Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

Among the horrors of the American opioid epidemic; our miserably failed professional mismanagement of pain; and the unintended tragedies of addiction, overdose, and death, it may be easy to overlook that longstanding human nemesis, ethyl alcohol. Alcohol is by far the most commonly used psychoactive drug (excluding the generally harmless caffeine) in Western society.

Doctor, are you an alcoholic?

Of every 100 Americans who drink (140 million), about 12 (16 million) are considered in need of treatment for an alcohol use disorder, and eight will become chemically dependent on alcohol.[1] Of those eight, one will become addicted very early, even after the first drunken episode. The problem is that we do not yet have a good way to predict who that one person will be.

You mean, the odds are roughly 90% that I can drink without worrying about becoming an alcoholic? Pretty good odds. But let's look at it another way. When I go to an airport to get on an airplane, if I knew that there was a 1-in-10 chance that the plane would crash, no way would I take that flight. Horrible odds.

How can you tell whether you have a drinking problem now? Take the Michigan Alcohol Sensitivity Test (MAST) 24 yes-no questions, good for you personally and for many of your patients.

If 24 questions seem like too many, try these seven key queries (Short MAST):

  1. Do you feel that you are a normal drinker? ("normal" = drink as much or less than most other people)

  2. Do friends or relatives think you are a normal drinker?

  3. Are you able to stop drinking when you want to?

  4. Can you stop drinking without a struggle after one or two drinks?

  5. After heavy drinking, have you ever had delirium tremens or severe shaking, or heard voices or seen things that are really not there?

  6. Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages? (If yes, how many times?)

  7. Have you ever been arrested or taken into custody, even for a few hours, because of other drunk behavior? (If yes, how many times?)

For the first four, a yes answer is good. For questions 5, 6, and 7, a yes answer is really bad.

If 24 or seven questions are still too many, try the CAGE questionnaire—four simple yes-no questions:

  1. Have you ever felt that you should cut down on your drinking?

  2. Have people annoyed you by criticizing your drinking?

  3. Have you ever felt bad or guilty about your drinking?

  4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (ie, an eye-opener)?

Two or three yes answers, you have a problem. A yes answer to number 4, you have a big problem.

For both the CAGE and the MAST, sensitivity and specificity run in the 80%-90% range, according to several published studies,[2,3] and they are very cheap to administer.

If you need any reminder about why excess drinking of alcohol is bad medically, consider this rundown of alcohol-attributed deaths, per recent year [4,5]:

Acute causes: 50,000: especially due to overdose, falls, drowning, motor vehicle accidents, homicide, suicide.

  • If you drink, don't drive; don't walk either, at least not around motor vehicles. Dead pedestrians often have high blood alcohol levels.

  • Mixing guns and booze is especially dangerous.

Chronic causes: 39,000: especially from liver disease, pancreatitis, a variety of cancers, cardiomyopathy, stroke.

Annual total: nearly 90,000.

For perspective, drug (other than alcohol) overdose deaths in the United States in 2017 totaled 72,000, including 35,000 for heroin and opioids (prescription and street origin).[6] Added perspective: Tobacco smoking kills about 480,000 Americans per year.[7] And cannabis (so far) does not toxicologically kill anyone, although we don't yet know the pathologic effects of chronic cannabis use.

So, Doctor, be honest with yourself. I know you don't smoke tobacco cigarettes; you are too smart to do that. But watch your drinking. It can get you too.

That's my opinion. I am Dr George Lundberg, at large for Medscape.


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