Ethanol, or ethyl alcohol, is commonly referred to as “alcohol.” This term is somewhat misleading, because there are numerous other alcohols. However, ethanol is probably the most commonly used and abused xenobiotic in the world. Its use is pervasive among adolescents and adults of all ages, socioeconomic groups, and represents a tremendous financial and social cost.3,197 The ethanol content of alcoholic beverages is expressed by volume percent or by proof. Proof is a measure of the absolute ethanol content of distilled liquor, made by determining its specific gravity at an index temperature. In the United Kingdom, the Customs and Excise Act of 1952 declared proof spirits (100 proof) as those in which the weight of the spirits is 12/13 the weight of an equal volume of distilled water at 51°F (11°C). Thus, 100 proof spirits are 48.24% ethanol by weight or 57.06% by volume. Other spirits are designated over or under proof, with the percentage of variance noted. In the United States, a proof spirit (100 proof) is one containing 50% ethanol by volume.
The derivation of proof comes from the days when sailors in the British Navy suspected that the officers were diluting their rum (grog) ration and demanded “proof” that this was not the case. They achieved this by pouring a sample of grog on black granular gunpowder. If the gunpowder ignited by match or spark, the rum was up to standard, 100% proof that the liquor was at least 50% ethanol. This became shortened to 100 proof (Table 80–1).
TABLE 80–1.Basic Information and Calculations ||Download (.pdf) TABLE 80–1. Basic Information and Calculations
Ethanol molecular weight (MW): 46 Da
Specific gravity: 0.7939 (~0.8) g/mL
Volume of distribution (Vd): 0.6 L/kg
Average reduction in blood ethanol concentration (elimination phase):
Nontolerant adult: 3.26–4.35 mmol/L/h (15–20 mg/dL/h, 100–125 mg/kg/h)
Tolerant adult: 6.52–8.70 mmol/L/h (30–40 mg/dL/h, 175 mg/kg/h)
For a 70 kg individual:
|Dose of Ethanol ||Estimated Serum Ethanol Concentrationa |
|10 mL/kg of 10% (20 proof) ||167 mg/dL (36.30 mmol/L) |
|3 mL/kg of 10% (20 proof) ||50 mg/dL (10.87 mmol/L) |
|1.5 mL/kg of 10% (20 proof) ||25 mg/dL (5.43 mmol/L) |
|150 mL (5 “shots”) of 40% (80 proof) ||143 mg/dL (31.09 mmol/L) |
|30 mL (1 “shot”) of 40% (80 proof) ||27 mg/dL (5.87 mmol/L) |
|A “standard drink,” defined as 1.5 fluid (fl) oz (eg, a single jigger or shot) of 80 proof spirits (“hard liquor”), 1.5 fl oz (eg, a single jigger or shot) of brandy, 2–3 fl oz ofcordial, liqueur, or aperitif, 3–4 fl oz offortified wine (eg, sherry or port), 5 fl oz of table wine, 8–9 fl oz of malt liquor, or 12 fl oz of regular beer158 ||43 mg/dL (9.35 mmol/L)|
In addition to beverages, ethanol is present in hundreds of medicinal preparations used as a diluent or solvent in concentrations ranging from 0.3% to 75%.28,44,52,145,152,196 Mouthwashes may contain up to 75%ethanol (150 proof), and colognes typically contain 40% to 60% ethanol (80 to 120 proof).15,96,152,166 These products occasionally cause intoxication, especially when unintentionally ingested by children.31,49,84,198
Veisalgia, “alcohol hangover,” comes from the Norwegian kveis, “uneasiness following debauchery” and the Greek algia, “pain.” The “hangover” syndrome has been attributed to congeners, substances that appear in alcoholic beverages in addition to ethanol and water.26,33,34 Congeners contribute to the special characteristics of taste, flavor, aroma, and color of a beverage. The combinations and exact amounts of congeners vary with the type of beverage, ranging from 33 mg/L in vodka, to averages of 500 mg/L in some whiskies and as much as 29,000 mg/L in specially aged whiskies or brandies.26,33,34 The conventional listing of congeners includes fusel oil (a mixture containing amyl, buytyl, propyl, and methyl alcohol), aldehydes, furfural, esters, low molecular weight organic acids, phenols, and other carbonyl compounds, tannins, solids, and a relatively large number of additional organic and inorganic compounds, usually in trace amounts.26,33
Consumption of illicitly produced ethanol (“moonshine”) has resulted in methanol, lead or arsenic poisoning, and botulism.19,46,66,93,110,116,132,149 Incidental lead contamination is also reported in draught beers or wine contained in lead-capped bottles.173,174 Of historic interest is that the addition of cobalt salts to beer to stabilize the “head” (foam) led to outbreaks of congestive cardiomyopathy among heavy beer drinkers in Canada and Belgium in the 1960s (Chap. 94). The clinical-pathological pattern of this disease is distinct from the classical alcoholic cardiomyopathy.126,128
Alcoholism is the leading cause of morbidity and mortality in the United States. The prevalence of ethanol dependence in the United States has been relatively stable, at around 6% for men and 2% for women.25 The overall estimated annual cost of US health expenses related to ethanol is $185 billion.138 More than 70% of the estimated costs were attributed to lost productivity, most of which resulted from ethanol-related illness or premature death. Most of the remaining estimated costs were expenditures for health care services to treat ethanol induced disorders (14.3%), property and administrative costs of ethanol-related motor vehicle crashes (8.5%), and criminal justice system costs of ethanol-related crime (3.4%). More than 200,000 Americans die annually of alcoholism, far more than those who die of all illicit drugs of abuse combined. Ethanol is the leading cause of mortality in people 15 to 45 years of age. In 2011, there were 9878 ethanol-related traffic fatalities in the United States, which accounted for 31% of total traffic fatalities; 66% of ethanol-impaired driving fatalities involved drivers with blood ethanol concentration 80 mg/dL or higher, 27% were passengers riding with the ethanol-impaired drivers, and 7% were nonoccupants of a motor vehicle.137 Drivers aged 21 to 34 accounted for 44%, and drivers between 16 to 20 years accounted for 10% of all ethanol-impaired drivers in fatal crashes. Among 16 to 20 year-old male drivers, an increase of 20 mg/dL in blood ethanol concentration was estimated to more than double the relative risk of fatal single-vehicle crash injury compared with sober drivers of the same age and gender.209 When the blood ethanol concentration ranged from 80 to 100 mg/dL (17–22 mmol/L), 100 to 150 mg/dL (22–33 mmol/L), and greater than 150 mg/dL (33 mmol/L), the relative risk of fatal single-vehicle crash injury was 52, 241 and 15,560, respectively.
The Global Burden of Disease Study identified three effects of ethanol: harmful effects in relation to injuries, harmful effects in relation to disease, and the protective effect in relation to ischemic heart disease.138 Overall ethanol accounted for 3.5% of mortality and disability, 1.5% of all deaths, 2.1% of all life years lost, and 6% of all the years lived with disability.138 In the United States, according to National Highway Traffic Safety Administration (NHTSA) information, all jurisdictions have enacted per se blood ethanol concentration for adults operating noncommercial motor vehicles.137 The term “illegal per se” refers to state laws that make it a criminal offense to operate a motor vehicle at or above a specified ethanol (or drug) concentration in the blood, breath, or urine, which may or may not reflect clinical intoxication (Special Considerations: SC6). For example, although ethanol-tolerant patients may not exhibit impairment even at serum ethanol concentrations greater than 300 mg/dL (65 mmol/L), they are still considered impaired with regard to the laws that governs motor vehicle operation.1
There is a dose-response relationship between ethanol consumption and risk of death in men aged 16 to 34 and in women aged 16 to 54. Meta-analysis of aggregate data from epidemiologic dose-response ethanol and mortality cohort studies suggests that the level of ethanol consumption at which all-cause risk is lowest is approximately 5 g/d and that ethanol exerts a protective effect (J-shaped dose-response curve) up to a daily intake of approximately 45 g.9 It is suggested that sensible drinking of ethanol for men is 8 to 10 g/d up to age 34, 16 to 20 g/d between 34 and 44 years of age, 24 to 30 g/d between 44 and 54 years of age, 32 to 40 g/d up between 54 and 84 years of age, and 40 to 50 g/d over age 85. Women would be advised to limit their drinking to 8 to 10 g/d up to age 44, 16 to 20 g/d between 44 and 74 years of age, and 24 to 30 g/d over age 75.201 However, no safe level of prenatal ethanol exposure has been established. The combination of a national tolerance of drinking and heavy advertising of ethanol makes it especially appealing to young people. In a society increasingly concerned with drug abuse, the excessive use of ethanol constitutes a serious and pervasive problem as well as a major health issue.