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INEBRIANT GROUP ALCOHOL

The term inebriant refers to any drug capable of intoxicating. Alcohol is a classical example of an inebriant. There are several types of alcohol but when we talk about alcohol we mean Ethyl alcohol  also known as Ethanol (C2H5OH)
It is by far the most widely used drug in the world, even in countries where religious beliefs theoretically prevent it consumption.

Physical appearance: Pure ethanol is a colourless volatile liquid with a characteristic fruity odour and sweetish burning taste.  It is usually obtained by the enzymatic fermentation of carbohydrates (sugars) by yeast enzymes.

  • Direct fermentation cannot raise the concentration to more than 12-15 %, as the yeast is killed by the rising level of alcohol.
  • A higher concentration of alcohol can be obtained by distillation.
  • Absolute alcohol refers to 99% ethanol
  • Rectified spirit contains 95% ethanol
  • Industrial/methylated/denatured spirit contains a mixture of 90 to 95% ethanol and 5 to 10% methanol.
  • Surgical spirit refers to methylated spirit plus small amount of castor oil or Wintergreen (methyl salicylate)

Uses of Alcohol Beverage

  1. Solvent for perfumes, aftershaves and colognes
  2. Medicinal (as solvent or adjuvant)
  3. Preservative for viscera ( in the form of rectified spirit)

It has been said that alcohol preserves everything except secrets.

 

Beverage                                                                                  (percentage by volume)

  • Light beer ( Lager and pilsners) Alcohol content                         3 – 6
  • Heavy beer (Stout, Cider & Ale)                                                      6 – 8
  • Natural wine/Table wine                                                                 9 – 15
  • Fortified wine (Sherry & Port)                                                        17 – 21
  • Spirits ( Whisky, Gin & Brandy)                                                      35 – 45
  • Rum                                                                                                       50

 

  • Concept of unit of alcohol
  • To simplify the understanding of the amount of alcohol consumed, the concept of ‘unit’ of alcohol was introduced.
  • A unit being about 8 g of alcohol and is equivalent to
    • Beer half a pint (300 ml.)
    • Wine a 100 ml. glass of table wine
    • Spirits a single pub measure of spirit (25 ml.)

It is generally stated that liver damage is unlikely if a man consumes fewer than 21 units per week whereas a women  should consume fewer than 14 units per week to avoid liver damage.

  • Most absorption of alcohol takes place in the stomach, duodenum and the first part of the jejunum; The later two are the most effective areas of absorption.
  • Any condition that causes the drink to enter the small intestine more quickly than normal, such as gastrectomy or gastro-jejunostomy, will lead to more rapid absorption and an earlier, higher peak blood alcohol level.

Metabolism

  • As soon as alcohol enters the bloodstream mechanism for removal come into action. The overall rate of elimination is practically constant, and much less than the rate of absorption. The blood alcohol usually peaks between 30 and 60 minutes after drinking, although the range may be anything from 20 minutes to 3 hours. Any factor that affects the rate of absorption  will also affect the peak blood alcohol concentration.
  • Faster the alcohol absorption → less time for elimination → higher the peak.
  • Factors influencing the absorption and metabolism
  • Sex and weight- Blood alcohol level is 20% higher in a woman who drinks the same quantity of alcohol as a man of the same weight because of the increased amount of fat in her. The same applies for an obese man who has more fat than a lean man.
  • The duration of drinking- If alcohol is consumed slowly it may be eliminated almost as quickly as it is absorbed, giving rise to much lower peak alcohol concentration.
  • The nature of the drink consumed- Alcohol absorption is maximal from drinks of 20% strength. Below this level the dilution in a larger volume delays mucosal transfer, whilst stronger spirits irritate the gastric mucosa and delay gastric opening, thereby slowing down absorption. Presence of soluble nutrients in the drink also delays absorption.

Thus, drinking beer  lead to delayed and 25% lower peak than that achieved by drinking

the same amount of alcohol as spirit.

  • Food in the stomach- A full meal before drinking can reduce the peak by as much as 50%.
  • Physiological factors and genetic variation- Factors such as stomach wall permeability, blood supply to the alimentary tract and the rate of gastric emptying very from person to person  affecting the peak of alcohol concentration.
  • The rate of elimination- 90% absorbed alcohol is oxidized by the liver in a reaction catalysed by alcohol dehyrogenase. It accounts for the damaging effect that the long-term intake of alcohol has upon the organ. The remainder is excreted unchanged, mainly in urine but also in the sweat and breath. The rate of elimination is in-between 10 to 25 mg/100 ml blood per hour, the average being 15 mg/100 ml/hour.
  • Mode of action Alcohol is a CNS depressant. Its apparent stimulatory effects are due to the fact that it acts first on the so-called higher centres of the brain which govern inhibition.
  • There is a large variation in the susceptibility of drinkers to the effects of alcohol.
  • It depresses primarily the reticular system. The frontal lobes are sensitive to low concentrations (mood changes) followed by the occipital lobe (visual disturbance) and cerebellum ( loss of coordination)

EFFECT of Alcohol

Blood alcohol  Stage of         Effects

Mg/100 ml           Influence                                                       .

Under 50     Sobriety         No obvious effect but may be more talkative with a sense of well-being

50-100        Euphoria        Slurred speech, bravado, some loss of concentration & sensory
perception

100-150      Excitement      Emotional instability, marked loss of concentration, poor sensory
Perception

150-200      Drunkenness     Disorientation, mental confusion

and dizziness. Decreased pain sense ,impaired balance and
slurred speech.

200-300      Stupor       General inertia, approaching paralysis

Marked lack of response to stimuli.

Vomiting, incontinence of urine & faeces.

300-450   Coma        Coma and anesthesia. Depressed or

abolished reflexes.

Over 500 Death          Probable death from respiratory paralysis.

  • Medico-legally, stages 3 and 4 of alcoholic intoxication are the most important since most of the offences associated with drinking are committed during these two stages.
  • Stage 7 (death) is extremely rare in pure alcohol ingestion. In most cases, there is recovery after a few hours of sleep, with some residual effects (hang over) consisting mainly of headache, irritability, fatigue, nausea, abdominal discomfort, etc.

Differential Diagnosis of Alcohol Intoxication

Pre-coma                                                           Coma

  1. Barbiturate ingestion                                     Hypoglycemic or diabetic coma

(and other similar drugs)

  1. Carbon monoxide poisoning                      2. Coma due to other drugs (Hypnotics)
  2. Hypoglycemia
  3. Head injury (post-concussional state)
  4. Cerebrovascular accident
  5. Psychotic states
  6. Disseminated sclerosis

(and other similar neurological afflictions)

Usual Fetal dose

  • Blood alcohol level usually over 500 mg/100 ml means death will occur.
  • Survival has been recorded even with a blood alcohol level of 1500 mg/100 ml
  • Consumption of 1000 to 1500 ml of a strong distilled spirit like whisky or rum , over a short period of time can be lethal.

Treatment (acute poisoning)

  • Stomach wash ( not useful if done more than 2 hours after alcohol ingestion)
  • 50% dextrose (50 to 100ml) intravenously repeated as required
  • Activated charcoal (action debatable)
  • Thiamine 100 mg IV
  • Supportive measures
  • Treatment of chronic poisoning :-The aim is to gradually withdraw alcohol until finally the patient can manage a normal life on his own without the ‘support’ of alcohol.
  • If the intake is abruptly stopped , severe withdrawal reactions can take place.
  • De- addiction must be undertaken in the hospital
  • Many methods have been tried of which use of the drug ‘Disulfiram’ is found to be suitable and effective

How Disulfiram acts :- It acts by its action in the metabolic pathway of alcohol.  It inhibits oxidation of acetaldehyde to acetic acid resulting in accumulation of the former, producing unpleasant symptoms (flashing , headache, palpitation, vertigo, vomiting, abdominal and chest pain hypotension etc.)

  • Person on Disulfiram would experience the above mentioned unpleasant symptoms whenever he takes some alcohol so he avoids intake of alcohol as long as he is on Disulfiram.
  • Guidelines of Disulfiram administration
  • Patient abstain from alcohol for 12 hours before starting of therapy.
  • It must be given orally
  • Patient warned not to consume alcohol when on drug as it provoke a severe reaction.
  • May have to be taken for prolonged period.

 

Alcohol withdrawal syndromes

  1. Common abstinence syndrome: when sudden withdrawal, 6 to 8 hours later- nausea, agitation, tremor, headache and
  2. Alcoholic hallucination: after 24 to 36 hours – there are delusions and hallucinations
  3. Seizures (rum fits): Usually after 48 hours- clonic-tonic movement, with or without loss of consciousness
  4. Delirium tremens: after 3 to 5 days ( Medical emergency)
  5. Wernicke-Korsakoff syndrome

Postmortem Appearances

  • Acute poisoning

External: Congestion of the conjunctivae, odour of alcohol around the mouth & nose.

Internal: Congestion of GI tract, pulmonary and cerebral oedema, congestion of other       viscera.

Chronic alcoholics

Additional features like fatty or cirrhotic liver, degenerative changes in the brain, etc.

Apart from routine viscera, Blood samples from peripheral vein like femoral vein should
be preserved for analysis.

Qualitative analysis is of little value rather a quantitative analysis is essential.

Deaths associated with alcohol

  • Respiratory paralysis from acute poisoning
  • Road traffic accidents
    1. Drinking & driving may cause death to himself, passenger of the vehicle, pedestrians & occupant of other vehicle.
    2. Drunk pedestrians
  • Fall from height
  • Drowning (shallow water)
  • Burning
  • Electrocution
  • Asphyxial death from aspiration of vomits.
  • Death from violence
  • Alcohol induced diseases
    1. Alcoholic liver disease- Fatty liver, Cirrhosis,
    2. Alcoholic cardiomyopathy

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