By Greg Skipper, MD A friend of mine went to play golf in Scotland, and while there he went to a pub to get a sandwich. The pub owner asked why he was in Scotland. My friend responded, \u201cTo play golf.\u201d The owner retorted, \u201cLaddie, you are in the right place.\u201d The bartender then offered my friend a beer. My friend responded, \u201cI don\u2019t drink,\u201d and the bartender then replied, \u201cLaddie, you are in the wrong place.\u201d Drinking patterns in Scotland aside, it is almost inconceivable that two pilots would show up at Glasgow Airport recently to fly after drinking, knowing the consequences. And just six weeks before those United Airlines pilots were pulled from their flight, two pilots with Canadian airline Air Transat were arrested at the same airport on suspicion of being \u201cimpaired through alcohol.\u201d Piloting Drunk Just Doesn't Make Sense It seems crazy. I tell my patients that addiction seems crazy because, in fact, it is crazy. That is why it is in the DSM-5, which is the acronym for the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders. It\u2019s one of the ways that I recognize addiction. If the behavior around the use of alcohol or drugs is just simply incongruent, if it doesn\u2019t make sense, if it appears totally nuts, then it is most likely addiction. The American Society of Addiction Medicine definition of addiction includes the statement: \u201cAddiction is characterized by inability to consistently abstain, impairment in behavioral control, diminished recognition of significant problems with one\u2019s behaviors.\u201d I don\u2019t know for sure that these pilots are addicted but the evidence suggests they are. Pilots are acutely aware that drinking prior to flying is illegal and will be met with criminal sanctions and termination. It is not a new concept. My father was an Air Force pilot, and 50 years ago he used to joke, \u201cYou can\u2019t fly if you smoke within 24 hours or drink within 50 feet of an airplane.\u201d Pilots know that drinking prior to flying is illegal and unethical. It is ingrained in their profession. It is the ultimate taboo. \u2018Common Sense\u2019 Theory of Addiction A few years ago I had a patient, a physician, who was found unconscious in the bathroom at the hospital with a needle in his arm. He claimed this was the first time he had ever injected drugs. Friends and family corroborated his claim, and we were unable to document otherwise. His hair test was negative, and because it takes about a week after using drugs for the hair test to become positive, the test was consistent with his story. Maybe this really was his first time, the test result suggested. Based on the criteria at the time, in what was then the DSM-IV, we could not diagnose the physician as being an addict. But this act of a doctor shooting up drugs at the hospital in the bathroom seemed so incongruent and \u201ccrazy\u201d that it seemed to me it represented addiction. I discussed the case with a prominent psychiatrist who was involved in writing the DSM-IV. His response was that the DSM-IV criteria aren\u2019t meant to supersede common sense. He agreed that a doctor shooting up drugs was \u201cover the line.\u201d During my 30-year-plus career, I have personally been involved in conducting more than 3,000 formal evaluations of professionals in a variety of fields, including airline pilots, following events such as these. The stories are always interesting, as I\u2019m sure those of the United Airlines pilots will be. For instance, I once treated a Navy pilot who had been deployed to the Persian Gulf, but because he was on an aircraft carrier and had no source of liquor, he started drinking mouthwash containing alcohol. He was drinking about a quart per day and it started causing neuropathies. The drunk pilot began stumbling and was taken off duty and evaluated in the ship\u2019s hospital. The doctors found numerous blood abnormalities, but they were stumped as to the cause. He was ultimately sent home to a military hospital, but they didn\u2019t discover the cause of the nerve damage until the crew cleaned out his room on the carrier and found an unusually large supply of mouthwash. The stuff contained alcohol but it also contained phenol, which is toxic to the nervous system in large amounts. It is fortunate that the devastating effect of the pilot\u2019s mouthwash consumption manifested itself when he was on the ship and not in the air. The result could have been like that of a civil aviation pilot I treated who forgot to refuel because he\u2019d been drinking and crash-landed his small plane in the ocean.\u00a0Or worse \u2026 Can Alcoholic Pilots Return to the Skies? I have found that pilots are among the hardest people to treat because they are really into controlling everything and being the boss. They tend to come into treatment angry. While jail time is warranted for anyone \u201cbreaking the law,\u201d it is much better to send an alcoholic pilot to long-term treatment. The military usually takes them off duty and has them enter a 12- to 24-month outpatient rehab program. There is less tolerance for drug dependency. Military pilots who choose opioids or benzodiazepines often receive prison time at Leavenworth, not rehab. It may be surprising to many, but commercial pilots who have been busted for flying under the influence of alcohol can return to the cockpit, but only after rigorous treatment through the\u00a0Human Intervention Motivation Study\u00a0(HIMS) program and long-term monitoring. Though that may be alarming to some, I have found that pilots respond quite well to the specific direction and rules inherent in treatment and are highly successful in their recovery. For example, 87% of United Airlines pilots returned to flight duties after treatment for alcoholism. The three-year abstinence rate for commercial pilots is about 95% with an estimated lifetime abstinence rate of 88% to 90%. Drunk Pilots Are an Uncommon Occurrence Passengers can rest assured that while alcoholic pilots make news, they are rare. In 2015, random alcohol tests were given to 12,480 U.S. pilots. Only 10 failed, according to the Federal Aviation Administration. There were 13 fails in 2014 and five in 2013. But how can any pilot drink and fly? How, those of us who are earthbound might wonder, can those United Airlines pilots, or anyone else whom passengers entrust with their lives, violate the rules against mixing alcohol with commercial flight? Perhaps they think that flying a plane is almost totally automated these days, so anyone can do it. Perhaps they feel that flying is 99% boredom and that they are such great pilots that they can handle the other 1% just fine, even if they\u2019ve been drinking. Perhaps. But the argument is no different than that of the serial drunk driver, who is sure he can handle that drive home after staggering to his car. The difference is the drunk behind the wheel endangers a few people in his car and on the road, while the pilot under the influence holds the lives of hundreds in his or her hands. Choosing to enter the cockpit after drinking is a \u201ccrazy\u201d decision to make. Totally nuts. It demonstrates a lack of behavioral control. It is the act of an addict. Dr. Greg Skipper is the director of Professional Health Services at Promises. Dr. Skipper has worked in professional health, impairment and occupational and addiction medicine for over 30 years. He is certified by the American Society of Addiction Medicine and the American Board of Addiction Medicine, and is a diplomat of the American Board of Internal Medicine. Dr. Skipper is also an educator, author and a sought-after speaker who has been interviewed by leading national television and radio shows.