range of methods employed by the show’s characters.

A “town drunk” was a recurrent character in the show. But his intoxication was controlled and he was protected from harm by the show’s regulars in a 19th century version of harm reduction. This man was also able to resist drinking at key moments, and indeed was shown to be heroic in several episodes.

The dangers of alcohol were not ignored in Gunsmoke. Single men drank heavily at Kitty’s Long Branch saloon in Dodge City. They sometimes became obstreperous, and occasionally violence erupted. The regular town folk, who might have “medicinal” liquor in their homes, didn’t frequent the saloon. Alcohol, in short, was used differently by people in different social situations and settings. But negative behaviors associated with its use could be contained through a range of methods employed by the show’s characters.

As drugs became a prominent part of youth culture in the 1960s, marijuana was sometimes depicted as an illicit secret pleasure on mainstream media. For example, pot allusions suffused The Smothers Brothers Comedy Hour, a popular CBS variety show of the late 1960s. But tolerance for such light-hearted references to drugs was iffy. In fact, the drug allusions and anti-war sentiments that the show’s creators (embodied by Tommy Smothers, who delighted in tormenting CBS execs and censors) sneaked into the script caused constant friction with the network. The show was cancelled despite being one of television’s highest-rated programs.

Even long after this, in 1993-1994, PBS was forced to cancel its dramatization of Armistead Maupin’s stories, Tales of the City. The highly regarded series couldn’t continue due to objections in Congress to its ho-hum depictions of marijuana use and gay life in San Francisco. (Tales did return via streaming in 2019, including reruns of the original on Acorn and an updated version on Netflix.)

Streaming has allowed for the segmentation of media … This greatly broadened the ways in which drugs and intoxication could be shown.

The onset of recovery as a major, perhaps the principal, lens through which substance use was portrayed was introduced by the long-running series Murphy Brown, starring Candice Bergen, which CBS launched in 1988. Today, abstinent recovery (aka sobriety) remains the only accepted response to excessive substance use on US network television. The just-concluded hit CBS series Mom, for example, featured a fictional mother and daughter who are both in 12-step recovery.

But streaming has allowed for the segmentation of media for adult viewers in a way that wasn’t possible on network TV. This greatly broadened the ways in which drugs and intoxication could be shown. From 2015 through 2019, Netflix screened Jessica Jones, featuring a blackout-drinking former superhero. In 2016-17, TNT streamed the ironically titled Good Behavior, about a recovering woman on parole who still drinks and steals. In 2019, The CW began streaming In the Dark, whose world-weary blind lead drinks heavily to console herself.

These characters aren’t sober in either the traditional meaning of the word (i.e., not intoxicated—they get drunk), nor in AA’s terms (since they drink at all). But they are navigating life in overall constructive ways, despite problems. Like most of us.

The HBO Revolution: Mare and Hacks

HBO, meanwhile, has become a leader in a renewed vision of how people manage substances and their responses to drug-related problems.

Consider two currently streaming HBO series: Mare of Easttown and Hacks. Mare (starring Kate Winslett, with Jean Smart costarring as her mother) is a much-heralded noir police story in which people drink, vape and take drugs in a marginalized post-industrial town outside of Philadelphia.

It would seem that the creators are familiar with modern harm reduction.

Drug policy reform pioneer Ethan Nadelmann was enthusiastic after watching, remarking, “I loved how they got nicotine vaping, needle exchange programs (to distribute a missing person flyer), cannabis dispensaries and the unpleasantness of consuming too much edible marijuana in one sitting—all in the first episode!” It would seem that the creators are familiar with modern harm reduction.

As well as vaping, Mare drinks regularly—Rolling Rock (a regional Pennsylvania beer) and Jameson’s. For her part, her mother favors cocktails. Although they might seem to rely on alcohol, neither woman drinks to intoxication.

Other characters in Mare do have drinking issues, which are associated with the sexual assaults and other violence that form the show’s plot. However, as was true for Gunsmoke, alcohol is not shown as the cause of people’s problems. Problematic drinking and loss of control are not the show’s focus, which is rather the characters’ traumas, isolation and neediness. These human experiences may lead to problematic behaviors, which at times reach extreme levels, sometimes involving drugs.

Mare, as a 40-ish detective, doesn’t use nonprescribed drugs. But younger characters use marijuana and other drugs, and some become addicted. Those with drug-related problems include Mare’s deceased son and his surviving wife, whom Mare and her mother are contesting for custody of Mare’s grandson. Yet AA, NA and recovery are nowhere to be seen. Mare’s daughter-in-law does enter an unspecified form of rehab. But treatment hasn’t been effective for her in the past—just as it didn’t help Mare’s son.

None is presented as a definitive cause or solution … There are no magic bullets in Mare.

Mare herself goes to therapy. She lost both her father and son to suicide, and she understandably worries about her grandson’s mental health. Mare discusses with her therapist a panoply of psychiatric issues—including genetic inheritance, psychiatric meds and trauma. None is presented as a definitive cause or solution for the characters’ problems. There are no magic bullets in Mare.

Although viewers may see Mare as a trauma victim, the show rather portrays her as an existential hero. She has a purpose: pursuing the truth. This brings her into conflict with other characters, including her best friend. But it also enables her to move forward in life.

The show’s characters reflect Easttown’s socio-economic marginalization through a number of serious problems they have and crimes they commit that the show doesn’t shy away from.  At the same time, Mare, portrayed stunningly by Winslet, struggles to live her own complex life as best she can, as do the other characters, with differing degrees of success. Some, obviously, fail utterly.

Hacks, meanwhile, is a comedy with dark overtones. It also stars Jean Smart, this time as an older comedian struggling to remain on top of the Las Vegas game. She drinks, while a young comedy writer brought on to freshen her routines (played by Hannah Einbinder), takes a variety of drugs. The younger character, too, is struggling to establish her relevance, amidst sometimes iffy behavior. At one point, she snorts cocaine in a Las Vegas restaurant bathroom as a get-to-know-you with a man she meets.

That interaction ends disastrously. But the two women’s substance use is not portrayed as the path to perdition, as it would have been in the prior half-century of American mainstream media. Neither of the central women is self-conscious or apologetic about her substance use. Neither seems headed to rehab or AA.

All is not peaches and cream, however. Smart’s character can be bitter when drinking. But she doesn’t need to add alcohol to be mean. Her attitude has affected her parenting, and her daughter isn’t well launched. The comedian searches her daughter’s purse for drugs, which have been an issue for her daughter in the past (although she now practices harm-reduction recovery and drinks).

When substances are not regarded as the causes of people’s, and society’s, difficulties, we enter the realm of harm reduction.

Just as in Mare and Gunsmoke before it, drugs are not the sources of personal crises. The characters’ existential problems are instead steeped in psychological and societal issues.

When substances are not regarded as the causes of people’s, and society’s, difficulties, we enter the realm of harm reduction. This development represents a new consciousness around substance use defined by its realities, both good and bad.

One scene from Hacks is straight out of the Harm Reduction and Anti-Drug Stigmatization Handbook. Einbinder’s character has been doing coke, molly and cannabis over a day or two. During this time the two women have had a breakthrough in their relationship while sharing cannabis edibles. Smart needed the cannabis, which Einbinder provides from her personal supply, because she wasn’t given enough Vicodin to relieve her pain after having a facelift.

Einbinder then is hospitalized for abdominal pain. The ER doctor—hearing the list of drugs she has consumed—blames the drugs for her condition. He declares, without performing any tests, that she is suffering from dehydration. The older comedian then threatens the doctor and forces him to order a CAT scan for her young friend. The scan reveals that an ovarian cyst has burst, which saves Einbinder’s life.

Drugs were not the problem.

HBO, it seems, has become the bold frontier in the normalized portrayal of substance use.

Screenshot of Kate Winslet in Mare of Easttown via HBO trailer

Stanton Peele’s memoir: A Scientific Life on the Edge: My Lonely Quest to Change How We See Addiction, is available on Amazon.

The post “Mare of Easttown” and the Streaming Harm Reduction Revolution appeared first on Filter.

Meanwhile, New York Times columnist Jennifer Finney Boylan, like many of us, reminisced poignantly about time gone by this holiday season:

I am thinking about the things we have lost this year: over a quarter of a million dead in this country, lives upended and destroyed. And the small things too: the closeness of friends, a pint in a pub, a stranger’s handshake …

The old clock chimes. I remember that sound from my grandmother’s apartment, back when I went to visit her after school. She used to make me frozen pizza. Later, after a certain number of martinis, she’d always ask, “Have I ever told you the story of the night your father was conceived?” …

My daughter was home for Thanksgiving. On the night before she left, we all fell to singing songs. The last tune my child sang that night was “The Parting Glass.” “So fill to me the parting glass, and drink a health what’ere befalls; I’ll gently rise and softly call. Good night and joy be with you all.”

Notice how alcohol rears its head in every anecdote? Hasn’t Boylan gotten the message that drinking is unhealthy and dangerous, and destroys families? 

But she’s not the most prominent or culpable writer in this regard. Remember how Dickens’ A Christmas Carol ends? Scrooge visits his clerk Bob Cratchit’s happy family at their Christmas dinner, when Cratchit breaks out his famous punch.

The compound in the jug being tasted, and considered perfect, apples and oranges were put upon the table, and a shovel-full of chestnuts on the fire. Then all the Cratchit family drew round the hearth … At Bob Cratchit’s elbow stood the family display of glass. Two tumblers, and a custard-cup without a handle. These held the hot stuff from the jug, however, as well as golden goblets would have done; and Bob served it out with beaming looks. [My italics.]

Cratchit raises a glass, and Tiny Tim echoes his toast: “God bless us every one!”

Are they teaching poor Tiny Tim to consume alcohol—at Christmas yet?

Life across the ages, particularly spiritual or festive life, is imbued with alcohol—an accompaniment to both good times (Christmas, Chanukah, weddings, New Year’s Eve, toasting a newborn or a Briss) and bad (wakes, seeking solace after a breakup, dealing with a haunted house à la Poltergeist, quarantine).

That ethanol has always been a part of humanity is the conclusion of “the spiritual archeologist,” who says “alcohol and human evolution are interrelated.” University of Pennsylvania Museum bio-archeologist Patrick McGovern—in Uncorking the Past: The Quest for Wine, Beer, and Other Alcoholic Beverages—concluded that alcohol was a central presence in every seat of civilization. Exceptions, such as those in the Muslim world, represent relatively new impositions that are far from universally observed.

Brewing dates from the beginning of civilization in ancient Egypt, and beer and wine were offered to the gods, according to Iain Gately’s Drink: A Cultural History of Alcohol. Beer and wine were likewise central to Babylonian civilization, and wine goddesses were worshipped. The Code of Hammurabi deals with alcohol, but never mentions drunkenness. Ritual, apparently, encourages moderation. Early Middle-Eastern scientists used distillation extensively. They spread the process to Europe, according to Ahmad Yousef Al-Hassan, an historian of Arabic and Islamic science.

Anyone would think that addiction is overwhelmingly a socio-cultural phenomenon, rather than tied up in the inherent properties of substances.

Beer and wine have also been drunk by Indigenous populations throughout Africa and the New World, as described in MacAndrew and Edgerton’s classic work, Drunken Comportment. Dwight Heath, the premier anthropologist of alcohol use, experienced drinking a distilled spirit with the Camba people of Columbia. The Camba drank copiously, Heath reported, but without problems. Malcolm Gladwell described this process in the New Yorker:

Every weekend and holiday the Heaths went to a party where guests sat in a circle drinking a strong local rum from Saturday night until Monday morning, when they went to work. People regularly passed out at the party, awoke and started drinking again. 

Nonetheless, Heath told Gladwell:

There was no social pathology—none. No arguments, no disputes, no sexual aggression, no verbal aggression. There was pleasant conversation or silence. The drinking didn’t interfere with work. And there was no alcoholism. 

Similarly, Southern Europe, where wine is typically shared by all generations at meals, experiences far fewer alcohol harms than Northern Europe or the States, where adolescent binging sessions form most people’s introduction to drinking.

Anyone would think that addiction is overwhelmingly a socio-cultural phenomenon, rather than tied up in the inherent properties of substances—and that those concerned with public health should be engaged not with the futile attempt to remove drugs from our lives, but with encouraging skilled, positive drug use. As the subtitle of Gladwell’s New Yorker piece summarizes this perspective: “How much people drink may matter less than how they drink it.”

I have long argued that data show—despite the existence of plenty of real harms associated with alcohol—that its net, population-level health effect is often beneficial, depending on the context of its consumption. But its benefits to our cultural and social bonds go so much further.

As such, stripping away alcohol from our human narrative would represent a fundamental loss to our species. Fortunately, no such thing will happen.

On a personal seasonal note, I enjoyed my family’s Zoom Chanukah this year with a prayer I taught my kids and grandkids—one that long precedes me into the dawn of Judaism.

Barukh ata Adonai, Eloheinu Melekh ha-olam, borei peri hagafen. 

Blessed are You, God, Ruler of the universe, who creates the fruit of the vine.

Photo by Tengyart on Unsplash

The post Reason to Raise a Glass: The Alcohol-Zero-Tolerance Project Is Doomed appeared first on Filter.

RAND Corporation—the organization that in the late 1970s was vilified for reporting that most recovery from alcohol dependence was due to reduced drinking—has conducted another highly publicized study in 2020. Published by JAMA Network Open last month, it found that people are drinking more alcohol lately. This has led to alarmist headlines, like this one from ABC News: “Alcohol consumption rising sharply during pandemic, especially among women: An ‘effective pain killer’ in a time of trauma sparks concern among experts.”

Oh, wait—that’s why we’re drinking more. And we’re largely better off for it.

I have been around the commotion raised by both RAND studies. Only this time, the lurid headlines don’t come from AA, recovery and anti-alcohol public health factions. That’s not necessary; RAND is doing this PR itself:

RAND Press Release, September 29 

Alcohol Consumption Rises Sharply During Pandemic Shutdown: Heavy Drinking By Women Rises 41%

“Alcohol consumption can have significant negative health consequences, so this information suggests another way that the pandemic may be affecting the physical and mental health of Americans,” [said lead study author Michael Pollard.]

Forget the West Coast burning, Donald Trump permanently taking over the reins of government and spreading COVID, and your children never leaving the house.

Oh, wait—that’s why we’re drinking more. And we’re largely better off for it—or for smoking cannabis or using our other drugs of choice. “Whatever gets you through the night, it’s all right,” as John Lennon put it.

We and our ancestors have perpetually used psychoactive substances for two key reasons: to enjoy them, and to enable us to endure rough spots. In most cases, our drug use doesn’t become a destructive long-term habit, but instead enhances and supports our lives.

I have noticed what is being detected nationwide in my own neighborhood liquor store. Starting early in the pandemic, Time reports, “national alcohol sales increased 54 percent … and online sales leapt a staggering 262 percent” compared with the same period last year.

Time’s take offers far better insight into the RAND data and increased drinking in the pandemic than, say, NPR (“The Coronavirus Crisis: Hangover From Alcohol Boom Could Last Long After Pandemic Ends”) and USA Today (“Drowning our sorrows? American adults are drinking more alcohol amid COVID-19, study finds”).

Jeffrey Kluger’s Time piece seeks to lower the heat: “Americans Are Drinking More During the Pandemic—But Perhaps Not as Much as You’d Think.” It begins:

Humans, like nature itself, abhor a vacuum—and there’s been no vacuum lately quite like the tedious months of Covid-19 quarantine. In nature, air rushes in to fill the empty space. In the time of pandemic, it’s been alcohol. That, at least, is the finding of a new survey of American adults conducted by the RAND Corporation. . . . But the study bears close reading. 

What is Time doing—trying to be reasonable? The piece points out, regarding the RAND data:

Overall, men reported drinking heavily just 1 day (.95 days) per month in 2019; that increased by just one-tenth of a day (.07 days) per month this year. Women drank heavily on just half a day (0.44 days) per month in 2019; that increased by two tenths (0.18) of a day this year. So overall, men are still drinking heavily more than women are, and in both cases, the numbers factor out to just one bender per month. 

“Bender” is the wrong term, however, to apply to people identified by RAND as heavy drinkers. “Heavy drinking” women have had four or more drinks in two hours—five for men. It’s more accurate to say that they get drunk (if even that) once a month. 

Time continues:

Clearly, no amount of heavy drinking is healthy, and the overall increase of 14% among adults is an undeniable cause for concern. But for the moment at least, it appears that even in time of pandemic, both men and women are holding the worst of their imbibing to a comparative minimum.  

While I would dispute the negative construction of even this degree of drinking and health, Time’s conclusion (which I have italicized) is justified.

Of course, such data must always be filtered through a social prism. Deprived, marginalized, unemployed people, those who have the most reason to seek the compensations or anesthesia of substances, are not experiencing the pandemic in the same way as most readers of Time.  

People with the least resources and the most life stressors are, quite logically, the people who are most susceptible to risky patterns of drug use.

This is true, for starters, with deaths and illness due to COVID, which are highly segmented by race and zip code, as the New York Times explored. The Times found, consistent with all such data, that COVID deaths follow the same path as drug deaths: People who are already disadvantaged suffer the worst, by far.

With drugs, this is because social supports for moderate substance use are most available to people with the most resources. People with the least resources and the most life stressors are, quite logically, the people who are most susceptible to risky patterns of drug use. (The answer—contrary to American impulses—isn’t to deprive people of the substances on which they rely, but to enhance support and reduce stress. But that would require structural changes that Americans have consistently failed to make.)

Thus, amidst the moaning and grieving that middle-class people may be getting drunk or stoned occasionally, when we read about their stressed-but-privileged lives, that picture doesn’t reflect our era’s mushrooming deaths of despair.

The six states with the highest drug death rates (measured in 2018) are in impoverished Appalachia (West Virginia is No. 1 by a wide margin); are home to a troubled inner city (Maryland); are in rural New England (New Hampshire); or are impacted by post-industrial decline (Ohio, Pennsylvania and Delaware). Indeed, drug death rates have increased sharply during the pandemic, to new record levels in most states.

But we shouldn’t conflate these situations, as so much of the media does, with increased substance use by middle-class moms.

The “Mother’s Little Helper” Trope

The latest New York Times contribution to this discussion—“Mother’s Little Helper Is Back, and Daddy’s Partaking Too”—tells us how “after the kids go to bed, the grown-ups are drinking and smoking pot to distract themselves from the hellscape that is pandemic parenting.” The article describes a privileged group of parents:

7:51 p.m.: It’s exactly 125 days tomorrow. I am pretg drink.

7:52 p.m.: Drunk.

7:52 p.m. I can tell.

I have a years-long WhatsApp message group with a handful of fellow mothers of small children from across the United States and Canada. Since the pandemic began, what I refer to as “mom chats after dark” start at around 7:30 p.m., Eastern Standard Time. That’s when the children are asleep, and a wave of inebriation begins on the shores of the Atlantic and crashes across the continent. The above message was from July, when we hit 125 days of lockdown.

Another message, in September:

12:10 a.m.: I’m really high and eating this cake right now and it’s sooooo [expletive deleted] good.  

The horror! While the piece paints something of the landscape that prompts such a “wave of inebriation” (that last message was from a mother in California, trapped inside by smoke-filled air), the substance use itself seems nothing more than casual relief.

As one quoted expert notes:

The increase of substance use among parents is “just kind of understandable,” said Jonathan Metzl, the director of the department of medicine, health and society at Vanderbilt University. “This is an incredible, once-in-an-epoch stressful situation, and the kinds of outlets people usually have in their lives are just not available. We can’t go to the office, we can’t go to the gym, we can’t really see friends or family, and we never get a break.”

 To her credit, the author of the piece recognizes:

And we’re the lucky ones who can meet our children’s basic needs. Somewhere between 20 and 40 percent of parents of children under 5 have worried about their children getting enough to eat since the pandemic started, and many who cannot work remotely are scrambling for coverage with the fitful reopening of day care centers and schools.

Those parents tend not to be the people writing to a WhatsApp group about eating “[expletive deleted] good” cake after the kids go to bed.

Seniors Can Get in on the Act!

I’m in my 70s, my kids are in their 30s and 40s, and I live alone. I compared myself with a woman who wrote about her experiences in my University of Pennsylvania alumni magazine (I know, I’ve had a tough existence).

The woman, in her 80s, is depressed about spending her twilight years in the pandemic. She also lives alone. Although she has attentive family and old friends, she rarely sees them. She worries because she drinks a couple of glasses of wine in the evening, listening to music and watching Netflix and cable news.

Yes, I confess: I am one of those besotted heavy drinkers spotlighted in the RAND study!

My activities are similar to those of my counterpart. I differ from her in that I drink more bourbon, vodka and rum than wine. My daughter in New York gives me booze as presents. I too drink mainly at home, but sometimes at restaurants and bars, which are open for outdoor dining and drinking. I occasionally meet friends and colleagues at these establishments. I ride my bike there. I limit myself to one drink outside my home.

Overall, I have 2-4 drinks a day, which I believe, based on the data, to be a healthy level for me. I generally don’t become inebriated. I make sure I drink in a safe space. Once in a while, I have 5-6 drinks. Yes, I confess: Age 74, I am one of those besotted heavy drinkers spotlighted in the RAND study!

I actually attribute my relatively good health and productivity in part to alcohol. Our president doesn’t drink or take other recreational drugs. Which raises the question of whether he would be a better, and healthier, person if he drank and smoked cannabis. While he made more than one emergency visit to Walter Reed over the past year, I listened to Lou Reed.

I’m okay living this way for the foreseeable future. In fact, it seems pretty [expletive deleted] good, considering the alternatives.

Photo by Mitchell Luo on Unsplash

The post So We’re Drinking Our Way Through the Pandemic? It’s What Drugs Are For. appeared first on Filter.

Except that’s not the role Whitman chose when confronting one of the greatest public health crises of the last century.

By the late 1980s HIV/AIDS was devastating many communities, including people who inject drugs. In 1993, AIDS became the leading cause of death for young Black people. In 1994, as the HIV/AIDS epidemic grew in New Jersey, Christine Todd Whitman assumed the governorship of the state and appointed a Governor’s Advisory Council on AIDS.

To head this advisory group, Whitman selected a man she thought of as a safe choice: David W. Troast, who was known as a loyal Republican.

But he didn’t work out the way Whitman expected. Troast told the New York Times that “he was initially opposed to needle exchange programs, but was persuaded after visiting a similar program in the Bronx and by recent studies showing that easier access to clean needles slows the spread of the virus that causes AIDS.”  So the council—comprising religious and community leaders, healthcare professionals, social service providers, state legislators and administration officials—voted overwhelmingly in support of such a program.

To no avail. Whitman ignored her Advisory Council and nixed syringe exchanges. More than this, New Jersey law enforcement used decoy “addicts” to arrest activists who distributed needles, destroying organized needle exchange efforts in the state by 1998, with the governor’s full-throated approval for “enforcing the law.”

Observers were surprised at the virulence of such a campaign led by a “moderate” Republican. Per the 1999 Times article:

The needle-less campaign, and the unusually aggressive tactic of using sting operations to snare advocates for AIDS victims, has made New Jersey the most active front in the nation’s fierce political battle about the merit of needle exchanges. The state’s unrelenting opposition to the programs also places Gov. Christine Todd Whitman in the uncharacteristic role of hard-liner.

At the same time, neighboring Republican governors in New York, Connecticut and Pennsylvania used state money to fund syringe programs, which had been shown to save lives and, incidentally, to save taxpayers the high cost of treating people with HIV/AIDS.

In her actions, Whitman went against all of the major US public health agencies. Again, from the Times:

The Centers for Disease Control and Prevention, the National Institutes of Health and the Surgeon General have all released studies concluding that needle exchanges significantly decrease the spread of H.I.V. without increasing drug use. Mrs. Whitman dismisses their research as ”dubious, at best.”

Indeed, during her administration, New Jersey’s Robert Wood Johnson Foundation did decisive research showing that not only did such programs fight HIV transmission, they encouraged people with addiction to enter treatment.

However:

…when Governor Whitman was asked recently to explain the factual basis for her unflinching belief that needle exchanges send the wrong message to children, she grew frustrated, as if the hypocrisy of the programs were so obvious it needed no explanation.

”As a mother, I know that it sets a bad example,” she said during an interview last month. ”’Do as I say, not as I do’ is a lousy way to lead, whether you’re running a family or running a state.”

Does this stonewall denial of the science around a public health disaster remind you of any other Republican office-holder?

Troast had projected the numbers of people who would be saved by a state needle exchange program:

In New Jersey, intravenous drug use accounted for 51 percent of the state’s 28,125 reported AIDS cases from the early 1980’s through December [1995]. The state ranks fifth in total number of AIDS cases. Mr. Troast said needle exchange programs could save an estimated 650 lives a year by reducing the transmission of the H.I.V. virus, which causes AIDS, among the state’s estimated 200,000 intravenous drug users.

Whitman vetoed this life-saving policy in 1996. Only in 2007 did New Jersey become “the final state in the United States to adopt a needle exchange program.” Multiplying Troast’s estimated saving of 650 lives a year by the 11-year delay in implementing needle exchange in New Jersey arrives at a total of about 7,000 dead (this does not include transmission to children—New Jersey was also a leader in pediatric HIV/AIDS cases).

Whitman has never indicated any regrets about this delay and its consequences. Nor did it hurt her career in the least. Seemingly, these Black or drug-user lives mattered little to New Jerseyans of the era. Not only was she re-elected, she remains a revered representative of “moderation” in the Republican Party.

But did she really have to be platformed at the 2020 Democratic National Convention?

Photograph of Whitman in 2017 by Petty Officer 3rd Class Nicole Barger via US Coast Guard

The post Democrats Platform Arch-Enemy of Syringe Exchange on DNC Opening Night appeared first on Filter.

Among its topics, Guidelines tells Americans how much alcohol they should consume—or whether they should drink at all. For those familiar with America’s temperance history, this can be a weighted topic. 

The US, of course, banned the production, sale and commercial consumption of alcohol for 13 years, from 1920 to 1933. Among countries that have never prohibited alcohol are Italy, Greece, Spain, Germany, Japan and China. Indeed, the non-Muslim nations that have banned alcohol for substantial periods—Canada, Russia/Soviet Union, Finland, Iceland, Norway and the Philippines—can almost be counted on one hand.

The vacillating recommendations about alcohol in the US Guidelines over the decades make it a fascinating cultural document—especially since it is obligated to explain its advice in health terms. Let’s take a trip down memory lane.

1990:

“Alcohol has no net health benefit, is linked with many health problems, is the cause of many accidents and can lead to addiction. Its consumption is not recommended.”

1995:

“Alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history” [while] “current evidence suggests that moderate drinking … is associated with a lower risk for coronary heart disease in some individuals.”

2010:

The 2010 Guidelines’ alcohol section expert panel was headed by Eric Rimm, now director of the Harvard School of Public Health’s Program in Cardiovascular Epidemiology. The 2010 alcohol panel reported “strong evidence” that “the lowest mortality risk for men and women [occurs] at the average level of one to two drinks per day, [and] is likely due to the protective effects of moderate alcohol consumption on CHD [coronary heart disease], diabetes and ischemic stroke.”

The panel’s report further noted that “moderate evidence suggests that compared to non-drinkers, individuals who drink moderately have a slower cognitive decline with age.”

2015:

“If alcohol is consumed, it should be in moderation—up to one drink per day for women and up to two drinks per day for men … In comparison to moderate alcohol consumption, high-risk drinking is the consumption of 4 or more drinks on any day or 8 or more drinks per week for women and 5 or more drinks on any day or 15 or more drinks per week for men.”

“Excessive alcohol consumption … has no benefits.” [The implication that moderate drinking does have benefits was left unspoken.]

2020:

The Guidelines’ scientific panel for alcohol recommended reducing the amount of alcohol men should consume to one drink per day instead of two.

The New York Times article on the recommendations led by noting: “Can a daily drink or two lead to better health? For many years, the federal government’s influential dietary guidelines implied as much, saying there was evidence that moderate drinking could lower the risk of heart disease and reduce mortality … The 2010 guidelines mentioned that moderate drinking may even ‘help to keep cognitive function intact with age.’” 

“This would suggest that there is a lot of new science on this topic, and there’s not.”

Not so, the new Guidelines background report “shows.” As one public health expert intoned in the Times piece, “the committee has finally gotten away from this idea that a small amount of alcohol is good for you. They’re really taking a stand and saying drinking less is always better,” indicating abstinence is the best policy. 

The Guidelines’ push towards abstinence follows on the World Health Organization’s 2018 declaration that there is “no safe level of alcohol.” 

Rimm responded to the new recommendations: “This would suggest that there is a lot of new science on this topic, and there’s not. It’s unfortunate because it’s going to create some confusion.” 

What the Data Keep Showing

I have reviewed these data for Filter. Hundreds of studies have found moderate drinkers to be healthier, and to live longer, than lifetime abstainers (after eliminating from the analysis those who have quit drinking for health reasons or due to alcohol use disorders). Such data never stop cropping up. Consider this 2017 report in the Journal of the American College of Cardiology, based on US government research involving a third of a million Americans:

Data were obtained by linking 13 waves of the National Health Interview Surveys (1997 to 2009) to the National Death Index records through December 31, 2011. A total of 333,247 participants ≥18 years of age were included … 

Results: Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes [such as heart disease and all forms of cancer]. 

Whatever WHO and the Guidelines tell us, they can’t erase regular findings that moderate drinkers are healthier and live longer.

We must question how public health bodies feel safe to ignore such persistent findings.

Such data, as with that 2017 report, come from large-scale government research and prestigious health agencies. Rimm and colleagues reported in 2010 that there was “strong evidence” that moderate drinkers had the “lowest mortality risk” (i.e., lived longest). I have long noted—from 1993 in the American Journal of Public Health to 2017 in Pacific Standard—that this conclusion is justified scientifically.

What about their reporting moderately strong evidence for the cognitive benefits of moderate drinking?

In 2000, Archie Brodsky* and I found in an article in Drug and Alcohol Dependence that the clearest psychological benefit** from alcohol (other than enjoyment) was reduced dementia/Alzheimer’s in middle-aged and older adults. As did Rimm et al., we based this conclusion on a series of research results.

So it was unsurprising when, in 2020, the Journal of the American Medical Association (JAMA) Network published a study of cognitive functioning and alcohol consumption:

In this cohort study of 19,887 participants from the Health and Retirement Study … when compared with never drinking, low to moderate drinking was associated with significantly better trajectories of higher cognition scores for mental status, word recall, and vocabulary and with lower rates of decline in each of these cognition domains. Meaning: Current low to moderate alcohol consumption among middle-aged or older adults may be associated with better total cognitive function. 

JAMA is no fly-by-night operation. Once again, we must question how national and international public health bodies feel safe to ignore such persistent findings of benefits from sensibly consuming alcohol.

A Common Objection

One popular criticism of data showing benefits from alcohol is that they are not the result of drinking, but occur because healthier people drink. Indeed, better-educated, economically better-off people are more often drinkers.

At a minimum, however, this finding removes the pall of the “no safe level of alcohol” meme. A group of privileged people—including, in my experience, an overwhelming majority of public health professionals—more often drink than those who are less privileged. Yet they comfortably maintain better health.

Thanks to their advantages, people who are wealthier and better-educated tend to do things that are both good for them—for example, they eat better and exercise more—and that are enjoyable.

Brodsky and I noted that the most reliable finding of a psychological benefit from alcohol is that people typically find drinking to be pleasurable. Is that something to be ignored or disparaged in the public health field, when many studies link happiness to longer life? Instead, as I wrote for Filter, encouraging positive, pleasurable substance use should be a drug policy project.

But if the many variables involved in comparing US socio-economic groups leave you unconvinced, we can turn to international examples.

Could it be that those presenting alcohol in the worst light overrepresent cultures that have the most harmful relationships with alcohol?

Studies of drinking among European countries have made an astounding discovery: There is less alcohol-related harm in countries that drink more! I detailed these results from the European Comparative Alcohol Study (ECAS)—the first systematic European comparison of drinking problems—as presented in the volume Alcohol in Postwar Europe:

Alcohol in Postwar Europe thoroughly supported with data that alcohol-related problems were lowest in Southern Europe and highest in the North, despite the much greater controls the latter imposed and the lower drinking ages and far greater consumption in the former. 

Even more surprising was that alcohol-related mortality was also much higher in the North, due principally to the tendency in Temperance cultures to drink in heavy bursts, rather than regularly, but moderately. This leads to more accidents, violence, and suicide, and perhaps even to cirrhosis in Finland, Norway, Sweden—which consume the least alcohol—than in France, Italy Portugal, Spain, Greece, which consume the most.

ECAS found alcohol-related mortality was substantially higher in Northern than Southern Europe: 18 versus 3 such deaths per 100,000 for men, 3 versus 0.5 for women. There was an inverse relationship between alcohol consumption and alcohol-related mortality. 

What makes these results doubly noteworthy is that Northern European countries are better-off economically as a group than Southern ones. Italian alcohol researcher Allaman Allamani described this as a cultural phenomenon: 

In the Northern countries, alcohol is described as a psychotropic agent … It has to do with the issue of control and with its opposite—“discontrol” or transgression. In the Southern countries, alcoholic beverages—mainly wine-–are drunk for their taste and smell, and are perceived as intimately related to food, thus as an integral part of meals and family life.

Allamani went on to shed light on the continuing resistance to national differences like those revealed by ECAS:

Many European policies have been based on the brilliant and extensive studies carried out in Northern Europe and in North America. They put great emphasis on control and restriction measures. … As a consequence, alcohol studies and experiences are strongly influenced by both the Nordic and English-speaking countries. International agencies and WHO itself have possibly been influenced by this situation.

Could it be that those presenting alcohol in the worst light overrepresent cultures that have the most harmful relationships with alcohol? We surely have more to learn from cultures that navigate alcohol successfully and beneficially.

And perhaps the constantly yoyo-ing Dietary Guidelines for Americans should come with their own warning label attached: Consumption of this material may impair your ability to live well.  

Image by minka2507 from Pixabay/Public Domain

*Archie Brodsky is a member of the board of directors of The Influence Foundation, which operates Filter.

** We might debate whether reduced dementia/Alzheimer’s should be characterized as a psychological benefit or a physiological one. I note in this regard that (1) a persistent search has yet to identify reliable physiological markers of dementia/Alzheimer’s, and (2) among the best predictors of absence of cognitive decline are paid work engagement and life satisfaction, indicating a strong environmental and psychological component that might be labeled purpose and engagement.

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