Alcoholics who drink mouthwash: the spectrum of nonbeverage alcohol use

Motives for alcohol use, risky drinking patterns and harm reduction practices among people who experience homelessness and alcohol dependence in Montreal

BACKGROUND

People experiencing homelessness are disproportionately affected by harms related to alcohol use. Indeed, their alcohol dependence is associated with numerous physical and mental health problems along with strikingly high rates of alcohol-related mortality. Recent research has extensively examined alcohol use patterns among people experiencing homelessness in an effort to develop interventions and treatments for this problem. However, only a few studies have incorporated the perspectives of the individuals under study about their drinking or examined the ways in which they manage the associated harms. To bridge this gap, we conducted a qualitative study exploring the relation between the drinking motives, risky drinking patterns and harm reduction practices of a group of people (n = 34) experiencing homelessness in Montreal, Canada.

METHODS

The qualitative methods we used consisted of semi-structured interviews (n = 12) and focus groups (n = 2, with a total of 22 participants). The content of the collected data was then analyzed.

RESULTS

Participants identified their various motives for alcohol use (coping with painful memories, dealing with harsh living conditions, socializing/seeking a sense of belonging, enjoying themselves/having fun); their risky drinking patterns (binge drinking, mixing alcohol with drugs, non-beverage alcohol drinking, failing to keep sufficient alcohol on hand to prevent acute withdrawal, drinking in public settings); their harm reduction practices (planning how much to drink, keeping a supply of alcohol to prevent acute withdrawal, hiding to drink, concealing alcohol, drinking alone, drinking/hanging out with others, drinking non-beverage alcohol, and taking benzodiazepines, cocaine or other stimulant drugs); and the rationales underpinning their alcohol use and harm reduction practices.

CONCLUSION

Associating the drinking motives of a group of study participants with their risky drinking patterns and harm reduction practices shed light on their rationales for alcohol use, yielding insights that could be used to better tailor policies and interventions to their needs.

Hand Sanitizer Intoxication in the Emergency Department

Hand hygiene has always been an area of emphasis within the hospital setting, never more so than during the coronavirus disease 2019 (COVID-19) pandemic. The consumption of alcohol-containing hand sanitizer products, whether intentional or accidental, often garners attention, particularly since these products may contain methanol. This report describes a case of surreptitious theft and intentional ingestion of the emergency department's (ED) ethanol-based hand sanitizer by a patient who presented to the ED clinically intoxicated with a high ethanol level. When the patient remained clinically intoxicated for more than 18 hours and had a rising serum ethanol level in the ED, clinicians searched his belongings and found several purloined bottles of the ED's hand sanitizer. When confronted, the patient admitted to ingesting hand sanitizer during his ED stay. This case highlights the need for clinicians to be suspicious of intentional ingestion of ethanol-containing products for at-risk patients. Additionally, it demonstrates that measures and protocols should be put in place that minimize the ability for the inappropriate use of these widely accessible products within the hospital.

Non-beverage alcohol consumption among individuals experiencing chronic homelessness in Edmonton, Canada: a cross-sectional study

BACKGROUND

Among individuals experiencing homelessness, the prevalence of alcohol use disorder is extremely high. Alcohol-related harms are compounded by the use of non-beverage alcohol (NBA; e.g. rubbing alcohol, cooking wine). The dangers of NBA consumption pose significant risks to the individual and to others when consumed in large quantities and when mixed with other substances. The objectives of this paper are to describe the alcohol consumption patterns of individuals experiencing homelessness, identify substance use patterns, psychological stressors, and related harms associated with NBA consumption, and compare NBA consumers to non-NBA consumers in relation to their use of services and perceived barriers to care.

METHODS

Using a cross-sectional survey, 150 individuals experiencing homelessness were recruited from Edmonton's inner city and adjoining areas. Frequency, quantity, and volume of alcohol consumption were used to assess patterns of alcohol use in the last 6 months. Descriptive statistics and bivariate analyses were used to compare participants reporting NBA consumption and non-NBA consumption (p ≤ 0.05).

RESULTS

The majority of participants were male (71.3%) and self-identified as Indigenous (74.0%). Overall, 24% (n = 36) reported NBA consumption within the last six months. NBA consumers were older than non-NBA consumers (p = 0.005), reported different perceived living stability (p = 0.022), and had higher psychological distress (p = 0.038). The majority of NBA consumers reported not receiving harm reduction services while also not needing such services (n = 18, 51.4%), which differed from non-NBA consumers (p = 0.003). Structural barriers (e.g. availability, location, cost) were most frequently reported as reasons for unmet harm reduction (60.9%) and hospital care (58.3%) needs, while barriers to skills training (58.5%) and counselling services (53.6%) were mostly motivational (e.g. personal beliefs).

CONCLUSIONS

Within such an already marginalized population experiencing homelessness, individuals who consume NBA represent a vulnerable subpopulation who require adapted and distinct health and social services to stabilize and recover. Current harm reduction services are not prepared to effectively assist this group of individuals, and specific treatment programs are rare. Managed alcohol programs are a feasible approach but must be tailored to the specific needs of those who consume NBA, which is especially important for Indigenous people. More comprehensive assessments of NBA consumption are needed for program development and policy recommendations.

Three Weeks of Binge Alcohol Drinking Generates Increased Alcohol Front-Loading and Robust Compulsive-Like Alcohol Drinking in Male and Female C57BL/6J Mice

BACKGROUND

Current models of compulsive-like quinine-adulterated alcohol (QuA) drinking in mice, if improved, could be more useful for uncovering the neural mechanisms of compulsive-like alcohol drinking. The purpose of these experiments was to further characterize and improve the validity of a model of compulsive-like QuA drinking in C57BL/6J mice. We sought to determine whether compulsive-like alcohol drinking could be achieved following 2 or 3 weeks of Drinking-in-the-Dark (DID), whether it provides evidence for a robust model of compulsive-like alcohol drinking by inclusion of a water control group and use of a highly concentrated QuA solution, whether repeated QuA exposures alter compulsive-like drinking, and whether there are sex differences in compulsive-like alcohol drinking.

METHODS

Male and Female C57BL/6J mice were allowed free access to either 20% alcohol or tap water for 2 hours each day for approximately 3 weeks. After 2 or 3 weeks, the mice were given QuA (500 μM) and the effect of repeated QuA drinking sessions on compulsive-like alcohol drinking was assessed. 3-minute front-loading, 2 hour binge-drinking, and blood alcohol concentrations were determined.

RESULTS

Compulsive-like QuA drinking was achieved after 3 weeks, but not 2 weeks, of daily alcohol access as determined by alcohol history mice consuming significantly more QuA than water history mice and drinking statistically nondifferent amounts of QuA than nonadulterated alcohol at baseline. Thirty-minute front-loading of QuA revealed that alcohol history mice front-loaded significantly more QuA than water history mice, but still found the QuA solution aversive. Repeated QuA exposures did not alter these patterns, compulsive-like drinking did not differ by sex, and BACs for QuA drinking were at the level of a binge.

CONCLUSIONS

These data suggest that compulsive-like QuA drinking can be robustly achieved following 3 weeks of DID and male and female C57BL/6J mice do not differ in compulsive-like alcohol drinking.

Perceived harms and harm reduction strategies among people who drink non-beverage alcohol: Community-based qualitative research in Vancouver, Canada

BACKGROUND

There has been increasing interest in harm reduction initiatives for street-involved people who drink alcohol, including non-beverage alcohol such as mouthwash and hand sanitizer. Limited evidence exists to guide these initiatives, and a particular gap is in research that prioritizes the experiences and perspectives of drinkers themselves. This research was conducted to explore the harms of what participants termed "illicit drinking" as perceived by people who engage in it, to characterize the steps this population takes to reduce harms, and to identify additional interventions that may be of benefit.

METHODS

This participatory qualitative research drew on ethnographic approaches including a series of 14″town hall"-style meetings facilitatied and attended by people who self identify as drinking illicit or non-beverage alcohol (n = 60) in Vancouver, British Columbia. This fieldwork was supplemented with four focus groups to explore emerging issues.

RESULTS

Participants in the meetings described the harms they experienced as including unintentional injury; harms to physical health; withdrawal; violence, theft, and being taken advantage of; harms to mental health; reduced access to services; and interactions with police. Current harm reduction strategies involved balancing the risks and benefits of drinking in groups and adopting techniques to avoid withdrawal. Proposed future initiatives included non-residential managed alcohol programs and peer-based supports.

CONCLUSIONS

Illicit drinkers describe harms and harm reductions strategies that have much in common with those of other illicit substances, and can be interpreted as examples of and responses to structural and everyday violence. Understanding the perceived harms of alcohol use by socially marginalized drinkers and their ideas about harm reduction will help tailor programs to meet their needs.

How do people with homelessness and alcohol dependence cope when alcohol is unaffordable? A comparison of residents of Canadian managed alcohol programs and locally recruited controls

INTRODUCTION AND AIMS

We investigated coping strategies used by alcohol-dependent and unstably housed people when they could not afford alcohol, and how managed alcohol program (MAP) participation influenced these. The aim of this study was to investigate potential negative unintended consequences of alcohol being unaffordable.

DESIGN AND METHODS

A total of 175 MAP residents in five Canadian cities and 189 control participants from nearby shelters were interviewed about the frequency they used 10 coping strategies when unable to afford alcohol. Length of stay in a MAP was examined as a predictor of negative coping while controlling for age, sex, ethnicity, housing stability, spending money and drinks per day. Multivariate binary logistic and linear regression models were used.

RESULTS

Most commonly reported strategies were re-budgeting (53%), waiting for money (49%) or going without alcohol (48%). A significant proportion used illicit drugs (41%) and/or drank non-beverage alcohol (41%). Stealing alcohol or property was less common. Long-term MAP participants (>2 months) exhibited lower negative coping scores than controls (8.76 vs. 10.63, P < 0.001) and were less likely to use illicit drugs [odds ratio (OR) 0.50, P = 0.02], steal from liquor stores (OR 0.50, P = 0.04), re-budget (OR 0.36, P < 0.001) or steal property (OR 0.40, P = 0.07). Long-term MAP participants were also more likely to seek treatment (OR 1.91, P = 0.03) and less likely to go without alcohol (OR 0.47, P = 0.01).

DISCUSSION AND CONCLUSIONS

People experiencing alcohol dependence and housing instability more often reduced their alcohol consumption than used harmful coping when alcohol was unaffordable. MAP participation was associated with fewer potentially harmful coping strategies.

Surrogate Alcohol or Nonbeverage Alcohol Consumption: The Surrogate Alcohol Questionnaire (SAQ)

BACKGROUND

Diagnosis and treatment of alcohol use disorders and their sequelae are common clinical questions for the consultation-liaison psychiatrist. At an urban, academic medical center, the authors consulted on several patients whose consumption of alcohol included nonbeverage forms of alcohol, (described in the literature as surrogate alcohols, nonbeverage alcohols, e.g., mouthwash).

METHODS

The authors describe 4 patients who presented with surrogate alcohol consumption. The authors review the clinical issues and literature related to surrogate alcohol use. The authors describe the array of substances, which either contain ethanol, but are not intended for drinking, or which contain other intoxicating alcohols (e.g., methanol), that are consumed in lieu of traditional beverage alcohol. Furthermore, the authors discuss standard medical treatment interventions for ethanol and non-ethanol based alcohols. The authors propose a screening tool, the surrogate alcohol questionnaire, a tool to facilitate better recognition of surrogate alcohol use.

Unintended consequences of local alcohol restrictions in rural Alaska

Since 1981, Alaskans have had the ability to enact by referendum local restrictions in alcohol sales, importation, and possession, known as "local options." Intended to empower rural communities to reduce alcohol abuse and associated violence and trauma, the "local option" laws have led to unintended consequences as individuals in alcohol-restricted communities seek intoxication from both legal and illegal sources of alcohol. Based on 68 interviews with 72 community members in eight rural sites in Alaska, this article examines these unintended consequences of local options restrictions and provides context to the challenges rural communities face in implementing alcohol policies.

Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study

Background

Managed alcohol programs (MAPs) are a harm reduction strategy for people with severe alcohol dependence and unstable housing. MAPs provide controlled access to alcohol usually alongside accommodation, meals, and other supports. Patterns of alcohol consumption and related harms among MAP participants and controls from a homeless shelter in Thunder Bay, Ontario, were investigated in 2013.

Methods

Structured interviews were conducted with 18 MAP and 20 control participants assessed as alcohol dependent with most using non-beverage alcohol (NBA). Qualitative interviews were conducted with seven participants and four MAP staff concerning perceptions and experiences of the program. Program alcohol consumption records were obtained for MAP participants, and records of police contacts and use of health services were obtained for participants and controls. Some participants’ liver function test (LFT) results were available for before and after MAP entry.

Results

Compared with periods off the MAP, MAP participants had 41 % fewer police contacts, 33 % fewer police contacts leading to custody time (x² = 43.84, P < 0.001), 87 % fewer detox admissions (t = −1.68, P = 0.06), and 32 % fewer hospital admissions (t = −2.08, P = 0.03). MAP and control participants shared similar characteristics, indicating the groups were broadly comparable. There were reductions in nearly all available LFT scores after MAP entry. Compared with controls, MAP participants had 43 % fewer police contacts, significantly fewer police contacts (−38 %) that resulted in custody time (x² = 66.10, P < 0.001), 70 % fewer detox admissions (t = −2.19, P = 0.02), and 47 % fewer emergency room presentations. NBA use was significantly less frequent for MAP participants versus controls (t = −2.34, P < 0.05). Marked but non-significant reductions were observed in the number of participants self-reporting alcohol-related harms in the domains of home life, legal issues, and withdrawal seizures. Qualitative interviews with staff and MAP participants provided additional insight into reductions of non-beverage alcohol use and reductions of police and health-care contacts. It was unclear if overall volume of alcohol consumption was reduced as a result of MAP participation.

Conclusions

The quantitative and qualitative findings of this pilot study suggest that MAP participation was associated with a number of positive outcomes including fewer hospital admissions, detox episodes, and police contacts leading to custody, reduced NBA consumption, and decreases in some alcohol-related harms. These encouraging trends are being investigated in a larger national study.

Mouthwash use and associated head and neck cancer risk

DATA SOURCES

All studies with questionnaire items on mouthwash use in the International Head and Neck Cancer Epidemiology Consortium (INHANCE).

DATA EXTRACTION AND SYNTHESIS

Pooled analysis data from case controlled studies using Individual Patient Data (IPD) meta-analysis methods. Logistic regression was used to assess the association of mouthwash use with cancers of the oral cavity, oropharynx, hypopharynx and larynx, adjusting for study, age, sex, pack-years of tobacco smoking, number of alcoholic drinks/day and education.

RESULTS

Eight thousand, nine hundred and eighty-one cases of head and neck cancer and 10,090 controls from 12 case-control studies with comparable information on mouthwash use were included in the analysis. Compared with never users of mouthwash, the odds ratio (OR) of all head and neck cancers was 1.01 [95% confidence interval (CI): 0.94-1.08] for ever users, based on 12 studies. The corresponding ORs of cancer of the oral cavity and oropharynx were 1.11 (95% CI: 1.00-1.23) and 1.28 (95% CI: 1.06-1.56), respectively.

CONCLUSIONS

Although limited by the retrospective nature of the study and the limited ability to assess risks of mouthwash use in nonusers of tobacco and alcohol, this large investigation shows potential risks for head and neck cancer subsites and in long-term and frequent users of mouthwash.

Community Influence on Youth's Use of Inhalants and Other Legal Products to Get High in Rural Alaska

This study examines the use of inhalants and other harmful legal products (HLPs) to get high among pre-adolescents in frontier Alaska communities. Community factors that may influence use of HLPs are highlighted. This study uses secondary data from two NIH studies in 19 Alaska communities. A hierarchal generalized linear modeling technique was used to model community level effects on HLP use. The results show that lifetime use was reported by 18% of the pre-adolescents. Pre-adolescents in "dry" communities (with laws restricting alcohol use) had much higher lifetime and past 30-day HLP use. The results suggest that additional study of the relationship between use of HLPs and local laws governing availability is warranted.

A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol

BACKGROUND AND AIMS

Unrecorded alcohol constitutes about 30% of all alcohol consumed globally. The aims of this systematic review were to determine the epidemiology (occurrence, types, prevalence) of unrecorded alcohol consumption in different countries/regions, analyse the chemical composition of unrecorded alcohol and examine health outcomes caused by the consumption of unrecorded alcohol, based on either epidemiology or toxicology.

METHODS

A systematic search for, and qualitative analysis of, papers with empirical results on the different categories of unrecorded alcohol, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Unrecorded alcohol was widespread in all regions of the world. Artisanal fermented beverages and spirits were the most common categories of unrecorded alcohol globally, and were available on all continents. In India, industrially produced spirits (country spirits) were most prevalent. In Russia and countries of the former Soviet Union, surrogate alcohols complemented artisanal spirits. Cross-border shopping was the most prevalent method of obtaining unrecorded alcohol in parts of Europe. Ethanol was the most harmful ingredient of unrecorded alcohol, and health consequences due to other ingredients found in unrecorded alcohol were scarce. However, as unrecorded alcohol is usually the least expensive form of alcohol available in many countries, it may contribute to higher rates of chronic and irregular heavy drinking.

CONCLUSIONS

Very large amounts of alcohol are produced globally that go unrecorded. The primary harm from this kind of alcohol arises from the fact that it is typically much cheaper than licit alcohol.

Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse

BACKGROUND

Managed alcohol programmes (MAP) are a harm reduction strategy used to minimise the personal harm and adverse societal effects that alcohol dependence can lead to by providing an alternative to zero-tolerance approaches that incorporate drinking goals (abstinence or moderation) that are compatible with the needs of the individual, and promoting access to services by offering low-threshold alternatives. This enables clients to gain access to services despite continued alcohol consumption and works to help the patient understand the risks involved in their behaviour and make decisions about their own treatment goals.

OBJECTIVES

To assess the effectiveness of MAP treatment regimens (serving limited quantities of alcohol daily to alcoholics) on their own or as compared to moderate drinking (self-controlled drinking), screening and brief intervention using a harm reduction approach, traditional abstinence-based interventions (12 step programmes) and no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO up to March 2012. This search was expanded by handsearching of high-yield journals and conference proceedings that had not already been handsearched on behalf of The Cochrane Collaboration, searching reference lists of all papers and relevant reviews identified, references to ongoing and recently completed clinical trials in the National Research Register and IFPMA Clinical Trials Database (which contains ClinicalTrials.gov, Centerwatch, Current Controlled Trials and ClinicalStudyResults.gov, and Osservatorio Nazionale sulla Sperimentazione Clinica dei Medicinali). Trials registers, grey literature and reference lists were also searched. Individuals, organisations and experts in the field were contacted.

SELECTION CRITERIA

Randomised control trials (RCT), controlled clinical trials (CCT), interrupted time series (ITS) studies, and control before and after (CBA) studies involving vulnerable people aged 18 years or older who were at high risk for alcohol abuse attending MAP, defined as a structured programme that provided clients with controlled amounts of alcohol on a daily schedule, comparing no treatment, moderate drinking, brief intervention or 12-step variants.

DATA COLLECTION AND ANALYSIS

All study citations were collated into a single database. Two review author independently screened titles and abstracts and selected references potentially relevant to the review. Differences between selection lists were resolved by discussion. Two review authors independently evaluated whether studies should be included or excluded according to the eligibility criteria. In the event of a disagreement, a third author was consulted.

MAIN RESULTS

No studies were included in the review. This systematic review was intended to assess the effectiveness of a brief MAP on the reduction of incidence of harmful behaviour; however, no evidence was available to make this comparison; 22 articles were considered possibly relevant and all were excluded. Most articles were excluded because they failed to compare or consider managed alcohol as the experimental or control intervention, as well as one study (Baker 2010), which was also excluded because study participants were under 18 years of age. No study reviewed offered an intervention that was compared with managed alcohol or considered it as the intervention of interest, providing insufficient evidence to address the objectives of the review. Four studies (Aalto 2001; Baker 2010; Bertholet 2005; Tracy 2007) considered alcohol reduction as an outcome of interest, while four engaged interventions in a shelter setting or targeted vulnerable people (Baker 2010; Bradford 2005; Lapham 1993; McGlynn 1993); only one study (Kidd 2011) offered a qualitative assessment of a participant being admitted to MAP, but offered no analysis of the programme itself. These results accurately reflect the use of MAPs in current practice as existing programmes are ongoing only in a small number of sample pilot projects that target individuals with severe alcohol dependence or who consume non-beverage alcohol.

AUTHORS' CONCLUSIONS

The lack of evidence does not allow for a conclusion regarding the efficacy of MAP on their own, or as compared to brief intervention, moderate drinking, no intervention or 12-step variants. It is the review authors' opinion that it is likely to be the objective of MAPs that reduce their reportability and use in current practice, rather than a failure to provide an intervention that reduces the effects of alcohol dependence. Aiming to reduce harmful or antisocial behaviour in vulnerable individuals through the regulation of daily alcohol intake, rather than reducing harmful alcohol intake over time, provides considerable difficulty in developing measures of success from self-reported data (low treatment thresholds), monitoring long-term efficacy or establishing causal links between programme admission and a reduction in targeted behaviours, owing to the fact that prolonged participation in the programme is likely to indicate a willingness in the individual to change their behaviour patterns. More effort is needed to develop reporting measures, as well as methodologies, which address these specific challenges.

Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review

BACKGROUND

The purpose of this review is to systematically evaluate the effects of an essential-oil mouthwash (EOMW) compared to a chlorhexidine mouthwash with respect to plaque and parameters of gingival inflammation.

METHODS

PubMed/MEDLINE and Cochrane CENTRAL databases were searched for studies up to and including September 2010 to identify appropriate articles. A comprehensive search was designed, and the articles were independently screened for eligibility by two reviewers. Articles that evaluated the effects of the EOMW compared to chlorhexidine mouthwash were included. Where appropriate, a meta-analysis was performed, and weighted mean differences (WMDs) were calculated.

RESULTS

A total of 390 unique articles were found, of which 19 articles met the eligibility criteria. A meta-analysis of long-term studies (duration ≥ 4 weeks) showed that the chlorhexidine mouthwash provided significantly better effects regarding plaque control than EOMW (WMD: 0.19; P = 0.0009). No significant difference with respect to reduction of gingival inflammation was found between EOMW and chlorhexidine mouthwash (WMD: 0.03; P = 0.58).

CONCLUSION

In long-term use, the standardized formulation of EOMW appeared to be a reliable alternative to chlorhexidine mouthwash with respect to parameters of gingival inflammation.

Reviewed evidence about the safety of the daily use of alcohol-based mouthrinses

Current scientific knowledge provides clear evidence that alcohol-based mouthwashes can be beneficial in a daily oral health routine, including dental hygiene and plaque control. Several issues are worth discussing, in spite of the wealth of supporting evidence. Despite some undesirable effects to some people, like burning sensation, and some contraindications, like the use by infants, alcohol addicts and patients with mucosal injuries, there is no reason to avoid the use of alcohol-containing mouthwashes as long as they are used following proper guidance by dental professionals and the manufacturers' instructions. The alleged correlation between oral cancer and alcohol-based mouthrinses presents so little, weak, inconsistent and even contradictory evidence in the literature that any kind of risk warning to patients would be uncalled for. Antimicrobial mouthrinses are safe and effective in reducing plaque and gingivitis, and should be part of a comprehensive oral health care regimen that includes brushing, flossing and rinsing to prevent or minimize periodontal disease.

Safety evaluation of topical applications of ethanol on the skin and inside the oral cavity

Ethanol is widely used in all kinds of products with direct exposure to the human skin (e.g. medicinal products like hand disinfectants in occupational settings, cosmetics like hairsprays or mouthwashes, pharmaceutical preparations, and many household products). Contradictory evidence about the safety of such topical applications of the alcohol can be found in the scientific literature, yet an up-to-date risk assessment of ethanol application on the skin and inside the oral cavity is currently lacking.The first and foremost concerns of topical ethanol applications for public health are its carcinogenic effects, as there is unambiguous evidence for the carcinogenicity of ethanol orally consumed in the form of alcoholic beverages. So far there is a lack of evidence to associate topical ethanol use with an increased risk of skin cancer. Limited and conflicting epidemiological evidence is available on the link between the use of ethanol in the oral cavity in the form of mouthwashes or mouthrinses and oral cancer. Some studies pointed to an increased risk of oral cancer due to locally produced acetaldehyde, operating via a similar mechanism to that found after alcoholic beverage ingestion.In addition, topically applied ethanol acts as a skin penetration enhancer and may facilitate the transdermal absorption of xenobiotics (e.g. carcinogenic contaminants in cosmetic formulations). Ethanol use is associated with skin irritation or contact dermatitis, especially in humans with an aldehyde dehydrogenase (ALDH) deficiency.After regular application of ethanol on the skin (e.g. in the form of hand disinfectants) relatively low but measurable blood concentrations of ethanol and its metabolite acetaldehyde may occur, which are, however, below acute toxic levels. Only in children, especially through lacerated skin, can percutaneous toxicity occur.As there might be industry bias in many studies about the safety of topical ethanol applications, as well as a general lack of scientific research on the long-term effects, there is a requirement for independent studies on this topic. The research focus should be set on the chronic toxic effects of ethanol and acetaldehyde at the point of impact, with special regard to children and individuals with genetic deficiencies in ethanol metabolism.

Surrogate alcohol: what do we know and where do we go?

BACKGROUND

Consumption of surrogate alcohols (i.e., nonbeverage alcohols and illegally produced alcohols) was shown to impact on different causes of death, not only poisoning or liver disease, and appears to be a major public health problem in Russia and elsewhere.

METHODS

A computer-assisted literature review on chemical composition and health consequences of "surrogate alcohol" was conducted and more than 70 references were identified. A wider definition of the term "surrogate alcohol" was derived, including both nonbeverage alcohols and illegally produced alcohols that contain nonbeverage alcohols.

RESULTS

Surrogate alcohol may contain substances that cause severe health consequences including death. Known toxic constituents include lead, which may lead to chronic toxicity, and methanol, which leads to acute poisoning. On the other hand, the role of higher alcohols (e.g., propanol, isobutanol, and isoamyl alcohol) in the etiology of surrogate-associated diseases is currently unclear. Whether other constituents of surrogates have contributed to the high all-cause mortality over and above the effect of ethanol in recent studies also remains unclear.

CONCLUSIONS

Given the high public health importance associated with the consumption of surrogate alcohols, further knowledge on its chemical composition is required as well as research on its links to various disease endpoints should be undertaken with priority. Some interventions to reduce the harm resulting from surrogate alcohol could be undertaken already at this point. For example, the use of methanol or methanol-containing wood alcohol should be abolished in denatured alcohol. Other possible surrogates (e.g., automobile products) should be treated with bittering agents to avoid consumption.

Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol

BACKGROUND

People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle.

METHODS

Subjects enrolled in MAP were dispensed alcohol on an hourly basis. Hospital charts were reviewed for all emergency department (ED) visits and admissions during the 3 years before and up to 2 years after program enrollment, and the police database was accessed for all encounters during the same periods. The results of blood tests were analyzed for trends. A questionnaire was administered to MAP participants and staff about alcohol use, health and activities of daily living before and during the program. Direct program costs were also recorded.

RESULTS

Seventeen adults with an average age of 51 years and a mean duration of alcoholism of 35 years were enrolled in MAP for an average of 16 months. Their monthly mean group total of ED visits decreased from 13.5 to 8 (p = 0.004); police encounters, from 18.1 to 8.8 (p = 0.018). Changes in blood test findings were nonsignificant. All program participants reported less alcohol consumption during MAP, and subjects and staff alike reported improved hygiene, compliance with medical care and health.

INTERPRETATION

A managed alcohol program for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters.

Acute Ethanol Intoxication After Consumption of Hairspray

A 61-year-old woman with a history of alcohol dependence came to the emergency department with ethanol intoxication. Her serum ethanol concentration was 322 mg/dl. When questioned, she admitted to consuming a 14-oz bottle of hairspray mixed with water because of its denatured alcohol content. The woman had used nonbeverage sources of alcohol on a regular basis for a number of years after learning of the practice from fellow attendees of Alcoholics Anonymous meetings. Her primary reason for this behavior was to hide her continued alcohol abuse from her family. She consumed hairspray that contained 50% denatured alcohol by volume; the amount she ingested was equal to 7 fluid oz of ethanol, the equivalent of 14 1.25-oz shots of 80-proof liquor. Her serum ethanol concentration was consistent with that predicted by pharmacokinetic equations based on the consumption of one bottle of hairspray. The hairspray product contained specially denatured alcohol 40-B, which consists of ethanol and small quantities of t-butyl alcohol and denatonium benzoate. Ethanol is the substance of primary toxicologic concern. Clinicians need to be aware that numerous nonbeverage sources of alcohol exist and should be considered when a patient presents with acute intoxication. The source and its components should be identified as soon as possible in order to assess other potential toxicities.

Fatal large-volume mouthwash ingestion in an adult: a review and the possible role of phenolic compound toxicity

OBJECTIVE

To describe a case of fatal mouthwash ingestion and review possible sources of toxicity.

DESIGN

Case report.

SETTING

Veterans Administration Medical Center.

PATIENT

Single patient with massive mouthwash ingestion.

MAIN RESULTS

This patient was a 45-year-old man who developed cardiovascular collapse and multiorgan system failure following a massive ingestion of mouthwash (almost 3 liters). His presentation was remarkable for a profound anion-gap metabolic acidosis and a significant osmolar gap. No other co-ingestants were identified, and he expired despite full supportive care including dialysis and mechanical ventilation. An autopsy failed to identify any other cause of death. Nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure in the reported toxic range of these ingredients.

CONCLUSIONS

When ingested in large quantities, the phenolic compounds in mouthwash may contribute to a severe anion-gap metabolic acidosis and osmolar gap, multiorgan system failure, and death. These compounds, in addition to alcohol, may account for the adverse effects associated with massive mouthwash ingestion.

Overlooked sources of ethanol

The case of a 55-year-old female who presented to the emergency department with acute ethanol intoxication and suicidal ideation is reported. After initiating routine management, we discovered that her serum ethanol levels remained persistently elevated as a result of the patient's secretly ingesting mouthwash. This occurred after she was searched and allowed to retain personal hygiene products. Alcohol-dependent patients may consume ethanol products that are not manufactured for ingestion. These products include cosmetics, cough and cold remedies, and personal hygiene products. The ethanol content of these nonbeverage ethanol (NBE) products exceeds that of many conventional alcoholic beverages. Financial constraints and ease of availability are factors leading to their consumption. This report serves as a reminder to be aware of the existence and popularity of NBE in order to avoid potential morbidity and even mortality associated with its use.

Influencing Public Health Policy through Action-Oriented Research: A Case Study of Lysol Abuse in Alberta

Conventional approaches to health policy research have been criticized for generating findings of limited practical utility. In response to this concern, alternative research approaches have been developed which are more “action-oriented.” Using an action-oriented approach, the problem of Lysol abuse in Alberta was examined. Lysol, a household disinfectant, is consumed by chronic alcoholics for its alcohol content. The results of the study indicated that, because of Lysol's price and availability, several hundred individuals in the inner city of Alberta's capital drink the disinfectant on a regular basis. The release of these findings appear to have influenced a number of subsequent policy developments, including the introduction of new provincial legislation to regulate Lysol sales. These developments have had a positive effect in reducing the magnitude of the Lysol abuse problem. The results of this case study suggest that action-oriented research can be a useful technique.