The General McCaffrey Scientific Fool Award
Dr. Anti-Harm Reduction: Enoch Gordis, M.D.
Winner of the General McCaffrey Scientific Fool Award for Scientism and Bureaucracy in Place of Scientific Integrity
The physician head of the federal agency charged with alcoholism research and treatment in the U.S. disavows unpopular scientific evidence his agency uncovered while at the same time parading the same results to the advantage of his agency.
Ignaz Philipp Semmelweis was a Hungarian physician (1818-1865) who first used exclusively antiseptic techniques in delivering babies. At the Vienna General Hospital he discovered that childbed fever, which then killed about 12 mothers out of every 100, was contagious and that doctors were spreading the disease by not washing their hands. Although Semmelweis was ridiculed, he nonetheless persisted, publishing The Etiology, Concept and Prophylaxis of Childbirth Fever in 1860. He was attacked ferociously despite the demonstrable truth and efficacy of his position, became mentally ill, and died in scientific disrepute. The year Semmelweis died, however, Joseph Lister developed modern antiseptic operating techniques, thereby proving Semmelweis correct.
What Semmelweis stands for today is bravery in maintaining a scientific position despite the opposition of the scientific establishment, and of faith in the value of scientific evidence even when it is unpopular. Enoch Gordis, director of the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA), stands for exactly the opposite stance towards evidence, truth, and establishment approval. For Gordis, no amount of evidence justifies crossing bureaucratic authority and received opinion.
When Gordis became director of the NIAAA in 1986, he trumpeted the need for a new, scientific approach to treating alcoholism, harkening back to medical misconceptions of former eras:
[T]he history of medicine demonstrates repeatedly that unevaluated treatment. . . is frequently useless and wasteful and sometimes dangerous and harmful. . . . [T]o determine whether a treatment accomplishes anything we have to know how similar patients who have not received the treatment fare. Perhaps untreated patients do just as well. . . . Perhaps treated patients do worse. . . . (Gordis, 1987, p. 582)
From the start of his tenure, Gordis has always maintained that alcoholism is a disease, one that should be amenable to modern medical treatment. Despite the slowness of the medical advances Gordis believes will revolutionize alcoholism treatment to produce real gains in the incidence or amelioration of alcoholism, he never misses an opportunity to tout this line of thought. Responding to a U.S. News and World Report story (September 8, 1997) which alluded to the skepticism about alcoholism treatment he expressed in 1987, Gordis wrote to the magazine (September 27, 1997):
By quoting my 1987 view of alcoholism treatment. . . the article disregarded 10 years of treatment research progress. These advances are of two major types: the ability based on new knowledge from neuroscience research to develop pharmacologic treatments that act on brain mechanisms involved in alcohol dependence and the ability to apply modern research techniques to evaluate both new and traditional behavioral treatments.
Let us consider the second type of advance Gordis claims has occurred - the primary example of which was Project MATCH, the largest and most expensive clinical trial of psychotherapy ever conducted. Despite high hopes by its distinguished investigators (Gordis wrote in the treatment manuals developed for MATCH, "Researchers in Project MATCH are among the most senior and experienced treatment scientists in the field"), no underlying matching of types of alcoholism treatment to alcoholic patient characteristics successfully predicted improved outcomes.
But Gordis adeptly shifted ground, claiming instead: "The good news is that treatment works. All three treatments evaluated in Project MATCH produced excellent overall outcomes" (Bower, 1997, p. 62). Readers may note that MATCH omitted the requirement for such a claim that Gordis had insisted on in 1987 - alcoholics who were not treated at all. Instead, Gordis put the best light on the approximately $30 million of government funds he and the NIAAA had spent on MATCH's disappointing results. In actual fact, the main result of Project MATCH was to dismantle Gordis's cherished notion that the application of modern medical-like diagnostics to the "illness" of alcoholism would be repaid with greatly improved treatment targeting and efficacy. Apparently, alcoholism just doesn't work that way.
But Gordis is being selected for the McCaffrey Award not because of his starry eyed but unfounded faith in the value of medicine, genetics, and differential diagnosis and treatment in alcoholism. What really earns him this honor is his attitude towards reduced or moderated drinking by alcoholics. The September 8 U.S. News and World Report cover was dominated by a picture of a highball and the title "What AA Won't Tell You," followed by "Controlled drinking [CD] works for many problem drinkers who are not alcoholics; but it's heresy to say so."
The article (as clearly indicated in its subtitle) does not recommend CD therapy for alcoholics. Rather, it recommends reduced drinking to a greatly inflated number of problem drinkers it claims to exist in the U.S. Nonetheless, Gordis felt compelled to devote the better part of his letter to cautioning against the dangers of such treatment for alcoholics: "Regarding the need for abstinence as a treatment goal, current evidence supports abstinence as the appropriate goal for persons with the medical disorder 'alcohol dependence' (alcoholism)."
One might imagine that the remarkable advances Gordis claims in research on basic brain mechanisms could allow alcoholics to drink normally. Rather than scientific aspiration, Gordis actually reflects the strange amalgam of medicine and moralism - the latter represented by temperance, AA, and the "spiritual" 12-step approach - that has always marked American attitudes towards and approaches to alcoholism.
But let us return to the treatment results based on MATCH which Gordis had been trumpeting at the time he wrote to U.S. News. Of what did these excellent outcomes consist? Subjects in MATCH (virtually all of whom were diagnosed alcohol dependent) reduced drinking from 25 to 6 days a month after treatment, while reducing the amount consumed from 15 to 3 drinks on each drinking occasion! Moreover, they demonstrated such concrete benefits as reduced alcohol problems and improved liver functioning (Connors, 1998). Thus, Project MATCH was the most forceful scientific demonstration ever that reduced drinking is a strong possibility and has major benefits for severely alcoholic individuals.
Perhaps readers can guess why Project MATCH and Gordis did not focus on abstinence outcomes instead. Among those subjects who received only outpatient treatment, 19 percent abstained for one year following MATCH. Of those who first received hospital treatment, followed by MATCH aftercare, 35 percent abstained throughout the year. This minimal abstinence occurred even though the treatments in MATCH were devised by the best alcoholism experts in the U.S., who trained and supervised counselors throughout the therapy administration. At the same time, subjects were selected so as not to have concurrent drug dependencies, problems with the criminal legal system, or serious mental illnesses while also having stable residences (Peele, 1998). If these patients receiving these treatments could not or would not abstain, then certainly the typical alcoholism patient in the U.S. won't do so.
Of course, perhaps such selected and excellently treated alcoholics may be much better at reducing drinking than typical alcoholism patients. In fact, NIAAA data proved otherwise. In an NIAAA national survey of 4,500 individuals who were ever alcohol dependent, epidemiologist Deborah Dawson (1996) found that half were drinking without signs of alcohol abuse or dependence over the past year, compared with fewer than a quarter (22 percent) who had abstained during the prior year!
Clearly, then, NIAAA research has signaled a revolution in thinking about the value of nonabstinence outcomes in alcoholism, given especially Gordis's reliance on nonabstinent improvement among MATCH alcoholics to justify the costs of Project MATCH - indeed to justify the entire mission of the NIAAA and alcoholism treatment in the United States. One is reminded, in this regard, of a statement over a decade-and-a-half earlier by alcoholism researcher Edward Gottheil:
If the definition of successful remission is restricted to abstinence, . . . treatment centers cannot be considered especially effective and would be difficult to justify from cost-benefit analyses. If the remission criteria are relaxed to include moderate levels of drinking, success rates increase to a more respectable range. . . . [Moreover] when the moderate drinking groups were included in the remission category, remitters did significantly and consistently better than nonremitters at subsequent follow-up assessments. (Gottheil et al., 1982, p. 564)
Gordis not only continued to ignore the measurable benefits of reduced drinking outcomes for alcoholics that his own agency had so thoroughly documented, his letter actually expressed alarm about controlled drinking goals for alcohol dependent drinkers. His explanation: "Any approach to the management of any of these alcohol problems should not be accepted without scientific demonstration of its merits." If MATCH's findings of little continuous abstinence, large reductions in average drinking, and concomitant reductions in behavioral and medical problems did not support the value of reduced drinking efforts for alcoholics, then no research on alcoholism could ever do so. Here we actually see the direct link between Gordis and General McCaffrey: both have a peculiarly American and visceral distaste for policies that assist addicts who continue to use a substance in reducing the harms they experience.
Enoch Gordis is first and foremost a bureaucrat who knows on which side his bread is buttered and what is within the limits of acceptable alcoholism treatment in the U.S. He will not step out on a limb to identify ingrained misconceptions about alcoholism no matter what the scientific evidence indicates or how helpful such information could be to alcoholics. No, Gordis won't take that chance. Why would he? Look what happened to Ignaz Semmelweis.
Bower, B. (1997, January 25). Alcoholics synonymous: Heavy drinkers of all stripes may get comparable help from a variety of therapies. Science News, pp. 62-63.
Connors, G.J. (1998, Spring). Overview of Project MATCH. Addictions Newsletter (The American Psychological Association, Division 50), pp. 4-5.
Dawson, D.A. (1996). Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research, 20, 771-779.
Gordis, E. (1987). Accessible and affordable health care for alcoholism and related problems: Strategies for cost containment. Journal of Studies on Alcohol, 48, 579-585.
Gottheil, E., Thornton, C.C., Skoloda, T.E., & Alterman, A.L. (1982). Follow-up of abstinent and nonabstinent alcoholics. American Journal of Psychiatry, 139, 560-565.
Peele, S. (1998, Spring). Ten radical things NIAAA research shows about alcoholism. Addictions Newsletter (The American Psychological Association, Division 50), pp. 6; 17-19.