Drinking on an empty stomach: a scoping review of the evidence on how consuming food with alcohol affects short-term outcomes

BACKGROUND

Alcohol is a leading risk factor for death worldwide. Governments issue official guidelines on reducing the short-term risks associated with alcohol as do alcohol industry-funded organizations. Both sources frequently recommend consuming food with alcohol, however, it is unclear what evidence these recommendations are based on. The aim of this scoping review was to map and summarize evidence on the short-term effects of consuming food and alcohol.

METHODS

A scoping review, following PRISMA Extension for Scoping Reviews, searched CINAHL, Cochrane Library, Embase, Medline, PsychINFO and NICE Evidence Search (published inception to June 2021). Studies in English, investigating co-consumption of food and alcohol and reporting short-term health outcomes or acute effects, were included.

RESULTS

Of the 15 246 studies identified, 10 met the inclusion criteria. There was little evidence on the effects of food co-consumption on most short-term alcohol-related outcomes. Included studies were low in quality and inconsistent in their reported outcomes.

CONCLUSIONS

Despite a weak and inconsistent evidence base, food co-consumption is often recommended by both official guidance and alcohol industry-funded sources. Food co-consumption as a harm reduction measure, while plausible, requires a stronger evidence base and more nuanced messaging due to the risk of encouraging heavier, sustained drinking.

Additional Conditions Amenable to Observation Care

ED observation units (EDOUs) are designed for patients who require diagnostics or therapeutics beyond the initial ED visit to determine the need for hospital admission. Best evidence is that this care be delivered via ordersets or protocols. Occasionally, patients present with conditions that are amenable to EDOU care but fall outside the commonly used protocols. This article details a few of these conditions: abnormal uterine bleeding, allergic reaction, alcohol intoxication, acetaminophen overdose and sickle cell vaso-occlusive crisis. It is not meant to be exhaustive as patient care needs can vary hospital to hospital.

From Death to Death Certificate: What do the Dead say?

This is an overview of medicolegal death investigation and death certification. Postmortem toxicological analysis, particularly for ethanol and drugs of abuse, plays a large role in the forensic investigation of natural and unnatural deaths. Postmortem drug concentrations must be interpreted in light of the autopsy findings and circumstances. Interpretations of drug and ethanol concentrations are important for death certification, but they also may be important for other stakeholders such as police, attorneys, public health practitioners, and the next-of-kin.

Estimated blood alcohol concentrations for child and adolescent drinking and their implications for screening instruments

OBJECTIVE

Blood alcohol concentrations (BACs) in children after consumption of different numbers of standard drinks of alcohol have not been estimated previously. The goal was to determine the number of drinks at each age that led to a BAC of > or =80 mg/dL, the National Institute on Alcohol Abuse and Alcoholism criterion for binge drinking.

METHODS

The updated Widmark equation to estimate BAC was modified to take account of the differing body composition (total body water) and accelerated rates of ethanol elimination of children. The modified formula was used with 1999-2002 National Health and Nutrition Examination Survey data to estimate BACs for >4700 children and adolescents from 9 through 17 years of age, for intake levels of 1 to 5 standard drinks.

RESULTS

The estimated BACs for children after consumption of just 3 standard drinks within a 2-hour period were between 80 and 139 mg/dL for boys 9 to 13 years of age and for girls 9 to 17 years of age, indicating substantial potential alcohol impairment. With 5 drinks within 2 hours (the level used to define binge drinking among college students), children 9 to 13 years of age were estimated to have BACs 2 to 3 times the adult legal limit for intoxication of 80 mg/dL.

CONCLUSION

Binge drinking should be defined as > or =3 drinks for 9- to 13-year-old children, as > or =4 drinks for boys and > or =3 drinks for girls 14 or 15 years of age, and as > or =5 drinks for boys and > or =3 drinks for girls 16 or 17 years of age.

Low-alcohol beers: contribution to blood-ethanol concentration and its elevation above the UK legal limit after 'topping-up'

AIMS

The aim of this study was to establish the contribution of low-alcohol beers to blood-ethanol concentration (BEC) and to test if 'topping-up' with these beverages can increase BEC above the 80 mg/dl UK legal limit.

METHODS

Healthy male and female volunteers received a dose of ethanol designed to give a BEC of just below 80 mg/dl, and then received one pint (600 ml) of a 1% v/v alcohol beer in the fasting state or after lunch, or of a zero-alcohol or a 0.5% v/v alcohol beer after fasting. BEC was determined enzymatically and data were subjected to ANOVA.

RESULTS

Topping-up with a pint of a 1% v/v alcohol beer increased BEC >80 mg/dl in fasting subjects, contributing an extra 12-17 mg/dl, which lasted longer in males (80 min) than in females (20 min). A 0.5% v/v alcohol beer increased BEC above 80 mg/dl only in males, which lasted for 60 min. After food intake, the 1% v/v alcohol beer increased BEC above 80 mg/dl transiently only in males.

CONCLUSIONS

Low-alcohol beers make a significant contribution to blood-ethanol concentration and can increase it above the UK legal limit. Their use as a 'top-up' should be discouraged. Low-alcohol beers have a place as a substitute for normal-strength beverages as a strategy for decreasing alcohol consumption in general and in countries where low legal alcohol limits are in force or being contemplated.

Inter- and intra-subject variability in ethanol pharmacokinetic parameters: Effects of testing interval and dose

Calculation of a blood alcohol concentration (BAC) at the time of an offence by forward or back-extrapolation, using population average values for ethanol pharmacokinetic parameters or a single estimate of individual specific parameters, ignores the possibility of inter- and intra-subject variability. In order to estimate inter- and intra-subject variability in the elimination rate and absorption rate, BAC was measured over time in 12 male volunteers on 4 occasions. Subjects received 0.44 g kg(-1) body weight of ethanol on the first study day, and 0.70 g kg(-1) body weight on subsequent study days 1, 11 and 12 weeks later, to enable comparisons in variability over short and long time periods and when the same or different doses were administered. Evidence of both inter- and intra-subject variability was found, with inter-subject variability substantially smaller than intra-subject variability when the dose varied. Forensically important differences in pharmacokinetic parameters were observed within individuals between occasions. These findings could have an important impact on medico-legal issues related to ethanol pharmacokinetics.

The relationship between alcohol elimination rate and increasing blood alcohol concentration—Calculated from two consecutive blood specimens

In the period 1991-2005, a blood-alcohol concentration (BAC) analysis was carried out at the Institute of forensic medicine in Novi Sad including 2023 two consecutive blood specimens using the Headspace Gas Chromatography method. Cases with no alcohol concentration values, as well as cases where blood samples were taken within 1 h after the criminal act, were not taken into consideration. Following this rule, 1198 cases were considered in this study and all samples were grouped in 29 ranges of BAC1 of delta(BAC) = 0.1 g/kg, starting from 0.1-0.19 g/kg to 2.9-2.99 g/kg of absolute alcohol. Gathered results and elimination curve differ from the zero-order model of elimination proposed by Widmark and point to an elimination process similar to a well-known Michaelis-Menten elimination kinetics model and its variants. Results reported in this study show dependence of alcohol elimination rate (beta-slope) and BAC value. The analysis of beta60-slope versus BAC shows that a correlation between beta60 (y) and BAC (x) has a logarithmic trend line. The value of alcohol elimination rate shows a slight increment with increase of BAC alcohol, with the mean value of beta60 = 0.221 +/- 0.075 g/kg. Differences in values of beta60 among consecutive intervals of delta(BAC) = 0.1 g/kg are not significant (p>0.05). When obtained samples were grouped into ranges of 0.5 g/kg each in these intervals beta60 had the following values by range: 0.1-0.49 g/kg = 0.139 g/kg +/- 0.035; 0.5-0.99 g/kg = 0.184 g/kg +/- 0.043; 1-1.49 g/kg = 0.213 g/kg +/- 0.052; 1.5-1.99 g/kg = 0.239 g/kg +/- 0.058; 2-2.49 g/kg = 0.265 g/kg +/- 0.073; 2.5-2.99 g/kg = 0.306 g/kg +/- 0.096. Differences in values of beta slope among consecutive intervals of delta(BAC) = 0.5 g/kg are significant (p<0.01). The elimination curve in the BAC interval 0.5-2.5 g/kg has a linear trend, while beta-slope (y)/BAC (x) correlation is given as beta60 = 0.15 g/kg + (0.05 g/kg x BAC). Retrograde calculation of the blood alcohol concentration in tempore criminis (BAC(tc)) based on the determined alcohol concentration in the blood specimen (BAC(t)) shows a statistically significant difference between BAC(tc) calculated using a standard zero-order model versus corrected methodology. The higher the BAC(t) and the longer the calculation time, the greater and statistically more significant (p<0.01) is the difference between the calculated values of BAC(tc).

Ultra-rapid rate of ethanol elimination from blood in drunken drivers with extremely high blood-alcohol concentrations

The rate of alcohol elimination from blood was determined in drunken drivers by taking two blood samples about 1 h apart. These cases were selected because the individuals concerned had reached an extremely high blood-alcohol concentration (BAC) when they were apprehended. This suggests a period of continuous heavy drinking leading to the development of metabolic tolerance. Use of double blood samples to calculate the elimination rate of alcohol from blood is valid provided that drunken drivers are in the post-absorptive phase of the BAC curve, the time between sampling is not too short, and that zero-order elimination kinetics operates. Evidence in support of this came from other drunken drivers in which three consecutive blood samples were obtained at hourly intervals. The mean BAC (N = 21) was 4.05 g/l (range, 2.71-5.18 g/l), and the average rate of alcohol elimination from blood was 0.33 g l(-1) h(-1) with a range of 0.20-0.62 g l(-1) h(-1). The possibility of ultra-rapid rates of ethanol elimination from blood in drunken drivers having extremely high BAC deserves to be considered in forensic casework, e.g., when retrograde extrapolations and other blood-alcohol calculations are made. The mechanism accounting for more rapid metabolism is probably related to induction of the microsomal enzyme (CYP2E1) pathway for ethanol oxidation, as one consequence of continuous heavy drinking. However, the dose of alcohol and the duration of drinking necessary to boost the activity of CYP2E1 enzymes in humans have not been established.

Controlling for Serum Albumin Level Improves the Correlation Between Serum Fatty Acid Ethyl Esters and Blood Ethanol Level

BACKGROUND

Fatty acid ethyl esters (FAEEs) are generated by the nonoxidative metabolism of alcohol and correlate positively with blood alcohol levels (BAL). As FAEEs are produced predominantly in the liver and bind to albumin in plasma, blood FAEE concentrations may be affected by serum albumin levels. The aim of this exploratory study was to define the relationship of FAEE levels with BAL after adjustment for serum albumin concentration.

METHODS

Fatty acid ethyl ester, BAL, and albumin concentrations were measured from de-identified, ethanol-containing serum samples (N=18). The assay focused on 3 FAEE species ethyl palmitate, ethyl stearate, and ethyl oleate. The relationships of individual and total FAEE concentrations with BAL using albumin as a covariate were analyzed. Values for Pearson's r between the BAL and the natural log-transformed FAEE (ln FAEE) levels were calculated, and then compared with partial correlation coefficients when controlling for albumin. The impact of serum albumin levels on the relationship between ln FAEE and BAL was evaluated by simple linear regression analysis.

RESULTS

Concentrations of total FAEE ranged from 632 to 20,166 nM, and BAL ranged from 9 to 375 mg/dL. In the 18 samples, the Pearson correlation coefficient between BAL and total FAEE levels was 0.868, and increased to 0.909 when controlling for albumin (p<0.0001). Similar statistically significant increases in the partial correlation coefficient occurred for each of the individual species of FAEE when controlling for albumin. In simple linear regression, albumin significantly reduced the variability in the model correlating BAL and FAEE for each of the individual species, as well as for total FAEE.

CONCLUSIONS

The association between FAEE levels and BAL is enhanced by consideration of serum albumin concentrations. Our findings suggest that serum albumin should be included in any model attempting to define the relationship between BAL and FAEE.

Standardization of Alcohol Calculations in Research

BACKGROUND

Nonstandardized reporting of alcohol consumption, definitions of what constitutes a standard drink, and incomplete dosing or estimates of intoxication are common problems in many areas of alcohol research. To enhance communication among scientists and to make interpretation of results more accurate and meaningful, researchers need to apply systematically current scientific principles in calculating drinks, doses, and alcohol concentrations. Basic formulas are compiled and explained to assist alcohol researchers and standardize the reporting and interpretation of alcohol data.

METHODS

Basic alcohol calculations are reviewed, and 20 mathematical calculations in alcohol pharmacokinetics and pharmacology are derived. Examples of how each calculation works are presented.

RESULTS

The formulas presented enable researchers to calculate accurately and systematically the amount of alcohol in any beverage and estimate the blood alcohol concentration in a range of subjects with individual characteristics and drinking patterns.

CONCLUSIONS

Accurate estimates of alcohol use and intoxication are important in many areas of research. Applying standards to the way alcohol is measured and interpreted enables better communication, more accurate analyses, and, in some cases, may impact the interpretation of results. Regardless of the field of study, alcohol researchers are encouraged to and can apply uniform standards in measuring alcohol consumption and estimating the effects of alcohol using the scientific methodologies described.

Impact of sex: determination of alcohol neuroadaptation and reinforcement

This article represents the proceedings of a symposium at the Research Society on Alcoholism meeting in Santa Barbara, California. The organizers/chairs were Kristine M. Wiren and Deborah A. Finn. Following a brief introduction by Deborah Finn, the presentations were (1) The Importance of Gender in Determining Expression Differences in Mouse Lines Selected for Chronic Ethanol Withdrawal Severity, by Kristine M. Wiren and Joel G. Hashimoto; (2) Sex Differences in Ethanol Withdrawal Involve GABAergic and Stress Systems, by Paul E. Alele and Leslie L. Devaud; (3) The Influence of Sex on Ethanol Consumption and Reward in C57BL/6 Mice, by Kimber L. Price and Lawrence D. Middaugh; and (4) Sex Differences in Alcohol Self-administration in Cynomolgus Monkeys, by Kathleen A. Grant.

A study of blood and urine alcohol concentrations in cases of alleged drug-facilitated sexual assault in the United Kingdom over a 3-year period

This paper details the alcohol concentrations found in a selection of 1,014 cases of claimed drug-facilitated sexual assault analysed at The Forensic Science Service, London Laboratory between January 2000 and December 2002. Where appropriate, either a whole blood sample and/or a urine sample was analysed for alcohol, common drugs of abuse and potentially stupefying drugs. The samples were collected from a complainant within 12 h of an alleged incident in 391 of the 1014 cases analysed. Of these, the majority (81%) contained alcohol. The presence of alcohol itself was not surprising as most of the alleged incidents were associated with social situations such as at a public house, bar, night-club or party, where it is expected that alcohol would have been consumed. However, 233 (60%) of the 391 cases had a high back-calculated figure, where high is defined as greater than 150 milligrams per 100 millilitres (150 mg%). Some of these samples were also found to contain illicit drugs. This is the first paper to our knowledge which discusses in detail the significance of the alcohol concentrations found in cases of this type.

A Large-Scale Study of the Relationship Between Blood and Breath Alcohol Concentrations in New Zealand Drinking Drivers*

Blood alcohol concentrations (BAC) and corresponding breath alcohol concentrations (BrAC) were determined for 21,582 drivers apprehended by New Zealand police. BAC was measured using headspace gas chromatography, and BrAC was determined with Intoxilyzer 5000 or Seres Ethylometre infrared analysers. The delay (DEL) between breath testing and blood sampling ranged from 0.03 to 5.4 h. BAC/BrAC ratios were calculated before and after BAC values were corrected for DEL using 19 mg/dL/h as an estimate of the blood alcohol clearance rate. Calculations were performed for single and duplicate breath samples obtained using the Intoxilyzer (groups I-1 and I-2) and Seres devices (groups S-1 and S-2). Before correction for DEL, BAC/BrAC ratios for groups I-1, I-2, S-1, and S-2 were (mean+/-SD) 2320+/-260, 2180+/-242, 2330+/-276, and 2250+/-259, respectively. After BAC values were adjusted for DEL, BAC/BrAC ratios for these groups were (mean+/-SD) 2510+/-256, 2370+/-240, 2520+/-280, and 2440+/-260, respectively. Our results indicate that in New Zealand the mean BAC/BrAC ratio is 19-26% higher than the ratio of the respective legal limits (2000).

Alcohol metabolism of local Chinese in Hong Kong: a statistical determination on the effects of various physiological factors

A study was designed to examine the elimination rate of alcohol from the body of the local Chinese after consumption of different types of alcoholic drinks. The breath alcohol of 184 healthy volunteers was determined and converted into blood alcohol levels after they finished drinking. Information on the type and volume of alcoholic drinks consumed, age group, sex, drinking habit, and drinking on empty stomach or with/after meal was recorded for each participant. The results show that the elimination rate of an individual can be explained in terms of physiological variables including sex and drinking habit. The determined elimination rates allow forensic toxicologists to back calculate the blood alcohol concentration (BAC) of the drivers at the time of accident in drunk driving cases. The elimination rates of blood alcohol at 95% prediction intervals for male and female are in the range of 9.5-23.8 mg/100 ml/h and 11.1-37.1 mg/100 ml/h, respectively.

Relevance of the developmental toxicity of ethanol in the occupational setting: a review

Numerous studies have been conducted investigating the reproductive toxicology of ethanol, the overwhelming majority concerning the adverse effects of consuming alcohol in beverages during pregnancy. Because many of the in vivo studies were designed to model alcoholism, they used comparatively high doses and assessed relatively few endpoints. Outcomes may have been affected by disturbances of metabolism at such high exposures, giving rise to secondary effects on development. The available data on ethanol from "conventional" developmental toxicity study test methods of the type used for regulatory hazard assessment of chemicals are limited. It is in this context, however, i.e. the use of ethanol as an industrial chemical rather than as a component of beverages, that this review is based. Using the usual criteria applied for the purpose of hazard assessment of industrial chemicals, it is concluded that there is no evidence that industrial exposure to ethanol is a developmental toxicity hazard. Developmental toxicity may result from drinking alcoholic beverages, the threshold level for all aspects of which has yet to be de fi ned. This is not, however, considered relevant to the low blood alcohol concentrations resulting from any conceivable inhalation or dermal exposure in the workplace or through the directed use of any consumer product containing ethanol.

Aspirin intoxication in a child associated with myocardial necrosis: is this a drug-related lesion?

A 5-year-old girl with a mild upper airways infection was admitted to the hospital because of sudden vomiting and drowsiness that evolved to stupor; she was dehydrated, hypotensive, and tachypneic; laboratory tests revealed noncompensated lactic acidosis. She also had hypoglycemia followed by hyperglycemia, and progressive bradycardia leading to reversible cardiac arrest. Her clinical condition complicated by sinus bradycardia, ventricular tachycardia, third-degree atrioventricular blockage and lethal asystole. At the final stage of her illness, the serum salicylate concentration was 383.8 mcg/mL. Based on this single data, a retrospective toxicological analysis estimated a theoretical peak level of serum salicylate of approximately 1570 mcg/mL (therapeutic range, 20-250 mcg/mL) although the real amount of aspirin that this child ingested is difficult to calculate because aspirin is a drug that shows a so-called zero order kinetics. At autopsy, the most striking finding was multiple foci of coagulative necrosis involving the entire thickness of the myocardium with scant inflammatory infiltrate composed mainly of macrophages and polymorphonuclear leukocytes. The morphologic characteristics of the myocardial lesion in addition to salicylate blood levels suggests the possibility of an adverse drug reaction of the type acute toxic myocarditis.

Ethanol metabolism in patients with liver cirrhosis

Aspects of human metabolism of ethanol are reviewed with the main focus on the rate of ethanol clearance from blood in patients suffering from liver cirrhosis. Studies in humans and experimental animals do not support the notion of a slower rate of ethanol metabolism in patients with liver cirrhosis compared with those with normal liver function. The rate of ethanol disappearance from blood in healthy non-alcoholic subjects falls within the range 9-20 mg/dL/h and there is no compelling evidence to suggest that this should be much different in cirrhotic patients.

Effects of moderate alcohol consumption on the central nervous system

The concept of moderate consumption of ethanol (beverage alcohol) has evolved over time from considering this level of intake to be nonintoxicating and noninjurious, to encompassing levels defined as "statistically" normal in particular populations, and the public health-driven concepts that define moderate drinking as the level corresponding to the lowest overall rate of morbidity or mortality in a population. The various approaches to defining moderate consumption of ethanol provide for a range of intakes that can result in blood ethanol concentrations ranging from 5 to 6 mg/dl, to levels of over 90 mg/dl (i.e., approximately 20 mM). This review summarizes available information regarding the effects of moderate consumption of ethanol on the adult and the developing nervous systems. The metabolism of ethanol in the human is reviewed to allow for proper appreciation of the important variables that interact to influence the level of exposure of the brain to ethanol once ethanol is orally consumed. At the neurochemical level, the moderate consumption of ethanol selectively affects the function of GABA, glutamatergic, serotonergic, dopaminergic, cholinergic, and opioid neuronal systems. Ethanol can affect these systems directly, and/or the interactions between and among these systems become important in the expression of ethanol's actions. The behavioral consequences of ethanol's actions on brain neurochemistry, and the neurochemical effects themselves, are very much dose- and time-related, and the collage of ethanol's actions can change significantly even on the rising and falling phases of the blood ethanol curve. The behavioral effects of moderate ethanol intake can encompass events that the human or other animal can perceive as reinforcing through either positive (e.g., pleasurable, activating) or negative (e.g., anxiolysis, stress reduction) reinforcement mechanisms. Genetic factors and gender play an important role in the metabolism and behavioral actions of ethanol, and doses of ethanol producing pleasurable feelings, activation, and reduction of anxiety in some humans/animals can have aversive, sedative, or no effect in others. Research on the cognitive effects of acute and chronic moderate intake of ethanol is reviewed, and although a number of studies have noted a measurable diminution in neuropsychologic parameters in habitual consumers of moderate amounts of ethanol, others have not found such changes. Recent studies have also noted some positive effects of moderate ethanol consumption on cognitive performance in the aging human. The moderate consumption of ethanol by pregnant women can have significant consequences on the developing nervous system of the fetus. Consumption of ethanol during pregnancy at levels considered to be in the moderate range can generate fetal alcohol effects (behavioral, cognitive anomalies) in the offspring. A number of factors--including gestational period, the periodicity of the mother's drinking, genetic factors, etc.--play important roles in determining the effect of ethanol on the developing central nervous system. A series of recommendations for future research endeavors, at all levels, is included with this review as part of the assessment of the effects of moderate ethanol consumption on the central nervous system.

Disposition and first-pass metabolism of ethanol in humans: is it gastric or hepatic and does it depend on gender?

OBJECTIVE

To assess the extent and site of the first-pass metabolism of ethanol and to examine whether first-pass metabolism and disposition of ethanol are dependent on gender.

METHODS

After a standardized lunch, healthy subjects (six women and six men) received on two separate occasions a 60-minute intravenous infusion of ethanol (0.3 gm/kg) and concomitantly an equimolar dose of d3-ethanol/kg either orally (over 20 minutes) or intraduodenally (infused over 30 minutes). Blood levels, urinary excretion of d0- and d3-ethanol, and sedative effects were monitored for 6 hours. Disposition and first-pass metabolism of ethanol were evaluated by applying an open two-compartment model with Michaelis-Menten elimination.

RESULTS

Comparison of the corresponding intravenous/oral versus intravenous/intraduodenal data of each individual revealed that total first-pass metabolism (gastric plus hepatic) was not pronounced in either males (9.1% +/- 4.0%; mean +/- SD) or females (8.4% +/- 3.1%) and that this first-pass metabolism was partly of gastric origin. Dose-corrected values for area under blood concentration-time curve were on average 28% higher (p < 0.0001) in the women than in the men. Mean total blood ethanol disappearance rate was higher (p < 0.001) in women (3.92 +/- 0.40 mmol/L . hr) than in men (3.19 +/- 0.48 mmol/L . hr). Renal clearance was gender-independent and negligible. A linear relationship (p < 0.001) could be found between the blood levels of ethanol and sedation index. Because the slope was steeper in women (1.04) than in men (0.42) a higher central nervous system sensitivity to the sedative effects of ethanol in women can be assumed.

CONCLUSIONS

Under realistic life conditions (social drinking of moderate doses of ethanol after a light lunch) only a minor, gender-independent first-pass metabolism is observed that is partly of gastric origin.

[Drunkenness in traffic in Geneva: distribution and detection]

All cases of inebriety (up to the Swiss Legal BAC: 0.8 gr/kg) in traffic (pedestrians and drivers) recorded by the police during one year are the object of the study. Their frequency and blood alcohol levels are related to individual variables (sex, age, nationality) and also to environmental variables (vehicle, month, day, time). Clinical appreciation of intoxication levels by physicians taking blood samples is also verified. Inherent difficulties of methodological bias coupled to the use of official data, are examined by systematically taking into account the way in which intoxication was detected (with or without accident). In all, 951 cases of alcohol intoxication were studied.

Variability of ethanol absorption and breath concentrations during a large-scale alcohol administration study

Ethanol disposition was evaluated in 77 female and 97 male college seniors during an alcohol challenge study. All were regular drinkers who exceeded legal intoxication levels at least twice a month by history. A standard ethanol dose (females, 0.43 g/kg; males, 0.51 g/kg) was administered over 10 min, after a 4-hr fast, and breath alcohol concentrations (BrACs) were measured for 2 hr. Intersubject variability in BrACs was greatest early in the study, during ethanol absorption; the coefficient of variation decreased from 39% at 14 min to 14% at 125 min after the start of drinking. The time to peak BrAC varied from 10 to 91 min after the start of drinking (mean 39.6 min). Mean BrACs were significantly lower in females than males; mean peak BrACs were 0.054 g/210 liters in females and 0.058 g/210 liters in males (p = 0.031). The beta- and r-values for both genders were higher than those typically used in ethanol dose calculation formulas. Data are discussed to direct future research. The constants used in Widmark's formula need to be revised differentially for males and females in this population to reach specific target BrACs. Furthermore, substantial variability in absorption rates must be accounted for when assessing rising versus falling limb BrAC phenomena.

Ischemic heart disease and epilepsy: two major causes of out-hospital natural death in male alcoholics

The objectives of this research were to study the distribution of in- and out-hospital deaths and causes of death in male alcoholics and in particular to analyze obscure cases. In a population-based sample of 1123 men treated in one detoxification unit during 1986-1989, 97 patients with alcohol dependence (DSM-III-R) died < or = 1 year after in-hospital detoxification. In each case, the cause and the manner of death were assessed by scrutiny of information in hospital and autopsy records, toxicological examinations, and police reports. The results were that 71 of the 97 men died outside hospital. The overall autopsy rate was 89%. Ischemic heart disease accounted for 18 out of 41 evaluable natural out-hospital deaths. Epileptic seizures were judged to be the cause of death in five cases and could also have contributed to seven out of eight obscure out-hospital deaths. Ethanol in blood or urine was detected in 19 of the 23 deaths attributed to trauma or intoxication, whereas only four out of the 18 out-hospital deaths from ischemic heart disease were ethanol-positive. It was concluded that early detection and adequate treatment of ischemic heart disease and epilepsy might improve prognosis in patients with alcohol dependence. The use of clinical information could be of crucial importance in evaluating possible causes of death, especially in obscure cases.

Between-subject and within-subject variations in the pharmacokinetics of ethanol

1. Twelve healthy men drank 0.80 g ethanol kg-1 body weight on four occasions spread over several weeks. Ethanol was given as 96% v/v solvent which was diluted with orange juice to make a cocktail (20-25% v/v). This drink was ingested in exactly 30 min at 08.00 h after an overnight (10 h) fast. 2. Samples of venous blood were obtained at exactly timed intervals of 0, 10, 20, 30, 45, 60, 90, 120, 150, 180, 240, 300, and 360 min after the start of drinking. The concentrations of ethanol in whole blood were determined by headspace gas chromatography. 3. Summary measures were used to evaluate the concentration-time profiles of ethanol for each subject. The between-subject and within-subject components of variation for the pharmacokinetics of ethanol were derived by one-way analysis of variance (ANOVA). 4. The variation between different subjects dominated the total variance for all of the pharmacokinetic parameters studied except the rate of disappearance of ethanol from blood (ko). For this latter parameter, 42% and 58% of the total variation arose from variations between- and within-subjects respectively. These results might be important to consider when experiments on the clinical pharmacokinetics of ethanol are being planned.