ALCOHOL

59. Alcohol is one of the most widely used psychoactive drugs known to man; it has apparently been with us since the dawn of civilization. Breweries flourished in Egypt almost six thousand years ago and there is evidence that Stone Age prehistoric man made alcoholic beverages long before that.223 The use of alcohol has appeared in varying degrees in most societies throughout recorded history and has traditionally played an important symbolic as well as pharmacological role in many social, religious and medical practices and customs. Just as the use of alcohol has been almost universal, so, apparently, has its misuse. Consequently, some degree of opposition to 'drink' appears to have arisen in all indulging cultures, although attempts to eradicate its use have met with a uniform lack of success.

What is this drug which has been hailed as the 'water of life' and 'nectar of the gods' by some, and damned by others as 'second only to war' as a source of human problems? Made up of three common elements, carbon, hydrogen and oxygen, ethyl alcohol (C2H5OH) is a colourless, inflammable and volatile liquid. The word 'alcohol' by itself is usually taken to mean ethyl alcohol or ethanol (common beverage alcohol), although there is a vast number of other substances in the aliphatic alcohol family, many of which are highly toxic in even low doses.

Although the technique of producing alcoholic beverages by fermenting fruit, grain, vegetables, and other food-stuffs has hardly been a secret over the past few thousand years, the exact process by which the drug is generated was first illuminated by Louis Pasteur in the middle of the nineteenth century. His investigations revealed that alcohol was produced by a single celled microscopic plant, one of the yeast fungi, which by a metabolic form of combustion breaks down certain sugars, releasing carbon dioxide (CO2) with ethyl alcohol as a by-product. This production of CO2 is responsible for the 'head' on a glass of beer, and the 'popping' of champagne corks, as well as the leavening effects of yeast in the rising of bread. Since yeast cannot digest starch, mash from cereal grains such as barley, rye, corn and rice must be malted (i.e., converted to maltose sugar) prior to fermentation in the production of beer, gin and whisky.

60. Fermentation normally continues until the sugar supply is exhausted. However, as the amount of alcohol in the fermenting solution increases, the metabolic activity of the yeast is slowed until it is finally killed when the alcohol level reaches about 14%, thus setting a limit on the maximum strength of natural (undistilled) beverages. The distillation process of boiling off and isolating the more volatile alcohol from the other fluids (mostly water) allows a further increase in ethanol concentration. Although this technique was used in Middle Eastern cultures centuries earlier, the production of 'spirits' by distillation has been known in Europe for less than seven hundred years. Today, ethanol can be produced synthetically.

In Canada, beer usually contains about 5% alcohol by volume, natural wine 7% to 14%, fortified wine up to 20% and spirits or liquor (distilled) approximately 40% alcohol. In other words, a 12 oz. bottle of beer or 3 to 4 oz. of wine contain about as much alcohol as 11/2 oz. of whisky.

61. The notion of alcohol 'proof' originated centuries ago from a crude but effective analytic technique designed to assess the strength of spirits. If gun powder soaked with the beverage exploded on ignition, this was taken as 'proof' that the liquor was more than half alcohol. 'Proof spirit' in the United Kingdom and Canadian system contains about 57% alcohol, while in the United States proof is calculated as twice the per cent by volume (e.g., 80% proof whisky is 40% alcohol).80

Canada has experimented with alcohol prohibition in varying ways since 1878. Although there are currently some 'dry' localities, alcohol is generally legally available across the country. An interesting bit of drug history is connected with alcohol law: over 300 years ago the prohibition of liquor sales to Indians was Canada's first alcohol regulation. Some such discriminatory policies are only now being eliminated. 32

62. There was a 15-year period of prohibition in the United States, ending in 1934. The failure of that programme has been attributed to the unworkable form of the laws, inadequate enforcement, corruption among public authorities and, perhaps most importantly, a general lack of public support. During that period, the elimination of legitimate alcohol outlets resulted in home breweries and distilleries, 'bootleg' liquor or toxic substitutes, and smuggling, and created an economic vacuum rapidly filled by organized crime. Many authorities feel that this multi-million-dollar illicit market provided the initial capital for the construction of a network of syndicated criminal and quasilegal business empires which have considerable economic and political strength in North America today.

Alcohol is now used by more than three-quarters of the Canadian population over the age of 15. Although most of it is undoubtedly consumed primarily for its pharmacological properties, there is a significant aspect of alcohol usage which is, in some respects, independent of its immediate drug effects. There are many long-standing customs, traditions and superstitions which pervade alcohol use in the Western world. Because it has become an integral part of our culture, the set and setting surrounding alcohol use is substantially different from that associated with other drugs in Canada.

63. Alcohol may have special meanings in various social contexts. Alcohol use is often symbolically and pharmacologically associated with the acknowledgment of birth, death, marriage and other contracts, adulthood, friendship, and, to some, it may imply virility and masculinity. Although it is employed in some religious ceremonies, many individuals have moral apprehensions about alcohol and may approach its use with feelings of ambivalence and guilt. Some reject it outright on grounds of principle, while still others feel that moderate use is morally acceptable. In many social circles abstinence is frowned upon and 'teetotallers' are looked upon with suspicion. On the other hand, it is obvious that considerable alcohol intoxication is tolerated, condoned and even encouraged in many situations in North American society. When one considers the fact that these various attitudes are ultimately tied to, or interact with, the diverse pharmacological potentials of alcohol in determining the overall drug effect, the complexity of the psychopharmacology of the drug in North America becomes apparent. Because its use is so ingrained at all levels of society, there is a tendency for many Canadians not to even consider alcohol a drug.

In a wider context, Jaffe, in The Pharmacological Basis of Therapeutics observes: 111

The large role that the production and consumption of alcoholic beverages plays in the economic and social life in Western society should not permit us to minimize the fact that alcoholism is a more significant problem than all other forms of drug abuse combined.

Medical Use

64. Alcohol is currently recognized as an official drug in the British and U.S. Pharmacopeias, although the various alcoholic beverages, as such, are no longer listed for medical use. Alcohol has been cited over the past few thousand years as a cure for nearly every ailment or disease. Most of the medical benefits were probably more imagined than real, and many of alcohol's legitimate pharmacological functions have now been filled by more effective drugs, although it still plays a useful role in medicine.

Alcohol is often used as a preservative, solvent, and vehicle for other drugs, and is contained in tinctures, elixirs, spirits and many medicinal syrups. It is used to cleanse, disinfect and harden the skin, to cool it during fever, to decrease sweating (and is included in many antiperspirant deodorant), to reduce bed sores, to treat fainting, to temporarily or permanently block nerves by injection, and to stimulate appetite and digestion. In concentrations around 70%, alcohol is an effective antibacterial agent, although it is not satisfactory for disinfecting open wounds since it damages the raw tissue.186

Alcohol is still sometimes recommended as a tranquillizer, sedative, or hypnotic and may also serve as a mild mood stimulant for some individuals. It is no longer considered a safe surgical anaesthetic, since the dose necessary to produce unconsciousness is often dangerously close to the fatal level. However, the drug does produce mild analgesia (pain reduction) at lower doses. Alcohol is still used in the lay and folk medicine to 'treat' the common cold, although its benefits, if any, are probably limited to an improvement in mood and increased relaxation and rest.

Administration, Absorption, Distribution and Physiological Fate

65. Alcohol is usually taken orally and is rapidly and completely absorbed in the gastrointestinal tract. Some absorption takes place in the stomach although diffusion into the blood stream is most rapid from the upper intestine and, consequently, the quicker the alcohol passes through the stomach the shorter the latency of its action. Food eaten before or with alcohol tends to decrease the drug effect by slowing stomach emptying, and a meal before drinking alcohol may reduce the peak alcohol level in the blood by almost one-half compared to that attained by drinking on an empty stomach. Once absorbed, alcohol is distributed quite uniformly in all bodily fluids, easily enters the brain, and in pregnant women crosses the placental barrier into the foetus. Alcohol temporarily diffuses into fat tissue and consequently, a lean muscular individual will normally experience a greater pharmacological effect with a given dose than will a person with much body fat.

Approximately 95% of the alcohol in the body is broken down by oxidation in the liver and the rest is excreted unchanged, primarily in the urine and breath. While certain alcoholic beverages, such as beer, contain some protein and carbohydrates, alcohol itself provides only calories when metabolized and has little general food value. Depending on the form of alcoholic beverage and possible mixers, an ordinary drink may contain 90 to 150 calories or more. The rate of disappearance of alcohol from the body is quite constant within individuals at a given time, and the average 150 lb. man can metabolize about 9 ml. (0.3 oz) of alcohol per hour.

A convenient index of the quantity of the drug in the body is the blood alcohol level, represented in per cent by weight. Since the amount of alcohol excreted in the breath bears a fixed relationship to that in the blood, it is possible to accurately estimate the blood alcohol level from expired air. This principle is utilized in the Breathalyzer tests now employed in the enforcement of driving laws.

Short-Term Effects

66. Alcohol exerts its more significant effects through the central nervous system, usually producing a general sedation or depression of neural activity over a wide dosage range, although in certain circumstances, considerable behavioural and psychological arousal may result. Little is known as to the specific mechanism by which alcohol produces its psychopharmacological action. As with most drugs, alcohol effects, especially those resulting from low or moderate amounts, depend to a large extent on the individual and the situation in which the drinking occurs. A drink or two may produce drowsiness and lethargy in some instances, while the same quantity might lead to increased activity and psychological stimulation in another individual, or in the same person in different circumstances. Furthermore, a dose which is initially stimulating may later produce sedation.

In many social settings, alcohol seems to result in a lessening of inhibition and a feeling of well being, sociability and camaraderie in most individuals. For many people alcohol relieves tension and anxiety - the common notion that one 'needs a drink' when worried, irritated or upset, reflects a general acknowledgment of this function. Although alcohol usually elevates mood at first, a general lack of emotional control, including anxiety, withdrawal, self-pity and depression may occur later. Alcohol has been frequently cited as an important contributing factor in many suicides.

Hostility and aggression are not at all uncommon in some drinkers, and fights and other forms of violent antisocial behaviour are often reported to accompany bouts of heavy drinking. It appears that some criminals fortify their courage by drinking prior to a sortie and alcohol intoxication reportedly plays a significant role in a large proportion of the violent crimes (murder, rape and assault against persons and property) in North America.18

67. Alcohol does not have a specific aphrodisiac (sex stimulating) effect per se, although the emotionality and general lessening of inhibitions often induced may lead to an increase in sexual activity and other normally restricted behaviour. An increase in desire or opportunity may be neglected by acute sexual impotence, however.

Although delusions, illusions and amnesic 'black outs' may occur in some individuals, acute alcohol psychosis (pathological intoxication) in normally moderate drinkers is rare. Even so, many persons might sympathize with the Roman philosopher Seneca who, almost 2,000 years ago, observed that, 'Drunkenness is nothing but a condition of insanity purposely assumed'.197

In moderate amounts (e.g., a few drinks) alcohol may increase or decrease heart rate, produce a 'flushing' or dilation of small blood vessels in the skin (giving a sensation of warmth), lower body temperature, stimulate appetite and the secretion of saliva and gastric juices, increase urination, produce a slowing of the electroencephalogram (EEG), increase reaction time, reduce muscular co-ordination. In addition, alcohol generally reduces performance on tests of a wide variety of psychological functions. Tests requiring a high degree of attention, concentration or vigilance are particularly sensitive to alcohol effects, and impairment is usually most pronounced on complex and recently learned tasks. In a few situations, however, a small amount of alcohol may actually improve performance. In high doses, alcohol produces drunkenness, disorientation and confusion, slurred speech, blurred vision, inadequate muscular control, and often induces nausea and vomiting. As an increasing quantity is ingested, there occurs a depression of respiration, general anesthesia and unconsciousness and, rarely, death due to respiratory arrest and circulatory failure. Acute alcohol intoxication is often followed by pronounced 'hangover' symptoms characterized by nausea, weakness, dizziness, poor coordination and a variety of aches and pains. Some authorities consider this post-inebriation phase a form of acute withdrawal syndrome.

68. Effects of alcohol on driving ability are well known - even moderate amounts produce serious impairment in many individuals. A recent study of alcohol involvement in fatal motor vehicle accidents in three Canadian provinces presented findings similar to those reported regularly across North America.37 It has commonly been observed that alcohol is a factor in a large proportion of all fatal traffic accidents. Approximately 70% of drivers killed in single vehicle accidents and 50% of drivers killed in multi-vehicle collisions had been drinking. Among all driver fatalities, alcohol was detected in the blood of 60 to 70 per cent of those considered responsible for their own deaths. Furthermore, more than half of the pedestrians killed in traffic accidents had recently been drinking, and there are numerous reports that alcohol is a contributing factor in a great number of industrial accidents as well. A large proportion of the people involved in such accidents are chronic alcoholics, although the majority are apparently 'social' drinkers.

The intensity of the acute effects of alcohol can, to a certain extent, be predicted from the amount of alcohol in the blood, although the relationship between the quantity of alcohol present and the central nervous system (CNS) response may vary considerably from individual to individual. Recent Federal legislation prohibits driving with blood alcohol level greater than 0.08%. Depending on the person, this concentration may be produced by three or four ordinary drinks, if consumed in a short time. While certain individuals might be capable of driving satisfactorily with this much alcohol, most persons are probably impaired by even lower quantities. Although the Breathalyzer can be used to assess acute alcohol intoxication, there are no simple methods of detecting a 'hangover', and there are indications that this post-inebriation phase also has severe effects on psychomotor performance.

Long-Term Effects

69. Many authorities differentiate between 'low risk' (moderate) and 'high risk' (heavy) drinking in discussing the long-term effects of alcohol. For most otherwise normal individuals, moderate drinking over a prolonged period of time may produce little significant psychological or physiological change. High risk or heavy drinking (e.g., five or six or more drinks a day) may lead to a variety of disorders, however, many of which are subsumed under the general term 'alcoholism'.

There is considerable disagreement among authorities as to the proper delineation of the concept of alcoholism - definitions may be as general as 'a family of disorders accompanying chronic heavy drinking 'with various social and economic complications, or may contain more restrictive specifications of physical dependency or psychological and physiological harm. Jellinek has described five different types of alcoholics which differ in degree and kind of psychological, behavioural and physiological involvement.112 In some areas of North America, at least two per cent to five per cent of alcohol users become alcoholics and many more would be considered problem drinkers.

70. No group of drug-dependent persons presents a sorrier picture of psychological and physiological pathology than that of the 'skid row' derelict alcoholics. Frequently observed in these individuals and many other alcoholics are disorders of the digestive tract, cardiovascular system, lungs, kidney, pancreas and the nervous system, with sleep disturbance and various kinds of irreversible neurological damage and cerebral atrophy. Considerable attention has been focused on liver disorders in heavy drinkers, and it is well established that alcohol is a major contributing or causal factor in liver cirrhosis. Alcoholics may develop specific psychotic syndromes, permanently impaired memory, epilepsy, chronic incoordination, sexual impotence, loss of appetite and a variety of nutritional disorders which may result in an increased susceptibility to other diseases and infections.111

In the past, these and numerous other disorders were thought to be a direct result of alcohol toxicity, but now many of these pathologies are considered to be of secondary origin - often a function of chronic dietary deficiencies, poor personal care and other aspects of the general life style which may accompany alcoholism. The diet of certain alcoholics may consist of 40-50% alcohol, with periods of weeks or even months of nothing else, and thus may be dangerously low in proteins, vitamins, minerals and other essential foodstuffs. Proper diet and medical care may be able to prevent or alleviate many, but not all, of the problems associated with chronic alcoholism.182

Only a minority of alcoholics are 'down and out' derelicts, and there are many alcohol-dependent persons in all levels of society who function in varying degrees of effectiveness in spite of the handicap. Psychological and physiological disorders in these individuals vary considerably as a function of general life style, drinking patterns and perhaps certain inherited characteristics. Many heavy drinkers show little functional impairment.

Tolerance and Dependence

71. Tolerance to most of the effects of alcohol develops with frequent use, although it does not occur as rapidly or to the same degree as with the opiate narcotics. The rate of acquisition and extent of tolerance depends on the pattern of use, and regular heavy drinkers may be able to consume two or three times as much alcohol as a novice. In Western culture, some symbolic masculinity frequently accompanies the development of tolerance and the ability to 'hold one's liquor'.

Most intermittent or moderate drinkers show little tendency to increase dose, although regular heavy drinkers may, in order to obtain the desired psychological effects, ingest quantities which lead to chronic alcohol toxicity symptoms. In addition to the probable neurophysiological and metabolic mechanisms involved in tolerance, learning to function under the influence of alcohol may further reduce some of the acute behavioural effects of intoxication in regular users. Little or no tolerance develops to the lethal dose, however, and acute alcohol poisoning is a noted cause of death in alcoholics, although nausea, vomiting and unconsciousness usually prevent self-administration of a fatal overdose. In some alcoholics, tolerance later seems to decline and a special response or oversensitivity to certain effects of alcohol develops. In such individuals even a single drink may produce profound loss of control and initiate unrestricted further indulgence.

72. Physical dependence on alcohol occurs in some long-term heavy drinkers after the development of tolerance. Although alcoholic hallucinosis, delirium tremens ('DT's), and convulsions ('rum fits') were noted and studied in the nineteenth century, until recently there was a lack of consensus as to whether these symptoms were essentially the direct result of acute or chronic alcohol toxicity, secondary nutritional deficiencies, or part of a physical dependence withdrawal syndrome.

Isbell et al108 and Mendelson et al156 have clearly demonstrated that even when diet is controlled, a characteristic severe abstinence syndrome can occur after only a few weeks of continual heavy drinking. The quantities of alcohol ingested in these studies were much greater than those normally consumed, however, and with the usual drinking patterns, such physiological dependence does not occur until after 3 to 15 or more years of heavy consumption. Some heavy drinkers never become physically dependent on alcohol.112

73. The overall picture of the alcohol withdrawal syndrome is generally similar to that noted earlier for barbiturates. Nausea, anxiety, severe agitation, confusion, tremors, and sweating are followed by cramps, vomiting and illusions and hallucinations. After several days, delirium tremens may develop and convulsions, exhaustion and cardiovascular collapse may occur. The delirium tremens stage is fatal in about 10% of cases. Major recovery in those surviving usually occurs within a week, although certain psychological symptoms may continue for a longer period.234

Psychological dependence on alcohol seems to occur in many individuals, and such dependence appears to be generally accepted in contemporary North America. A great number of people regularly turn to alcohol for relief or aid prior to or after facing a stressful situation, to escape worries, troubles or boredom, to relax and enjoy a party, or even to sleep, and many feel they do not function as well in certain situations without a drink or two. There would appear to be a strong psychological component in the drinking behaviour of the developing alcoholic, as is exemplified in the usually compulsive nature of his drinking and his frequent inability to control his use of alcohol in spite of obvious consequences.

Alcohol and Other Drugs

74. A certain degree of cross-tolerance and cross-dependence occurs among the sedative drugs. Heavy alcohol users are normally resistant to the effects of barbiturates, minor tranquillizers, volatile solvents and anaesthetics, as well as alcohol, although the cross-tolerance does not significantly affect the lethal dose. Consequently, many over-dose deaths occur due to the mixing of these drugs in chronic users. Barbiturates and minor tranquillizers effectively block alcohol withdrawal symptoms and are frequently used in treating alcoholics in the acute phase of abstinence. Alcoholics are often heavy users of other sedative drugs as well and may switch from one to another, if it is convenient or necessary. The use of high toxic alcohols, such as methyl or 'wood' alcohol, and even automobile anti-freeze, has been reported in derelict alcoholics. In addition, persons dependent on opiate narcotics generally have a history of heavy alcohol consumption.

75. Certain drugs, such as disulfiram (Antabuse*) or Temposil*, which may have little direct pharmacological activity themselves, have the capacity to inhibit certain stages of alcohol metabolism in the body and can thereby produce a highly unpleasant toxic reaction known as the acetaldehyde syndrome when used in conjunction with alcohol. Such drugs have been used in the treatment of problem drinkers.

Amphetamines, caffeine and other stimulants may reduce the drowsiness often associated with inebriation, although they can not fully compensate for most of the effects of alcohol intoxication.