ALCOHOL

Introduction

Alcohol (ethanol or ethyl alcohol) is the world’s

favorite recreational drug, legally available to
adults and widely used for pleasure and
relaxation without consequence.

However, ethanol is also a drug of abuse and

chronic drinking eventually leads to dependence
with serious consequences for the individual
and society.
 ALCOHOL AND ITS PRODUCTS

• A)Distilled liquors
Brandy, Whisky, Arrack, Vodka, Rum,(30-50%)

• B)Fermented liquors
Beer, Fortified wines (04-18%)

• C)Compound liquors
Gin (40-50%)
Overconsumption of alcohol is contributing
factor in violent crimes such as physical and
sexual assault and homicide.

It also encountered in forensic investigations of

unnatural deaths such as suicides, drowning,
and especially road-traffic fatalities.
Forensic investigators need to understand what
happens to alcohol in the body and how
excessive drinking influences a person’s
behavior in a negative way.

The need to translate a person’s blood-alcohol

concentration (BAC) into the quantity of alcohol
consumed is also important and, indeed,
ethanol is one of the few drugs for which this
calculation is feasible and defensible.
Alcohol in the Body

Knowledge about the disposition and fate of

ethanol in the body and the factors influencing
these processes is necessary to answer many
questions arising in routine forensic
investigations and medico-legal casework.

The basic facts relating to absorption,

distribution, metabolism and elimination of
ethanol should be known.
Absorption
Absorption is the process by which a drug
passes from the site of administration into the
bloodstream and gets transported to all body
organs, fluids, and tissues.

Alcohol (ethanol) is a small uncharged molecule

totally miscible with water and absorption from
the entire gastrointestinal tract occurs by
passive diffusion across mucous membranes
according to the concentration gradient.
As liquids pass quickly through the mouth and
esophagus, little absorption takes place until
alcohol has reached the stomach.

The rate of absorption is maximal in the

duodenum, because its mucosa is thinner and
much larger area of the absorption surface
furnished by the microvilli and blood supply
more abundant than that of the stomach.
Absorption of alcohol occurs much faster when gastric
emptying is rapid, facilitating passage through the
pyloric sphincter into the small intestines.

Under normal conditions, the pylorus remains nearly

totally closed because of tonic contraction of the
pyloric muscle.

Factors that influence gastric emptying play an

important role in the rate of uptake of alcohol from the
gut, which in turn influences the maximum
concentration in the blood and the intensity of the
effects of alcohol on the individual.
Factors effecting the lowering of absorption;

a) Food in the Stomach

- The presence of food in the stomach reduces the rate of

gastric emptying,
- Dilutes the alcohol that enters the stomach,
- Limits the contact between the alcohol and the gastric
mucosa.

The amount of food ingested is seemingly more important than

its composition in terms of fat, protein, or carbohydrate content.
b) Nature of the Drink Consumed
- Alcohol absorption is maximal when the
concentration of the ingested solution is
between 10 and 20%.
Because alcohol is absorbed by passive
diffusion, the rate of absorption is slower
with drinks of lesser strength because of a
lower concentration gradient.

- Alcohol content of stronger drinks irritates the

gastric mucosa and pyloric sphincter, causing
increased secretion of mucus and delayed gastric
emptying.
c) Drugs
. Drugs that slow gastric emptying

- Drugs with anticholinergic actions, such as

Atropine, Chlorpromazine, Tricyclic
antidepressants.
- Drugs with an adrenergic action, such as
Amphetamines.
- Drugs with an opioid action, such as
Antidiarrheal medicines Codeine and
dihydrocodeine
Diamorphine (heroin), Methadone
Dextropropoxyphene (in co-proxamol).

. Drugs that hasten stomach emptying, such as

Metoclopramide, Cisapride, Erythromycin.
d) Physiologic Factors and Genetic Variation

Factors such as stomach wall permeability,

blood supply to the alimentary tract, and
the rate of gastric emptying will vary from
person to person, and from time to time in
the same person.
Factors influencing the peak blood alcohol
concentration reached after drinking the same
quantity of alcohol

(Factors that affect the blood alcohol curve)

Weight
• Alcohol is highly hydrophilic, so once it
enters the systemic circulation it is
distributed evenly throughout total body
water.
In general, if two different sized males
drink the same quantity of alcohol, a
higher peak concentration will be reached
in the lighter.
Sex
• Similarly, because women have more body
fat compared with men, and fat contains
no water, higher peak alcohol levels are
achieved in women than in men of the
same weight.
Duration of Drinking
• If a volume of alcohol is consumed over a
prolonged period, it may be eliminated
almost as quickly as it is absorbed, giving
rise to a much lower peak alcohol
concentration.
Nature of the drink
• Around20% is more absorbed, below this level
there is irregular absorption, above this level
gastric irritation.
 Rate of Elimination
- Reported values range from about 10 mg/100 mL
of blood per hour (mg/dL/h) to 25 mg/dL/h, with
an average of 15–18.6 mg/dl/h.
- approximately equivalent to the elimination of one
(01)unit of alcohol per hour in a 70-kg male.
- Habituation to alcohol is the single most important
factor affecting the rate of elimination. The
increased rate of elimination is thought to be
because chronic alcoholics have facilitated liver
enzyme systems.
The absorbed alcohol enters the portal venous
blood and passes through the liver and then to
the heart, and after picking up oxygen in the
lungs, it returns back to the heart and
distributes throughout the entire systemic
circulation.
Distribution
• Ethanol distributes into the aqueous
compartment of the body and the
concentrations reached in all body fluids and
tissues at equilibrium depend primarily on the
water content of these fluids and tissues.

• Specimens such as sweat, saliva, and urine,

which are almost 100% water, will contain a
higher concentration of ethanol than whole
blood, which is ∼80% w/w water.
• Likewise, the concentrations of ethanol
in plasma and serum (∼93% water) are
higher than the concentration in whole
blood.

• Studies have shown that the plasma :

blood distribution ratio of ethanol on
average is 1.16 : 1.

• Alcohol can travel the placental barrier and to breast milk

Alcohol concentration in urine in relation
to BAC ;

- Earlier urine was wildly used as it is

easy to obtain.

- Legal limit -107mg/dl.

- Ratio- 1.33:1
Problems

1. Can not relate the urine alcohol level

detected directly to the BAC.
2. Frequent urination.
3. Delayed presentation.
 Alcohol concentration in breath in relation to
BAC ;

• Alveolar air at 37 C is in equilibrium with the

pulmonary capillary plasma level.

• The ratio is around 2300:1

• Use to estimate BAC through Breathalyzer.

• A small amount of alcohol (15%) is oxidized by
the ADH in the stomach lining.

• As soon as alcohol enters the bloodstream,

mechanisms for its removal come into action.

• Some 5–10% of the total amount absorbed is

excreted unchanged in breath, urine, and
sweat.
• The remaining 90–95% of alcohol is oxidized
in the liver by alcohol dehydrogenase to form
acetaldehyde, and this is further metabolized
to acetate (acetic acid).

• As alcohol dehydrogenase becomes saturated

at relatively low alcohol concentrations, it
soon reaches its maximum working rate, and
alcohol elimination proceeds at this constant
rate.
• Acetic acid is toxic and causes
headache, dizziness, nausea and
vomiting.

• Alcohol can not be eliminated from

violent exercise or copious urination.
• The rate of absorption is very much
faster than the rate of elimination,
and this fact gives rise to the
characteristic blood alcohol curve.
Generally speaking, the peak blood alcohol concentration is
reached 30–60 minutes after drinking, although the range may
be anything from 20 minutes to 3 hours.

However,
- the peak blood alcohol concentration,
- the time taken to reach the peak,
- the area under the blood alcohol curve,
- the time taken to reach a zero blood alcohol level
varies from person to person and within the same person over
time.

Indeed, a large number of factors can influence the kinetics of

alcohol.
• If a person drinks two bottles of beer (5 vol%)
and one bottle of table wine (12 vol%), this
corresponds to an intake of 2 × 13.2 g or 26.4
g ethanol from the beer and 77.3 g from the
wine making a total consumption of 103.7 g of
pure ethanol.

• This information is necessary when various

types of blood-alcohol calculations are made
for clinical, research, and legal purposes.
As a rough guide,
- one measure of spirits, (1.5 ounces)
- one glass of wine, (05 ounces)
- one bottle of beer (12 ounces)
contain 1 unit or 8 g of alcohol.

However, there is a wide variation in the alcohol

content of different drinks, and any accurate
assessment of intake must bear this in mind.
• A unit of alcohol (25ml of spirit) increases the
level of alcohol (in the first hour) by
approximately 15mg/100ml in a male and
20mg/100ml in a female.

• Alcoholic beverages contain nearly 800

compounds in addition to ethanol.
These could be used to confirm consumption
of alcohol in debatable or complicated cases.
 Effects of Alcohol
• Among pharmacological agents, ethanol is
classified as a depressant of the central nervous
system even though drinking small quantities
tends to elicit a state of excitement and euphoria.
( these feelings arise by suppression of inhibitions
in the cerebral cortex and not as a direct
stimulant action of the drug).

• In larger doses may depress medullary processes.

 Alcohol and the Brain
Most of us have witnessed the outward signs of heavy
drinking:
• the stumbling walk,
• slurred words and
• memory lapses.
• People who have been drinking have trouble with their
balance, judgment and coordination.
• They react slowly to stimuli, which is why drinking
before driving is so dangerous.
• All of these physical signs occur because of the way
alcohol affects the brain and central nervous system.
 Alcohol and the Brain
• Alcohol affects brain chemistry by altering levels of
neurotransmitters.
• Neurotransmitters are chemical messengers that
transmit the signals throughout the body that control
- thought processes,
- behavior and
- emotion.
• Neurotransmitters are either excitatory, meaning that
they stimulate brain electrical activity, or inhibitory,
meaning that they decrease brain electrical activity.
 Alcohol and the Brain
• Alcohol increases the effects of the inhibitory
neurotransmitter GABA in the brain.
• GABA causes the sluggish movements and slurred
speech that often occur in alcoholics.

• At the same time, alcohol inhibits the excitatory

neurotransmitter glutamate.
• Suppressing this stimulant results in a similar type
of physiological slowdown.
 Alcohol and the Brain
• In addition to increasing the GABA
and decreasing the glutamate in the
brain, alcohol increases the amount
of the chemical dopamine in the
brain's reward center, which creates
the feeling of pleasure that occurs
when someone takes a drink.
 Alcohol affects the different regions
of the brain in different ways:
1.Cerebral cortex:
In this region, where thought processing and
consciousness are centered, alcohol depresses
the behavioral inhibitory centers, making the
person less inhibited.
• It slows down the processing of information
from the eyes, ears, mouth and other senses.
• It inhibits the thought processes, making it
difficult to think clearly.
 2. Cerebellum:
• Alcohol affects this center of
movement and balance, resulting in
the staggering, off-balance swagger
we associate with the so-called
"falling-down drunk."
 3. Hypothalamus and pituitary:

• The hypothalamus and pituitary coordinate

automatic brain functions and hormone
release.
• Alcohol depresses nerve centers in the
hypothalamus that control sexual arousal and
performance.
• Although sexual urge may increase, sexual
performance decreases.
 4. Medulla:

• This area of the brain handles such automatic

functions as breathing, consciousness and
body temperature. By acting on the medulla,
alcohol induces sleepiness. It can also slow
breathing and lower body temperature, which
can be life threatening.
• In the short term, alcohol can
cause blackouts.
• Short-term memory lapses in which
people forget what occurred over
entire stretches of time.
• The long-term effects on the brain
can be even more damaging.
Sequence of Central Nervous Depressant Effects of Alcohol

Stage of influence Blood alcohol concentration Clinical effect

(mg / 100ml)
Sobriety 10–50 Often no obvious effect May
feel ''relaxed“

Euphoria 30–120 Mild euphoria with

increased talkativeness
Decreased inhibitions
Increased self-confidence
Impaired fine motor skills

Excitement 90–200 Emotional instability

Poor sensory perception
Impaired memory and
comprehension
Incoordination and loss of
balance
Drunkenness 150–300 Disorientation, mental confusion
Disturbances of vision (e.g., diplopia)
Decreased pain sense
Increased incoordination with staggering gait
Slurred speech

Stupor 250–400 General inertia approaching paralysis

Marked lack of response to stimuli
Inability to stand or walk
Vomiting, incontinence of urine and feces

Coma 350–500 Coma and anesthesia

Depressed or absent reflexes
Cardiovascular and respiratory depression
Possible death

Death Over 450 Death from respiratory depression

CLINICAL SIGNS OF INTOXICATION
• Slurred speech/ suffused conjunctiva / warm and
flushed skin/memory loss/ over confidence.

• Dilated pupils/ decreased pupillary reflex/ lateral

nystagmus/ tunnel vision/ reduced light
adaptation/ reduced cornial reflex.

• Loss of coordination/ ataxia/inability to perform

fine movements.
Examination

1. Drinking and driving.

2. Public nuisance.
3. Domestic or public violence.
4. Drunk in the work place.
 METHYL ALCOHOL
• Common industrial chemical.
• Colourless clear fluid.
• Pleasant odour.
• Miscible with water.
 Used as
• To make formaldehyde
• Auto antifreeze
• Organic solvent
• Organic dyes
• Fuel/ paint
• Varnishes/ enamel
• Embalming fluid
 Can be absorbed by

• Ingestion
• Inhalation
• Skin contact
 Metabolism
• Methanol alcohol dehydrogenase

Formaldehyde

oxidises

Formic acid
Formic acid:
• can not be detoxified.
• Elimination takes 5-10 times longer than
ethanol.
• Can develop severe acidosis.
• Death can occur within 5 hours.

Symptoms with mild exposure

Headache/ vomiting/ irritation of all
membranes/vertigo/ ringing in ears
 Symptoms with moderate exposure
• Oedema of the optic nerve and entire retina
(action of formaldehyde)
. Temporary blindness
. permanent blindness
• CNS degeneration.
• Liver and kidney involvement.

As elimination is slow methyl alcohol can be

detected as long as 6 days in the blood
 Severe exposure
• All above are more profound.
• Abdominal pain/ colic/ GI irritation.
• Diarrhoea/ constipation/lethargy.
• CNS depression/sleepiness/ stupor/ dizziness.
• Dilated pupils/ diplopia/pulmonary
oedema/cerebral oedema/delirium/
metabolic acidosis/ coma and death.