Absorption, Distribution, and Elimination of Alcohol

  Wigmore on Alcohol

Reference Number: 

Widmark (or forward) BAC calculations, which are generally much less

reliable than back calcu lations, are presented in section .. The ef‌fects

of other drugs (e.g., cimetidine) and of trauma are covered in sections

. and ., respectively.

. ABSORPTION

Alcohol is generally absorbed after oral consumption via the stomach

and small intestine. Alcohol is a unique drug in that it can be substan-

tially absorbed via t he stomach (–), although absorption through

the small intestine is faster. The concentration of alcohol in the stom-

ach decreases rapidly, so it is rarely benef‌icial to lavage or remove the

contents of the stomach in alcohol-intoxicated patients as usually only

minimal a mounts of alcohol remain in the stomach by the time the pa-

tient presents to hospital ().

Food ingestion tends to slow the absorption of alcohol and decrease

the maximum BAC, but it does not substantia lly prolong the time to

peak BAC (–). Carbonation tends to cause a more rapid absorp-

tion of alcohol and increase the initial BAC (, ), but salty

foods and warm temperatures of alcoholic beverages do not signif‌icant-

ly change the rate of alcohol absorption (, ). Various gastric

surgeries such as a gastric bypass may substantially increase the rate of

alcohol absorption, and patients who undergo these operations should

be warned of this ef‌fect ().

Alcohol is not signif‌icantly absorbed by inha lation through the lungs

(–) or via dif‌fusion th rough the skin (, , , ).

Hence, frequent use of an alcohol-based hand sanitizer does not result

in a signif‌icant BAC (, ). Alcohol can be rapidly absorbed by

intravenous infusion (, ) or by rectal enema ().

Reference Number: 

, ..,  . . “The Absorption of Ethyl Alcohol from

the Gastro-Intestinal Tract as a Dif‌fusion Process.” Acta Physiologica

Scandinavia, /: –, / ( tables,  f‌igures,  references)

Abstract: The absorption of alcohol from the stomach was determined

in cats and humans. Several human subjects were admi nistered up to

 mL of a % or % alcohol solution via a stomach tube. The stomach

alcohol concentration was then determined over time. A mathematical

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

model (based on Fick’s law) of the dif‌fusion process was presented. In

human subjects with a closed pylorus, approximately % of the alcohol

was absorbed after  minutes, % after  minutes, a nd % after 

minutes. If the stomach was empty, % of the alcohol was able to be

absorbed within  minutes. Tests were also conducted on patients with

gastritis and ach lorhydria (associated with severe anemias a nd stomach

cancer), and no signif‌icant dif‌ferences in alcohol absorption from the

stomach were observed compared with that in normal s ubjects.

Table. Percent of Alcohol Absorbed from the Stomach and

Stomach Emptying Time in Five Normal Subjects after

Instillation of  mL of % Alcohol Solution

Percent Alcohol Absor bed from

Stomach

Time of Stomach Emptyin g

(min)

Subject No.  min  min

  

  

  

  

  

 = not available.

Source: Adapted from Berggren an d Goldberg (/).

The absorption of ethyl alcohol from the stomach follows the laws of

dif‌fusion. This means that the greater the concentration of alcohol in -

gested, the more rapidly absorption will t ake place with a higher and

earlier blood alcohol maximum.

Reference Number: 

, .. “The Simultaneous Emptying and Absorption of Ethanol from

the Human Stomach.” Digestive Diseases, : –,  ( tables, 

f‌igures,  references)

Abstract: A total of  meals ( of water and  of .% volume of sol-

ute per volume of solvent [v/v] ethanol) were given to seven healthy, fast-

ing subjects. The volume of the meals was  mL . Gastric contents were

aspirated at various times, a nd the alcohol concentration was measured

by an alcohol dehydrogenase (ADH) procedure. The emptying of ethanol

meals and water meals proceeded at the same rate up to about  min-

utes, when about % of the meal had left the stomach. The absorption

  Wigmore on Alcohol

Reference Number: 

of ethanol was related directly to the time present in the stomach. The

emptying was exponential i n rate.

The f‌indings of this study, in conjunction with those of a previous study,

suggest that similar amounts of ethanol can b e absorbed by the stom-

ach within  min whether emptying is delayed or allowed to proceed

normally. Both studies indicate that the stomach is an import ant site of

ethanol absorption.

Reference Number: 

, ., . , . , . , . ,  . -

. “Gastric Emptying and Gastrointestinal Absorption of Alco-

hol Ingested with a Meal.” Digestive Diseases and Sciences, : –,

 ( f‌igures,  references)

Abstract: The gastr ic evacuation and gastrointestina l (GI) absorption of

alcohol were measured by the intubation of seven male subjects. A hom-

ogenized meal containing carbon –labeled polyethylene glycol ([C]

PEG) and .g/kg of ethanol was given intragast rically. BACs were found

to increase rapidly in the f‌irst hour and plateau thereafter at a BAC of

about .g/mL. T he meal probably delayed the gastric emptying

of alcohol and prolonged its presence in the stomach, which resulted in

more absorption thorough the stomach wall.

The main f‌inding of the present study is that alcohol ingested w ith a

meal is mainly (%) absorbed by the stomach and to a lesser ex tent by

the duodenum (%); the amount of alcohol passing the angle of Treitz

is thus negligible. Previous data on the site of alcohol absor ption are sur-

prisingly scarce and were obtained with inadequate metho ds. Some very

old studies only rely on alcohol blood concentrations or on animal data.

Reference Number: 

, .., .. ,  . . “Distribution of Ethanol in the

Human Gastrointestinal Tract.” American Journal of Clinical Nutrition,

: –,  ( f‌igures,  references)

Abstract: Chronic a lcoholics often have abnorm alities of intesti nal ab -

sorption that revert to normal af ter the abstinence of alcohol and the

maintenance of a normal diet. In this study, f‌ive chronic alcoholics and

two normal subjects were given . g/kg of ethanol either by mouth

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

(PO) or intravenously (IV). A sampling tube was placed in the stomach

and intestine, and the f‌luids were ana lyzed by gas chromatography (GC).

For ethanol consumed PO, the gastric alcohol concentration peaked at

–g/mL after  minutes. The concentration in the duodenum and

proximal jejunum peaked at –g /mL after  minutes. After  

minutes, the concentrations of ethanol in the serum and a ll GI sites were

similar and declined in parallel to .–.g/mL by  minutes.

For ethanol given IV over . hours as a % v/v solution, the serum lev-

els peaked at .g/mL after  minutes and fell to .g/mL.

The concentration of ethanol in gastric, jejun al, and ileal contents peak-

ed at between  and  minutes, somewhat higher than in the serum.

After  minutes, al l sites were comparable in ethanol concentration to

that in the serum.

In the present subjects, after an initial e quilibrium period following its

acute administration, ethanol was distributed equ ally in the vascular

space, stomach, and small intestine. After oral inge stion, maximal etha-

nol levels were found in the stomach, duodenum, and proximal jejunum.

High ethanol levels were sustained for up to  hr at these sites.

Reference Number: 

, .. ., .. , .. ,  .. . “Gastric

Emptying in the Acutely Inebriated Patient.” Journal of Emergency

Medicine, : –,  ( tables,  references)

Abstract: Eleven female and  male alcohol-inebriated patients (ages

– years) with a breath alcohol concentration (BrAC) > .g/mL

(as determined with an Alco-Sensor) underwent the evacuation of the

stomach using a nasogast ric tube in order to ascertain if signif‌icant

amounts of alcohol can be removed prior to absorption. The time since

the last drin k were reported to range from  to  minutes (mean

 minutes). Venous BACs were also measured and ranged from .

to .g/mL. The volume of aspirate ranged from  to  mL

(mean  mL), and the gastric alcohol concentration ranged from . to

.% v/v (mean .% v/v). There was no signif‌icant correlation between

the patient’s stated drinking history or BAC and the aspirate volume or

alcohol concentration. The authors estimated the increase in BAC that

would result from the absorption of the measured alcohol in the gast ric

contents. However, the volume of distribution of alcohol used in this

  Wigmore on Alcohol

Reference Number: 

calculation was based on ly on the plasma volume (% of body weight)

rather than total body water (approximately % of body weight). The

corrected increases in BAC ranged from . to .g/mL.

Table. Self-Reported Types of Alcoholic Beverage Consumed by 

Intoxicated Patients

Beverage Type Percentage of Patients

Beer only 

Beer and liquor 

Beer, wine, and liquor 

Liquor only 

Liquor and mouthwash 

Wine only 

Wine and liquor 

Mouthwash only 

Source: Adapted from Pollack et al. ( ).

The occasional inebriated patient might benef‌it from g astric emptying

in the ED [emergency department]. These data, however, do not sup-

port routine gastric evacuation solely for the management of ethanol

ingestion, as the benef‌it would be small and would n ot justify the risk

and inconvenience of the intervention.

Reference Number: 

, ..,  .. . “The Ef‌fect of Food on Alcohol Absorption

and Elimination Patterns.” Journal of Forensic Sciences, : –,

 ( table,  f‌igures,  references)

Abstract: Six male and three female subjects consumed . g/kg of

ethanol as a % v/v solution as quickly as possible (mean time  min-

utes). The subjects consumed the alcohol after either a -hour fast or

after consuming a pepperoni pizza . The subjects provided a breath sam-

ple into an Intoxilyzer A every  minutes. The time to maximum

BAC was assumed to be the time in which the BrAC reached within

.g/mL of the maximum. The mean time to ma ximum was 

minutes for both fasting and food conditions. The mean m aximum BAC

was .g/mL on empty stomach and .g/mL on a full stom-

ach. The mean rate of alcohol elimination was .g/mL/h (range

.–.g/mL/h) on an empty stomach and .g/ mL/ h

(range .–.g/mL/h) with food.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

As expected, the presence of food in the s tomach reduced the peak

BrACs (averaging .% lower). However, regardless of stomach condi-

tion the time to reach maximum BrAC was relatively short, on average

being  min. The most important f‌inding of this s tudy was the short

time required to reach the maximum BrAC and the failure of food to

prolong the rising phase (upward sloped lag of the BrAC curve).

Reference Number: 

, ., . ,  . . “Ef‌fects of Meal Composition

on Blood Alcohol Level, Psychomotor Performance and Subjective

State after Ingestion of Alcohol.” Appetite, : –,  ( tables,

 f‌igures,  references)

Abstract: Fifty-one male subjects (ages – years) were divided into

six experimental g roups: alcohol-carbohydrate, placebo-carbohydrate,

alcohol-protein, pl acebo-protein , alcohol-fast , and placeb o-fast g roups.

Alcohol consumption was between . and . mL of vodka (% v/v

alcohol) calculated to obtain a BrAC of approximately .g/mL.

BrACs were determined every  minutes with an Alcolmeter AE-D.

High-protein or high-carbohydrate meals (with minim al fat content)

were consumed prior to alcohol consumption. Various psychomotor

tests were conducted, and subjective state was measured before and after

the alcohol administration. The mean peak BrACs were approximately

.g/mL (fasting), .g/mL (protein), and .g/mL

(carbohydrate). Two hours later, the BrACs were .g/ mL (fast-

ing) and .g/mL (protein and carbohydrate).

These f‌indings imply that the benef‌it s of eating before drinking are

modest at best, do not nearly eliminate per formance impairment and

that high carbohydrate foods are not noticeably superior to high protein

foods. Indeed the former may be more problem atic in practice as high

carbohydrate meals can make people feel less drun k while performing

as badly as without food.

Reference Number: 

, ..,  . . “Evaluation of Blood-Ethanol Prof‌iles after Con-

sumption of Alcohol Together with a Large Meal.” Canadian Society of

Forensic Science Journal, : –,  ( tables,  f‌igures,  refer-

ence s)

  Wigmore on Alcohol

Reference Number: 

Abstract: Sixteen male subjects (ages – years) consumed .g/kg of

ethanol over  minutes together with a large meal consist ing of raw her-

rings, meatballs, cheese, roas t beef, ice cream, and cof‌fee. Capillary blood

samples were taken at , , , , , , , and  minutes after

drinking ceased. The BACs were determined by the enzym atic method,

and the peak BACs ranged from . to .g/mL. The mean rate

of elimination was .g/ mL/ h (range .–.g/mL/h).

Approximately % of the f‌inal peak BAC was reached – minutes

after drinking ceased. One subject vomited  minutes after the end of

drinki ng and showed no ef‌fect on the BAC curve.

Table. Mean Percent of Maximum BAC Obtained in Drinking

Subjects after Consumption of Alcohol Ceased

Time after Consumpt ion of Alcohol

Ceas ed (min)

Mean % of Maximum BAC Obta ined



 

 

 

Source: Adapted from Jones and N eri ().

These results suggest that part of t he dose of alcohol is rapidly absorbed

into the blood despite the presence of undigested food in the s tomach.

However, the absorption of the remaining dose of alcohol might pro-

ceed for several hours.

Reference Number: 

, ., . , . ,  . . “The Ef‌fects of Car-

bon Dioxide in Champagne on Psychometric Performance and Blood-

Alcohol Concentration.” Alcohol and Alcoholism, : –,  (

table,  f‌igures,  references)

Abstract: Six male and six female subjects consumed .g/kg of alcohol

(approximately  mL) as champagne or degassed champagne that was

consumed within  minutes. T he champagne was degassed by whisking

it in an electric blender. The alcohol content of the champagne was .g/

dL and of the degassed champagne wa s .g/dL. Frequent blood samples

were collected using an indwelling catheter, and plasma alcohol concen-

trations (PACs) were determined by GC. The subjects conducted various

psychomotor tests such as choice reaction time (CRT), critical f‌licker fu-

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

sion (CFF), and compensatory tracking test (CTT). The mean PACs after

consumption of degassed champagne were signif‌ica ntly lower than the

mean PACs after consumption of champagne for the f‌irst  minutes

after consumption ceased. T here was a signif‌icant increa se in CTT (reac-

tion time) with champagne compared with degassed ch ampagne.

Table. Mean PAC after the Consumption of Champagne or

Degassed Champagne

Time after Alcohol

Consumption Ceased

(min)

Mean PAC after

Champagne Consumption

(g/ m L)

Mean PAC after Degassed

Champagne Consumption

(g/ m L)

. .

 . .

 . .

 . .

 . .

Source: Adapted from Ridout et al . ().

Although this was very much a pilot study, employing a small numbe r of

subjects, the results suppor t the popular belief that champagne may be

more intoxicating than wine, although the mechanism remains unclear.

Further research into the ef‌fects of CO in alcoholic drinks could be of

relevance to car drivers and others who wish to monitor th eir BACs.

Reference Number: 

, .,  .. . “Alcohol Concentration and Carbonation

of Drinks: The Ef‌fect on Blood Alcohol Levels.” Journal of Forensic and

Legal Medicine, : –,  ( tables,  f‌igures,  references)

Abstract: Nine female and  male subject s (ages – years) consumed

.g/kg and .g/kg of alcohol, respectively, as vodka neat (% v/v al-

cohol), vodka diluted with water (% v/v), and vodka with carbonated

water (% v/v) within  minutes. BrACs were determined every  min-

utes with an Alcolmeter S-D. The mean peak BrACs were ., .,

and .g/mL, respectively. The mean absorption rates were .,

., and .g/mL/min, respectively. Subjects absorbed alcohol

at a slower rate for undiluted vodka compared with diluted vodka.

Although this study has shown a signif‌icant lin k between alcohol con-

centration and alcohol absorption rates, it was performed in laboratory

conditions that do little to mimic drinking situations.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, .., .. , .. , .. ,  . -

. “The Inf‌luence of Temperature on Alcohol Absorption Rates in

Humans.” Military Medicine, : –,  ( f‌igure,  references)

Abstract: Six subjects (ages – years) consumed .g/kg of alcohol

diluted with water to  mL as a hot (ºC) or cold (−ºC) drink after a

-hour fast. The alcohol was consumed wit hin  minutes. BrACs were de-

termined every  minutes using an Alco-Sensor III. The subject s rinsed

their mouth with tap water at least  times before the f‌irst breath s am-

ple was collected. Although the subjects reported t hat the hot drink was

more potent and had a more rapid onset than the cold drink, neither the

peak BrACs nor the time to peak BrACs were statistical ly dif‌ferent.

If there is any enhancement of alcohol absorption by increasing the

temperature of the imbibed f‌luid, it was not of a magnitude to be clinic-

ally important, nor was th e dif‌ference statistically signif‌icant.

Reference Number: 

, .,  .  . “The Ef‌fects of Salty and Nonsalty Food

on Peak Breath Alcohol Concentration and Divided Attention Task

Performance in Women.” Substance Abuse, : –,  ( table,

 references)

Abstract: Twelve female subjects (ages – years) consumed either

a placebo or .g/kg of ethanol with  g of pretzels that contained

either low ( mg) or high ( mg) amounts of sodium, after a -hour

fast. BrACs were determined every  minutes using an Alco-Sensor II.

Various psychomotor tests were conducted. The mean peak BrACs were

.g/mL with low-sodium pretzels and .g/mL with high-

sodium pretzels. Sodium had no ef‌fect on the psychomotor tasks includ-

ing reaction time (RT).

It therefore seems appropriate to warn women (and men) that the con-

sumption of salty foods while drinking alcohol do es not contribute to

a slower absorption of alcohol or prevent the BAC from exceeding the

legal driving limit.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Reference Number: 

, .., .. , ..  ., . , . ,  ..

. “Comparison of Blood Alcohol Concentrations after Beer and

Whi skey.” Alcoholism: Clinical and Experimental Research, : –,

 ( table,  f‌igure,  references)

Abstract: Eleven male subjects (ages – years) consumed .g/kg of

alcohol as beer (.% v/v), white wine (% v/v), dry sherry (% v/v), and

whiskey (% v/v) after an overnight fast, with a standard breakfast or

after a standa rd breakfast. The alcohol was consumed w ithin  minutes.

The volumes of alcoholic beverages for a  kg subject were , , ,

and  mL, respectively for beer, wine, sherry, and whiskey. BrACs were

determined with a Lion Alcolmeter S-D every – minutes.

Table. Mean Peak BrACs after Consumption of Whiskey or Beer

under Dif‌ferent Food Conditions

Food Conditions Mean Peak BrAC after

Whiskey Consumption

(g/ m L)

Mean Peak BrAC after

Beer Consumption

(g/ m L)

 hour after a meal . .

With a meal . .

Fasting overnight . .

Source: Adapted from Roine et al. ().

These f‌indings are of practical impo rtance, because most peop le nor-

mally consume alcoholic beverages with or following meals; therefore

they should be made aware that, under these circumst ances, they may

be more af‌fected by a dilute beverage, such as beer, than by a concen-

trated one, such as whiskey for a given dose of alcohol.

Reference Number: 

, ., . ,  .. . “Faster Absorption of Etha-

nol and Higher Peak Concentration in Women after Gastric Bypass

Sur gery.” British Journal of Clinical Pharmacology, : –,  (

table,  f‌igure,  references)

Abstract: Twelve women who had undergone gastric bypass surgery (at

least  years earlier) and  matched controls (mean age  years) con-

sumed .g/kg of a lcohol in  minutes after an overnight fast. Venous

blood samples were collected via an indwelling catheter every  minute s,

  Wigmore on Alcohol

Reference Number: 

and BACs were determined by headspace GC. The mean peak BAC was

.g/mL for the women who had undergone the gastric surgery

and .g/mL for the controls. The median time to max imum

BAC was  minutes (range – minutes) for the women with gastric

surgery and  minutes (range – minutes) for the controls.

In conclusion, we suggest that after gastric bypa ss surgery, patients

should be warned about drinking alcohol too qui ckly because even

relatively small amounts of alcohol, such as two small glass es of wine

(.g/kg) might produce unexpectedly high BAC shortly af ter the end

of drinking. Also, when other surgical procedures are per formed on the

gut such as gastric resection and g astrectomy, a more rapid absorption

of ethanol can be expected.

Reference Number: 

, .., . ,  . . “Blood Ethanol Levels following

Rapid Intravenous Infusion.” Quarterly Journal of Studies on Alcohol :

–,  ( f‌igures,  references)

Abstract: Subjects were administered % v/v of ethanol IV with in –

minutes to help induce anesthesia at a dosage of .g/kg. Venous and

arterial blood sa mples were collected, and BACs were determined by GC.

AV equilibrium occurred in – minutes and tota l body equilibrium in

.– hour. This is a result of etha nol being of low molecular weight and

inf‌initely soluble in water. The rate of elimination is linear; the mean

rate was found to be .g/mL/h. There was little va riation in the

fall of BAC between individuals .– hours af ter infusion. In the f‌i rst

. hour after infusion, there were re-distr ibutional changes in BAC.

During the period of infusion the alcohol concentration wa s higher in

arterial than in venous blood. The pe ak arterial concentration as well as

the arteriovenous dif‌ference depended on th e speed of injection.

Reference Number: 

, ..,  .. . “Intravenous Injection of Alcohol by Drug

Injectors: Report of Three Cases.” Alcohol and Alcoholism, : –,

 ( references)

Abstract: Three male polydrug u sers (ages – years) reported injecting

alcohol IV. The alcohol was injected rather than consumed because of

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

the rapid onset of ef‌fect and the perceived lack of odor of alcohol on the

breath. The only described side ef‌fects were a burning pain and local

inf‌lammat ion at the injection site.

Two other unusual routes of alcohol ingestion have been reported in

the media recently, snorting vodka among middle-cla ss English club-

goers and the use of vodka-soaked tampons by teenage girls in E astern

Finland. Intravenous injection has some comm on features with these

other methods; e.g., rapid onset of ef‌fects , low doses required for in-

toxication and the reduced likelihood of recent alcohol consumption

being identif‌ied.

Reference Number: 

, .., .. ,  .. . “An Unusual Form of Fatal

Ethanol Intoxication.” Journal of Forensic Sciences, : –,  (

f‌igure,  references)

Abstract: A -year-old man was found dead, naked in – cm of fecal-

stained water in a bathtub, with a rect al enema that contained red wine.

Three nearly empty  L bottles of wine were found near the body. The

postmortem BAC was .g/mL, and the vitreous humor alcohol

concentration (VHAC) was .g/mL, which tends to indicate that

the victim died in the r ising (absorptive) BAC phase.

In summary, we report what we believe to be the f‌irst case in th e English

medical literature of an individual fatality from the us e of a wine enema.

Location of the victim as well as the presen ce of various articles indica-

tive of enema use is helpful in determining the mechanism of death .

Reference Number: 

, .., . ,  .. . “Alcohol-Based Hand Sanitizer:

Can Frequent Use Cause an Elevated Blood Alcohol Level?” American

Journal of Infection Control, : –,  ( references)

Abstract: A -year-old physician used an alcohol-based hand sanitizer

(ABHS) that contained % alcohol  times over  hours. Five milliliters

of ABHS was applied each time to the hands and forearms and allowed

to dry. The serum alcohol concentration (SAC) immediately after the last

application was less than the detectable li mit (i.e., .g/mL).

  Wigmore on Alcohol

Reference Number: 

We report a case of a  year old physician with a negative blood eth a-

nol level despite repetitive and high volume use of a % ethanol based

ABHS.

Reference Number: 

, .. “The Purell Defence: Can the Use of Alcohol-Containing

Hand Sanitizers Cause an Elevated Breath or Blood Alcohol Concen-

tration?” Canadian Society of Forensic Science Journal, : –, 

( table,  references)

Abstract: A -year-old US congressman ran a red light and was stopped

by the police. He did not pass the standardi zed f‌ield sobriety tests (SFSTs),

and his BrAC was .g/mL. T he defence raised the issue that the

BrAC was due to the use of an ABHS (Purell) and also suggested that

radio frequency interference (RFI) af‌fected the breath-testing instru-

ment used by the police. A review of dermal absorption of alcohol was

conducted in papers published since .

The dermal absorption of alcohol has been studie d for over sixty years.

The research has shown that only negligible amount s of alcohol are ab-

sorbed even after excessive use of an alcohol-containing hand s anitizer.

No forensically signif‌icant blood or breath alcohol concentr ation in

adults will occur via dermal absorption of alcohol.

Reference Number: 

, .. “Inhalation of Ethanol Vapour: A Case Report and Experimental

Test Involving the Spraying of Shellac Lacquer.” Journal of the Forensic

Science Society, : –,  ( f‌igure,  references)

Abstract: A subject was arrested for impaired driving, but prior to his

arrest he had been spraying an et hanolic solution of shellac onto a car

body. His BAC as measured by GC was .g/ mL. A reconstruc-

tion test was conducted on this subject. The concentration of ethanol

in the shellac was % weight of solute per volume of solvent (w/v). The

subject was tested in a small garage with no ventilation. No face mask

was worn. The spraying involved a mist of droplets saturating the air.

The minimum eth anol concentration of the air was –, parts per

million (ppm). The subject had three exposu res of , , and  minutes,

and he endured the exposures for as long as possible. After the end of the

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

exposures, the BACs obtained were .g/mL (breath, Alcotector

AED-), .g/mL (blood, GC), and .g/mL (urine, GC).

It is dicult to draw general conclusions from an experiment such [sic]

has been conducted. However, it was the consensus of opinion of the

observers present that the subject h ad endured as much exposure as

he could accept. This was particularly evident in t he second and third

spraying sessions. In this respect, it may be conclud ed that the BAC

found immediately following the last session (the longest and m ost ad-

verse) represented the maximum level obtainable. Clear ly, in relating it

to other circumstances, consideration must be given to the nature of

any solute present in the ethanol, those with irritant prop erties (in spray

form) being likely to limit acceptable exposure.

Reference Number: 

, ..,  .. . “Experimental Inhalation of Ethanol Va-

pou r.” Medicine, Science and the Law, : –,  ( tables,  f‌ig-

ures,  references)

Abstract: One male subject sat for  minutes in an enclosed room in

which  L of alcohol was placed in a dish that measured  by  c m.

Blood samples from the ear and urine sa mples were collected every 

minutes. BACs and urine alcohol concentrations (UACs) were deter-

mined using the GC method. All BAC results were  except for BAC of

the last ear-prick blood, which was only .g / mL. The experi-

ment was repeated with three male volunteers with the room temper-

ature elevated to between  and ºC to allow for a greater saturation

of alcohol. In addition, blood samples were collected via venipuncture,

which is less prone to contamination. The subjects sat in t he room for

 minutes, and during that time  mL of alcohol evaporated re-

sulting in a theoretical ai r alcohol concentration of .g / mL

atmosphere. All BACs and UACs were . In the last experiment, one sub-

ject consumed  mL of -proof alcohol, and blood and urine samples

were collected before and after exposure to alcohol vapors. There was no

ef‌fect of inhalation of alcohol on the BAC or UAC curves.

In these experiments, the author s were unable to demonstrate the

presence of ethanol in blood or urine as a result of inhalation of eth a-

nol vapour. Only once was a positive result obtained ( mg per  mL

blood) and this was clearly due to ar tefact.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, .,  .. . “Blood Alcohol Concentrations following

the Inhalation of Ethanol Vapour under Controlled Conditions.” Jour-

nal of the Forensic Science Society, : –,  ( tables,  f‌igure,

 references)

Abstract: One male subject (weight  kg) was exposed to . g/m of

ethanol vapor for  hours in an exposure cha mber. The alcohol vapor

was generated by passing an airstream over % ethanol and sending

it saturated into the chamber. Frequent blood samples were collected

from an arm with a cannula that wa s extended outside of the chamber

through a porthole, to prevent alcohol contamination. BACs were deter-

mined by headspace GC; all BACs were less than .g/mL.

From the experimental results and the estimated v alues, it appears that

exposure to ethanol vapour at the UK occupational exposure limit of

,  mg/m will not produce signif‌ica nt blood alcohol concentrations.

Reference Number: 

, ., . ,  . . “Drunken by a Bath in Champagne?

Error: No Relevant Ethanol Absorption through Intact Skin.” Blutalko-

hol, : –,  ( table,  f‌igures,  references)

Abstract: One male and two female subject s bathed for  minutes in al-

cohol baths of varying alcohol concentrations that were heated to ºC.

Four baths contained  L of sparkling wine in  L of water (% v/v

alcohol); two baths contained  L of sparkling wine (.% v/v alco-

hol); and one contained  L of pure alcohol in  L of water (.% v/v

alcohol). BrACs were measured with an A lcotest  while the subjects

were up to their neck in the bath. A positive BrAC was detected for all

subjects in the bath and ranged from . to .g/ mL, which

decreased to g/mL after – minutes of exposure to fresh air.

The ambient air around the bathtub was so saturated with alcohol that

the assistants (who did not bathe) had a BrAC of .–.g/mL.

A blood sample was collected at the end of bathing, and a positive BAC

(.g/mL) was detected in only the subject who had bathed in the

mixture of pure alcohol and water. The authors stated that intact hu-

man skin is not signi f‌icantly permeable to ethyl alcohol.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Table. BrACs of a Subject Who Bathed in  L of Sparkling Wine*

Time (min) BrAC (g/ mL)

.

.

 .

 .

 .

 .

 minutes after end of bath .

 minutes after end of bath .

* .% v/v alcohol, heated to ºC; at the end of bathin g, the BAC was .

Source: Adapted from Schrot et al. ().

Reference Number: 

, .., .. ,  .. . “Testing the Validity of

the Danish Urban Myth That Alcohol Can Be Absorbed through Feet:

Open Labelled Self Experimental Study.” British Medical Journal, :

c,  ( table,  f‌igure,  references)

Abstract: One female and two male alcohol-free subjects (ages –

years) immersed their bare feet into a wash basin contai ning . L of

vodka (.% v/v alcohol). Blood samples were collected from an indwell-

ing catheter every  minutes for  hours. PACs were determined using a

photometric method with a detection limit of .g/mL. No posi-

tive PACs were detected throughout the  hours of foot soaking. No skin

problems were observed during the experiment, and after the experi-

ment the skin on the subjects’ feet was clean and smooth.

Our results suggest that the transcut aneous intake of alcohol (vodka,

.% by volume) through feet is not possible. We therefore conclude

that the Danish urban myth about being able to get drun k by submer-

ging feet in strong alcoholic beverages is just that; a myth.

. DISTRIBUTION

Alcohol distributes throughout the total body water (, ) and

is in a higher concentration in tissues that have a high water concentra-

tion, such as blood and the brain (), and is in a negligible concen-

tration in tissues with a low water concentration, such as fat and bone.

  Wigmore on Alcohol

Reference Number: 

The distribution of alcohol throughout the body after it is consu med

orally i s as follows:

Stomach/small intestines → Liver → Right side of heart → Lungs → Left

side of heart → Body tissues (including the b rain) → Right side of heart

Two ef‌fects may occur during rapid absorption of alcohol, such as

via IV infusion or when there is rapid drinking on an empty stomach.

The f‌irst is that t he arterial blood concentration can initially exceed the

venous blood alcohol concentration. This AV lag is not signif‌icant for

typical dr inking patterns over a period of hours (–). Brain alcohol

concentration is more closely related to arterial blood alcohol concen-

tration (as ref‌lected by breath alcohol analysis) than venous blood con-

centration during AV lag (). The second ef‌fect of rapid absorption

can be an overshooting in the BAC, as the di stribution of alcohol to the

tissues is slower than the absorption of alcohol into the blood (). As

the distribution becomes more uniform with time, there can be a sud-

den decrease in BAC, greater than could occu r due to the elimination of

alcohol by the liver alone. This ef‌fect is known in Ger man as dif‌fusions-

sturz (dif‌fusion drop). This distribution ef‌fect may explain some of the

apparent high rates of elimination of alcohol reported in various ca ses.

Reference Number: 

, ...,  . . “Comparison of DO and Ethanol Dilutions

in Total Body Water Measurements in Humans.” Clinical Investigator,

: –,  ( tables,  f‌igures,  references)

Abstract: The total body water was determ ined in  male and f‌ive fe-

male subjects (ages – years) by the ethanol dilution and DO meth-

ods. Subjects consumed .g/ kg of ethanol within  minutes after a

-hour fast. Blood samples were collected by an indwelling catheter

every  minutes, and the BACs and SACs were determined by the GC

and ADH methods. The alcohol elimin ation rate for male and female

subjects was approximately . and .g/mL/h, respectively.

Particularly the comparison with DO dilution shows once again that etha-

nol is diluted only in body water. This conf‌irms that the ethanol concen-

tration in whole blood (water content about %) is smaller than that in

plasma (water content about %) or body water (% water content).

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Reference Number: 

, .., .. ,  .. . “Pharmacokinetics of Etha-

nol in Plasma and Whole Blood: Estimation of Total Body Water by

the Dilution Principle.” European Journal of Clinical Pharmacology, :

–,  ( tables,  f‌igure,  references)

Abstract: Fifteen male subjects (ages – years) were administered

.g/kg of ethanol IV over  hour. Frequent blood samples were col-

lected using an indwelling catheter, and whole blood and serum alcohol

concentrations were determined by GC. Hematocrit and water content

of the blood were also determined. The plasma alcohol concentration

was on average .% higher than the whole blood alcohol concentration.

The average rate of alcohol elimination was .g/mL/h for plas-

ma and .g/mL/h for blood.

The TBW [total body water] in male subjects decreases with age, b e-

ing about % of body weight in  to  y [sic] men and % of body

weight in men over  y. We found that TBW by ethanol dilution is

.% of body weight for men with mean age of  y. This result agrees

well with literature reports of isotope dilution technique s with DO or

tritiated water as tracers.

Reference Number: 

, .., . ,  .. . “Overshoot of Ethanol in the

Blood after Drinking on an Empty Stomach.” Alcohol and Alcoholism,

: –,  ( tables,  f‌igures,  references)

Abstract: Six female subjects (ages – years) were administered .g/

kg of ethanol IV orally with in  minutes. Both tests were conducted

weeks apart after an overn ight fast. Frequent blood samples were col-

lected from the cubital vein, and the BACs were determined by head-

space GC. Three of the six women had an overshoot in BAC after the

oral consumption that varied in itially from % to %.

In emergency medicine, it is not uncommon to treat teenage rs who

have become severely intoxicated because of rapid consumption of only

a few alcoholic drinks. The present study sug gests that one mechan-

ism to explain the pronounced inebriation is that absorption of etha nol

from an otherwise empty stomach occurs f aster than the distribution

  Wigmore on Alcohol

Reference Number: 

into the total body water. This results in higher BACs than would other-

wise be expected.

Reference Number: 

, .., . ,  .-. . “Magnitude and Time-Course

of Arterio-venous Dif‌ferences in Blood-Alcohol Concentration in

Healthy Men.” Clinical Pharmacokinetics, : –,  ( tables,

 f‌igures,  references)

Abstract: Nine healthy male subjects (ages – years) consumed .g/

kg of alcohol within – minutes. Blood samples were collected every

– minutes from indwelling catheters in a radial ar tery and cubital

vein in the same arm. BACs were determined by headspace GC, a nd

blood water content was also determined. The mean ma ximum BAC

was .g/ mL in t he arterial blood and .g/ mL in the

venous blood. The AV dif‌ference was greatest  minutes after the end

of drinking (mean .g/mL, range .–.g/mL). This

AV dif‌ference decreased with increasing time, and at a mean time of 

minutes (range – minutes) there was no AV dif‌ference. The mean

rate of elimination was . g/  mL/ h in the arterial blood and

.g/mL/h in the venous blood. The area under the drug concen-

tration–time curve (AUC) was the same for both the ar terial and venous

BAC curves. There were no dif‌ferences in blood water content.

The magnitude and duration of AV dif‌ferences reported in the present

study after a rapid consumption of alcohol will not necessar ily be the

same as under real- world drinking condition s when the alcohol is con-

sumed in smaller portions over a longer time pe riod. Drinking alcohol

over several hours allows more time for equilibration to occur between

the arterial blood and tissue water. Under social drinking conditi ons, it

seems more likely that the amount of alcohol contained in the last d rink

determines the magnitude of the AV dif‌ferences in alcohol concentra-

tion.

Reference Number: 

, .., . ,  .. . “Concentration-Time Prof‌iles of

Ethanol in Arterial and Venous Blood and End-Expired Breath dur-

ing and after Intravenous Infusion.” Journal of Forensic Sciences, :

–,  ( table,  f‌igures,  references)

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Abstract: The arterial BACs, venous BACs, and BrACs were determined

in  male subjects (mean age  years) who were administered .g/

kg of alcohol IV within  minutes. Frequent samples of arterial a nd

venous blood were collected, and BACs were determined by headspace

GC. BrACs were determined with a BAC DataMaster (based on a blood-

breath ratio [BBR] of :). During the loading phase, the arteria l

BAC was greater than the venous BAC by approximately .g/mL.

Within  minutes of the end of the infusion of alcohol, the AV dif‌fer-

ences were negligible. In the late postabsorptive phase, the a rterial BAC

was less than the venous BAC by .–.g/mL. The mean peak

concentrations were .g/mL for ar terial blood, .g/mL

for venous blood, and .g/mL for breath. The mean rate of alco-

hol elimination was ., ., and .g/mL/h for those samples,

respectively. The BrAC was greater than the venous BAC until approxi-

mately  minutes after IV infusion ceased, and the greatest overesti-

mation was .g/mL . The BrAC was less than the BAC in the

postabsorptive phase.

Accordingly the use of a f‌ixed ratio of : would tend to underesti-

mate BAC during the postabsorptive period. The an alysis of venous

blood samples gives a minimum estimate of the exp osure of the brain

to alcohol which is important to remember when alcohol-induced im-

pairment of body functions is being considered . This follows because

the ef‌fects of alcohol on perfor mance and behavior are more closely

correlated with the concentration reaching the brain tissue as ref‌lec ted

in ABAC [arterial BAC] and BrAC.

Reference Number: 

, .,  .. . “Ethanol in Human Brain by Magnetic Reson-

ance Spectroscopy: Correlation with Blood and Breath Levels, Relaxa-

tion, and Magnetization Transfer.” Alcoholism: Clinical and Experimental

Research, : –,  ( tables,  f‌igures,  references)

Abstract: Eighteen male and two female subjects (mean age  years)

consumed .g/ kg of alcohol within  minutes. Six or seven blood

samples were collected from each subject via an indwelling catheter,

and SACs were determined using an enzy matic method. BrACs were de-

termined using an A lco-Sensor IV. Brain alcohol concentrations were

determined using proton magnetic resonance spectroscopy (MRS). The

  Wigmore on Alcohol

Reference Number: 

mean peak BAC was .g/mL, which was obtai ned at a mean of 

minutes after the star t of drinking. The mean alcohol elimination rate

was .g/mL/h. The correlation between BrAC and brain alcohol

concentration wa s r = .. The correlation between BAC and brain alco-

hol concentration w as r = ..

The correlation of brain EtOH [ethanol] measures are stronger with BrAC

than with BAC, owing possibly to the fact that BrAC more closely ref‌lect s

arterial rather than venous blood concentrations and, thus more closely

tracks brain EtOH levels. The correlations suggest t hat H MRS allows

direct measurement of transient changes of EtOH levels in the br ain for-

merly only possible indirectly through inference from BrAC levels.

Reference Number: 

, .., . , .. , . , . , . -

,  .. . “Spectroscopic Imaging of the Uptake Kinetics

of Human Brain Ethanol.” Magnetic Resonance Medicine, : –,

 ( table,  f‌igures,  references)

Abstract: Eight male subjects (ages – years) consumed .g /kg of

alcohol within  minutes. Blood samples were collected every  min-

utes from an indwelling antecubital vein catheter. The BACs were

determined enzymat ically in deproteinized blood. Brain alcohol concen-

trations were determined spectroscopically by nuclear mag netic reson-

ance (NMR). The mean peak BACs ranged from . to .g/mL.

The mean brain-blood alcohol ratio ranged from .: at  minutes and

decreased to .: at  minutes after drinking sta rted.

Table. Mean Brain–Venous Blood Alcohol Ratios at Various Times

since Drinking Started

Time since Drinking Started (min) Mean Brain–Venous Blood Alcohol Ratio

 .:

 .:

 .:

 .:

 .:

 .:

 .:

 .:

Source: Adapted from Hetherington et al. ().

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

This relationship is due to the relatively rapid passage of alcohol into and

out of the brain as opposed to skeletal muscle. Th us the venous drain-

age of skeletal muscle displays longer time constants for upt ake and

release. The variations in early tim e points largely ref‌lect intersubjec t

variability of gastric absorption, resulting in dif‌ferences in the kinet-

ics of brain uptake and venous appearance. A s the absorption phase is

completed and the venous blood levels peak, the br ain/blood alcohol

ratio equalizes and the variability between subjec ts decreases.

. ELIMINATION

The vast majority of alcohol is eliminated by the liver at a constant rate.

Alcohol is converted mainly by the ADH enzy me system in the liver into

acetaldehyde, then into acetic acid, and eventually into carbon dioxide

and water, as shown by the following chemical equation:

CHCHOH → CHCHO → CHCOOH → CO + HO

The rate of alcohol elimination can be increased by chronic use of

alcohol (, ). Prior or co-ingestion of food not only slows the

absorption of alcohol but increases the elimination rate as well ().

A high protein diet also tends to increase the rate of elim ination of alco-

hol (). Women generally have a higher rate of alcohol elimination

than do men (, ). The phase of menstrual c ycle does not af‌fect

the elimination rate (). Other routes of elimination via the lungs,

kidney, or gastric mucosa are of minor signif‌icance (, ); hence,

heavy exercise (, ) or renal failure (, ) does not sig-

nif‌icantly af‌fect the elimination of alcohol. Liver disease such as cirrho-

sis can lower the rate of alcohol elimination but typical ly not below the

lower range of elimination seen in persons without liver disease (,

, ). Due to the variability in the rates of alcohol elimination

over time, a single drinki ng test conducted to determine an individual ’s

precise rate of alcohol eliminat ion is not forensically appro priate ().

Reference Number: 

, ., . , . , .. ,  . . “Ethanol

Elimination-Rates Determined by Breath Analysis as a Marker of Re-

cent Excessive Ethanol Consumption.” Scandinavian Journal of Clinical

and Laboratory Investigation, : –,  ( tables,  references)

  Wigmore on Alcohol

Reference Number: 

Abstract: Fifteen alcoholics from a skid row who were admitted to a de-

toxif‌ication centre and  age-matched social drinkers had their rate of

ethanol elimination determined in their breath by an Alcotest  at

least  hours after adm ission. The mean of triplicate breath samples was

determined at least six times over a period of – hours. Blood samples

were also taken and ana lyzed for biochemical markers of excessive alco-

hol consumption such as γ-glutamyltransferase (GGT), mean corpuscu-

lar volume (MCV), hematocrit, etc. The BrACs of the alcoholics ranged

from . to .g/mL and of the social drinkers from . to

.g/mL. Thirteen of  a lcoholics had a rate of elimination great-

er than the highest rate of elim ination in the social drinkers.

Table. Comparison of Rates of Alcohol Elimination in Alcoholics

and Social Drinkers

Type of Drinker and Initial BAC

Range (g/ mL)

Range of Elimination

Rates (g/ mL/h)

Median Elimination Rate

(g/ mL/h)

All alcoholics (.- .) .–. .

Alcoholics with high BACs

(.–. )

.–. .

Alcoholics with mode rate BACs

(.–.)

.–. .

Social drinkers (. –.) .– . .

Source: Adapted from Olsen et al. ( ).

Our study demonstrated that breath analysis could be use ful in de-

tecting increased EER [ethanol elimination rate]. Factors such as breath-

ing technique, temperature, etc. which might inf‌luen ce the conversion

from breath- to blood-concentrations could be controlled and kept

constant. The results were immediately availabl e. The detoxif‌ication

period may be used to gain objective information abo ut previous drink-

ing history of a patient; information that could be useful for the fu rther

planning of treatment.

Reference Number: 

, ..,  . . “Kinetics of Ethanol and Methanol in

Alcoholics during Detoxif‌ication.” Alcohol and Alcoholism, : –,

 ( table,  f‌igures,  references)

Abstract: Sixteen male and four fema le alcoholics (ages – years) who

were admitted to a hospital in Malmo for detoxif‌ication had venous blood

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

samples collected every – hours for  hours. Blood alcohol and meth-

anol concentrations were determined by headspace GC. The admission

BACs ranged from . to .g/mL (mean .g/mL). The

admission blood methanol concentrations (BMCs) ranged from .

to .g/  mL (mean . g/ mL). BACs and BMCs were

not correlated. The BMCs remained relatively constant until the BAC

was g/mL. The rate of alcohol elimination ranged from .

to .g/mL/h (mean .g/mL/h).

Table. Initial BACs and Mean Alcohol Elimination Rate of

Alcoholics with Liver Disease

Subject’s Liver Disease In itial BAC (g/ mL) Mean Elimination Rate

(g/ mL/h)

Hepatitis . .

Cirrhosis . .

Hepatitis . .

Hepatopathy*. .

Hepatopathy . .

Hepatopathy . .

Hepatitis . .

* Female subject.

Source: Adapted from Jones Sternebring ().

For healthy individuals who drink alcohol occasionally, it is generally

agreed that the average rate of ethanol elimination from the blood is

about  mg/dL/hr (Widmark, ). The mean rate of ethanol elimina-

tion in the dependent alcoholics in this study wa s  mg/dL/hr and the

spread of values for individual subjects w as – mg/dL/hr. The dis-

appearance rate of ethanol therefore increased % on average (range

−% to +%) as a consequence of chronic ingestion of alcohol.

Reference Number: 

, .., .. , .. , .. ,  .. . “Inter- and

Intra-subject Variability in Ethanol Pharmacokinetic Parameters: Ef-

fects of Testing Interval and Dose.” Forensic Science International, :

–,  ( tables,  f‌igures,  references)

Abstract: Twelve male subjects (ages – years) consumed a low dose

of alcohol (.g/kg), and then , , a nd  weeks later consumed a high

dose of alcohol (.g/kg). The a lcohol was consumed within  minutes,

  Wigmore on Alcohol

Reference Number: 

approximately  hour after the consumption of a standard breakfast.

Venous blood samples were collected via an indwelling catheter, and

BACs were determined by direct injection GC. The mean a lcohol elim-

ination rate was ., ., ., and .g/mL/h for the four oc-

casions, respectively (standard deviat ion [SD] .–.g/mL/h).

Intra-subject variances ranged from . to . g/ mL/h de-

pending on the dose and time interval bet ween dosing. The maximum

dif‌ference between rates of elimination also va ried between . and

.g/mL/h.

Our results show forensically signif‌icant var iability in ethanol phar-

macokinetic parameters both between and within individuals. This

indicates that neither population average ethanol pharmacokinetic par-

ameters, nor individual specif‌ic param eters obtained from a single con-

trolled drinking experiment are likely to produce a highly accurate BAC

using forward or back-extrapolation, regardless of wh ether the dose is

matched.

Reference Number: 

, .., . , . , . ,  .. .

“Eating a Meal Increases the Clearance of Ethanol Given by Intra-

venous Infusion.” Alcohol and Alcoholism, : –,  ( table, 

f‌igures,  references)

Abstract: Six male and six fema le subjects (mean age  years) were given

.g/kg of etha nol over  minutes either after fasting or after a light

breakfast. Approximately  hours af ter the f‌irst infusion, the fasti ng sub-

jects consumed a standa rd lunch. When the BrACs of the subjects were

, an additional infusion of .g/kg of ethanol wa s administered. Blood

samples were taken frequently, and the BACs were determined by head-

space GC. Subjects also reported their su bjective feelings of intoxication.

The fasting subject s had a mean rate of elimination of .g/mL/h

before lunch and .g/mL/h af ter lunch. The other group, which

had breakfast but no lunch, had a mean rate of eli mination of . and

.g/mL/h, respect ively.

In conclusion, we found that the intake of food increased the clearance

of ethanol and diminished the feelings of intoxication even when etha -

nol was administered by intravenous infusion.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Reference Number: 

, ., . , . , . , . , . , 

.-. . “Ethanol Elimination Rates in Men and Women in Con-

sideration of the Calculated Liver Weight.” Alcohol, : –, 

( table,  f‌igure,  references)

Abstract: Sixty-four female and  male subjects (ages – years) con-

sumed between . and .g /kg of alcohol after a break fast. Numer-

ous blood samples were collected from an indwelling catheter, and SACs

were determined by enzymatic and GC methods. Liver weight was cal-

culated based on a normal body mass index. The mean peak BAC was

.g/mL for female subjects and .g/mL for male subjects.

The mean elimin ation rate was .g/mL/h for female subjects and

.g/mL/ h for male subjects. The mean liver weight was . kg for

female subjects and . kg for male subjects. The mean eli mination rate

per kilogram of liver was . g/h/kg for female subjects and . g/ h/kg

for male subjects, which is not a statistic ally signif‌icant dif‌ference.

This means, because women have signif‌icantly mo re liver tissue in com-

parison to a smaller distribution volume, they can b reak alcohol down

more quickly, which results in high elimination rates in women.

Reference Number: 

, ., . , . , . ,  .. . “A Regression

Model Applied to Gender-Specif‌ic Ethanol Elimination Rates from

Blood and Breath Measurements in Non-alcoholics.” International

Journal of Legal Medicine, : –,  ( tables,  f‌igure,  ref-

erences)

Abstract: The eliminat ion rates of  female and  male subjects were

determined by linear regression in their breath by A lcotest  and by

venous blood samples. The subjects were tested at least  hours after

the end of drinking, a nd the BACs ranged from . to .g/mL.

There were a total of , BAC and  BrAC measurements. The mean

rate of elimination for women in blood was .g/ mL/h (range

.–.g/ mL/ h) and .g/ mL/h for men (range .–

.g/mL/h).

The basis of the back calculation used in forensic case s in Germany to-

day stems from Freudenberg from . In his report the minimal rate of

  Wigmore on Alcohol

Reference Number: 

elimination of ethanol was determined to be .g/kg/h. The for mula

used included .% of cases which correspond to a .% probability of

an overestimate. The maximum elimination rate was deter mined to be

.g/kg/h using an equation of the same kind.

Reference Number: 

, .. “Dietary Inf‌luences on Ethanol Metabolism.” Drug-Nutrient

Interactions, : –,  ( tables,  f‌igure,  references)

Abstract: The alcohol elimination rate was determined in seven male

subjects (ages – years) after a high-protein, high-carbohydrate diet;

a high-protei n, low-ca rbohydrate d iet; and a low-protein, hy pocaloric

diet for – days each. At the end of each diet, the subjects consumed

.g /kg of alcohol within  minutes. Blood samples were collected

every .– hour, and the SACs were determined by an enzymatic

method. The rate of elimination was determined by the slope of the

SAC curve. The elimin ation rates were .–.g/mL/h (mean

.g/ mL/h), .–.g/ mL/h (mean .g/mL/ h),

and .–.g / mL/ h (mean . g/ mL/ h) for the three

diets, respec tively.

It is likely that protein deprivation and/or calorie def‌iciency mediates

ethanol metabolism through diminished hepatic ADH concentration or

altered mitochondrial NAD/NADH [nicotinamide adenine dinucleotide/

reduced form of nicotinamide adenine dinucleotide] ratios, or a com-

bination of both. Protein and calorie def‌iciency in huma ns may deplete

hepatic ADH in a manner similar to the rodent. Cal orie deprivation,

with the adaptive Cori cycle and possible altered mitochondrial f unc-

tion, may alter the reaction of ethanol to acetoaldehyde via diminished

capacity to contribute NAD.

Reference Number: 

, .,  . . “On the Ef‌fect of Muscular Exercise on the

Metabolism of Ethyl Alcohol.” Scandinavian Archives of Physiology, :

–,  ( tables,  f‌igures,  references)

Abstract: A detailed series of experi ments were conducted on seven male

subjects. The subjects consu med .–.g/kg of ethanol and then either

rested or exercised on a bicycle ergometer. Ventilation rates increased

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

three to four times over the resting conditions. Capilla ry blood samples

were taken and the alcohol concentration determined by the Widmark

method.

From the above experiments it will appear that we have not been able

to show any increased rate of disappearance of ethyl alcohol from the

human body during muscular exercise as compared to rest within thos e

limits of doses and amounts of work which we used. Th e only exception

is the minute, theoretically calculated, increas e in disappearance which

in our case did not exceed  to  per cent, owing to the forced ventila-

tion during muscular exercise. This increase, however, is of such small

value that with the method we have used we were not as a rule able to

demonstrate its ef‌fect.

Reference Number: 

, .., .. , .. ,  . . “Observations on the

Metabolism of Alcohol in Man.” British Journal of Nutrition, : –,

 ( tables,  references)

Abstract: A study on the ef‌fects of exercise on the rate of elimination of

alcohol was conducted on nine male subjects (ages – years) at rest

and after . km ( miles) of walki ng on a treadmill. Blood samples were

collected every hour, and the BACs were determined with an enzym atic

method. The mean rate of alcohol elimination was .g/mL/h at

rest and during exercise.

Alcohol (. g/ kg) was given to nine subjects and th e metabolic

changes followed for h on two occasions, once with complete rest an d

once with periods of exercise amounting to an  mile walk. No speci f‌ic

dynamic ef‌fect of the alcohol was obser ved and the exercise did not

increase the rate of elimination of alcohol.

Reference Number: 

, .., . ,  . . “Measurement of Total Body

Water in Patients on Maintenance Hemodialysis Using an Ethanol Di-

lution Technique.” Nephron, : –,  ( tables,  f‌igures, 

references)

Abstract: Ten female and  male patients (ages – years) with ter-

minal renal failure consumed on average .g/kg of etha nol diluted to

  Wigmore on Alcohol

Reference Number: 

% v/v within  minutes, after a -hour fast. Venous blood samples

were collected after , , , and  minutes. The average rate of

elimination was .g/ mL/h for blood and .g/ mL/h for

serum samples. The patients were on maintena nce hemodialysis.

In patients with terminal renal failure the elimination cur ves of ethanol

from the serum or the blood appear to follow zero order kin etics, at

least during the time interva l between  and  minutes after the

ingestion of ethanol, thus allowing for a simple extr apolation of the

serum ethanol concentration to time zero.

Reference Number: 

, ..,  .. . “Pharmacokinetics of Ethanol in Patients with

Renal Failure before and after Hemodialysis.” Forensic Science Inter-

national, : –,  ( table,  f‌igures,  references)

Abstract: Four male and three female patients (mean age  years) with

terminal rena l failure were administered .g/kg of ethanol IV over 

minutes after an overnight fast. A second dose of ethanol was adminis-

tered IV – hours later after the patients had undergone hemodialysis

and after consuming a st andard hospital lunch. Frequent blood samples

were collected via an indwelling catheter, and blood and plasma alcohol

concentrations were determined by headspace GC. The water content of

the blood was also determined. T he mean rate of alcohol elimination was

.g/mL/h before hemodialysis and .g/mL/h af ter. The

plasma–blood alcohol ratio was .: (range .:–.:). The apparent

increase rate of elimination may be due in par t to food consumption.

We conf‌irmed that the rate of elimination of alcohol from blood in pa-

tients with renal failure is of the same order of magnitude as in h ealthy

controls, namely . g/L/h, which agrees with the results rep orted by

Walle et al.

Reference Number: 

, .,  .. . “Liver Disease, Hepatic Alcohol Dehydro-

genase Activity, and Alcohol Metabolism in the Human.” Gastroenter-

ology, : –,  ( tables,  f‌igures,  references)

Abstract: Four normal controls and  patients with acute or chronic

liver disease were given . or . mL/kg of ethanol IV. BACs were deter-

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

mined by a potassium dichromate method at  and  minutes after

infusion. Liver biopsies were conducted to determine ADH activity.

The rate of elimination was .g/mL/h for normal controls and

.g/mL/h for patients with liver disease.

There was no relationship between hepatic alcohol dehydrogena se ac-

tivity and the rate of alcohol metabolism (milligrams per de ciliter per

hour) when it was administered intravenously. There was no apparent

impairment of the rate of alcohol metabolism in patients w ith acute and

chronic active liver disease as compared to normals. A lthough none of

the patients tested was moribund, m ost of them with liver disease were

jaundice and active cell necrosis was demonstrated in liver biops y.

Reference Number: 

, .. “The Ef‌fect of Liver Disease on the Rate of Ethanol Metab-

olism in Man.” Gastroenterology, : –,  ( table,  f‌igure, 

references)

Abstract: The rate of metabolism of ethanol was measured in  nor-

mal subjects and  patients wit h advanced alcoholic cirrhosis. Subjects

were given – mL of absolute ethanol, and – minutes were

allowed for complete absorption. Five milliliters of blood was drawn

every  minutes, and BACs were determined by a potassium dichro-

mate method. The ethanol space was found to be equiva lent to the body

water compartment.

Table. Range and Mean Rate of Alcohol Elimination in Healthy

Persons and Those with Liver Diseases

Condition of Liver Range of Elimination

Rates (g/ mL/h)

Mean Alcohol Eliminat ion

Rate (g/ mL/h)

Controls (no liver disease) .–. .

Cirrhosis (no jaundice) .–. . 

Cirrhosis (with jaundice) . –. .

Viral hepatitis (with jaundice) .– . . 

Source: Adapted from Lieberm an ().

The rate of metabolism of ethanol was mea sured in  persons without

liver disease and in  patients with advanced alcoholic cir rhosis. Only

those patients with the most advanced liver disease a s indicated by the

presence of jaundice, exhibited a signif‌icantly reduced rate. The cir rhotic

  Wigmore on Alcohol

Reference Number: 

patients without jaundice metabolized ethanol nor mally, although they

had clinical and laboratory evidence of serio us liver disease.

Reference Number: 

, .. “First-Pass Metabolism of Ethanol in the Human Stomach: A

Negligible Reaction.” Biochemical Archives, : –,  ( table,

 references)

Abstract: A simulation pharmacokinetic model of f‌irst-pass oxidation

of ethanol in the human stomach wa s presented. Ethanol must pass

through the gastric unstirred layer ( μm thick) and the gastric mu-

cosa ( μm thick) before reaching the systemic circulat ion.

Ethanol excretion by the lung and kidney accounted for only . and

.% of the ethanol dose respectively. These results are consistent

with the well known fact that ethanol elimination by the lung and k id-

ney in the human are relatively minor and for most purposes c an be

neglected. Since ethanol oxidation in the gast ric mucosa is even less,

.% of the dose, it may likewise be neglected in most cases , and is ob-

viously neither the sole site of, nor a major contributor to the f‌irst-pass

metabolism of ethanol.

Reference Number: 

, .-., .-. , .-. , .-. , .-. , .-. ,  .-.

. “No Sex and Age Inf‌luences on the Expression Pattern and Activ-

ities of Human Gastric Alcohol and Aldehyde Dehydrogenases.” Alco-

holism: Clinical and Experimental Research, : –,  ( tables,

 f‌igures,  references)

Abstract: Endoscopic gastric biopsy samples were obtained from 

male and  female Han Ch inese subjects, ages – years. The expres-

sion patterns (from gel electrophoresis) of the ADH and acetaldehyde

dehydrogenase (ALDH) were determined as well as the enzym atic ac-

tivities to ethanol and acetaldehyde. Both the expression patterns and

enzymatic activ ities of ADH and ALDH were unaf‌fected by age or sex

of the subject. The liver, not the stomach, is the main site for f‌irst-pass

metaboli sm (FPM) of alcohol.

In conclusion, the ADH or ALDH activities in human stomach do not

appear to dif‌fer signif‌icantly in relation to sex and age. Recent s tudies

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

have indicated that when the expression pattern and kinet ic properties

of the ADH family as well as the total organ ethanol- oxidizing activities

at both high and low alcohol concentrations are taken into considera-

tion, the stomach may account for a minor fraction of FPM in humans

after alcohol ingestion. Thus, gast ric ADH and ALDH are unlikely to

play a causative role in producing the reported variatio ns of the FPM of

alcohol with respect to sex or age.

Reference Number: 

, ., . , . ,  .-. . “The Inf‌luence of

Luteal and Follicular Phases on Major Pharmacokinetic Parameters

of Blood and Breath Alcohol Kinetics in Women.” Alcohol, : –,

 ( tables,  f‌igures,  references)

Abstract: Fourteen female subjects (ages – years) consumed alcohol

over  hours to obtain a target BAC of .g/mL during their luteal

and follicular phases of their menstrual c ycle. BrACs were determined

every – minutes using an Alcotest  evidential breath alcohol

testing instru ment. Near simultaneous venous blood samples were col-

lected using an indwelling catheter, and BACs were determined by two

enzymatic and t wo GC methods. In addition, blood estradiol, progester-

one, and testosterone concentrations were determined. The mean rate

of alcohol elimination was .g/ mL/h in the follicular phase

and .g/ mL/h in t he luteal phase. The Widmark r fac tor was

. in the follicular phase and . in the luteal phase. There were

no signif‌icant correlations between the rate of elimination of alcohol

and the blood progesterone, estradiol, or testosterone concentrations .

As a conclusion, there seems to be no dif‌ferences in the ethan ol phar-

macokinetic parameters during the menstrual cycle.

. PHARMACOKINETICS OF DRINKING DRIVERS

The pharmacoki netics of drinking drivers can be determined by the fol-

lowing:

• Observations or surveys of actua l drinking patterns

• Realis tic laboratory d rinking tests of consumpt ion of alcohol over

a period of hours

• Multiple blood samples from drinking dr ivers

  Wigmore on Alcohol

Reference Number: 

• Multiple breath samples from drinking drivers over a prolonged

period of time

• Blood and urine samples from dri nking drivers

• Postmortem blood and urine samples from dri nking drivers killed

in motor vehicle collisions (MVCs)

All of the studies disc ussed below show that the vast majority (>%) of

drinki ng drivers are not in the rising phase of the BAC curve at the time

of the driving or the ar rest, as is commonly alleged in cr iminal court.

This allows for the forensic validity of presumptions, or time of testing

laws and the back calculations of BAC.

Reference Number: 

, ..,  .. . “Drinking Establishment, Driving Risk, and

Ethno-pharmacology.” Proceedings of th International Congress on

Alcohol and Drug Dependence (Vol. ), Oslo, Norway,  ( tables, 

f‌igures,  references)

Abstract: A study was conducted of () the characteristics of , ac-

cident involved drivers, ()  telephone interviews with drinking driv-

ers, and ()  bartenders in the Lower Mainland of British Columbia.

Some results are shown in the table below.

Table. Location of Drinking by Drivers, Time over which Drinking

Occurred, Percent Drinking Beer, and Time Waited before

Driving

Location of Drinking Drinking Time

(h)

Percent Drinking

Beer

Time Waited before

Driving (min)

Pub .  

Hotel/ bar .  

Restaurant .  

Home .  

Source: Adapted from Cooper and Rot he ().

The subjective impressions people have of the ex tent of their drink-

ing thus may not match the reality represented by actual blood-alco -

hol accumulation. The people we talked to tended to express alcoho l

consumption solely in terms of quantity, while seemingly ignoring the

equally important factor of time .

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Reference Number: 

, .., . ,  . . “Gender Comparison of Alcohol Expos-

ure on Drinking Occasions.” Journal of Studies on Alcohol, : –,

 ( tables,  f‌igures,  references)

Abstract: A detailed telephone survey regarding alcohol consumption

was conducted on , male and  female current drinkers. Female

drinkers reported a mean consumption of . standard drinks, and

male drinkers reported a mean consumption of . drinks for a ty pical

drinking occasion. The duration of drinking episode was  minutes

for women and  minutes for men. Estimated BACs (eBACs) were cal-

culated for the reported drinking episode using TBW and an a lcohol

elimination rate of .g / mL/h for men and .g/ mL/h

for women. Of the , current drinkers,  men (.%) and  women

(.%) were determined to have alcohol abuse (i.e., be pathological drink-

ers). Pathological drinkers consumed a mean of eight dr inks per day for

men and f‌ive drinks per day for women. The mean dr inking ti me was

 minutes for male pathological drinkers and  minutes for female

pathological drinkers. The estimated pea k BACs for pathological drink-

ers were .g/mL (men) and .g/mL (women) compared

with .g/mL (men) and .g/mL (women) for non-patho-

logical drin kers. The most frequent hourly drinking rate was two d rinks

per hour for men (%) and one drink per hour for women (%).

The f‌indings of the current study are in general agree ment with previous

survey reports that women are less involved in alcoho l than are men.

Reference Number: 

, ..,  .. . “Alcohol Accumulation in Humans after

Prolonged Drinking.” Clinical Pharmacology and Therapeutics, : –

,  ( f‌igures,  references)

Abstract: A study was conducted of  female and  male subjects who

consumed either  or  mL ( or  f‌l. oz.) of % v/v alcohol/h/ kg (

lb.) of body weight. Drinking commenced after a breakfa st of toast and

fruit juice. Lunch consisted of meat sandwiches. BrACs were measured

every  minutes with a Breathalyzer. When  mL/ h was consumed, the

BrAC did not exceed .g/mL after  hours. When  mL/h were

  Wigmore on Alcohol

Reference Number: 

consumed, the BrAC exceeded .g /mL after . hours and ex-

ceeded .g/mL after  hours.

While the consumption of approximately  drink per hour will not usu-

ally prove dangerous, a second drink per hour will more than doubl e the

concentration in the blood.

Reference Number: 

, ..,  .. . “Evaluation of Breath Alcohol Prof‌iles

following a Period of Social Drinking.” Canadian Society of Forensic

Science Journal, : –,  ( tables,  f‌igures,  references)

Abstract: Six male and four female subjects consumed between 

and  mL (– f‌l. oz.) of liquor (% alcohol v/v) over  hours at their

own rate of drinki ng. BrACs were determined every – minutes with

an Intoxilyzer C. The time to peak BrAC after the end of drink-

ing was between  and  minutes (mean  mi nutes). The increase

in BrAC after the end of drinki ng was between  and .g/ mL

(mean .g/mL). The time from the end of drinking to the start

of the linear decline (i.e., a plateau) was between  and  minutes

(mean  minutes). The rate of alcohol elimination was between .

and .g/mL/h (mean .g/mL/h).

In a drinking experiment involving ten subject s under realistic social

conditions the time to the maximum BAC was obtained o n average 

minutes (range  to  minutes) after the end of drinking. This is signif‌i-

cantly shorter than for experiment s not involving drinking under social

conditions.

Reference Number: 

, .., ..  ,  .. . “A Comparison of Equal Al-

cohol Doses of Beer and Whiskey on Eleven Human Test Subjects.”

Canadian Society of Forensic Science Journal, : –,  ( tables,

 f‌igures,  references)

Abstract: Four female and seven male subjects (ages – years) con-

sumed .g/kg ( lean body weight) as whiskey (diluted with carbonated

soda and ice) and beer (% v/v alcohol) on two occasions after a fast of

at least  hours. The alcohol was consumed social ly over a period of

 hours and  minutes. BrACs were determined every – minutes

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

with an Intoxilyzer . The maximum BrACs occur red within  min-

utes after the end of drink ing. The mean rate of alcohol elimination for

either alcoholic beverage was .g/mL/ h. The mean peak BrACs

were . and .g/ mL for whiskey and beer, respectively. The

mean body fat was % for women and % for men.

While there were individual subject dif‌ferences, on average, eq ual doses

of ethanol per kg of lean body weight given in the same mann er, over

the same length of time, yielded s tatistically indistinguishable alcohol

concentration results, regardless of subject gender o r type of alcoholic

beverage consumed.

Reference Number: 

, .. “Ultra-rapid Rate of Ethanol Elimination from Blood in Drunk-

en Drivers with Extremely High Blood Alcohol Concentrations.” Inter-

national Journal of Legal Medicine, : –,  ( tables,  f‌igure,

 references)

Abstract: The alcohol elimination rate was determined in , driv-

ers in Sweden from whom two or three blood samples were collected

approximately  hour apart. The mean elimination rate was ./

mL/h, and the . percentile was between . and .g/mL/h.

There were  cases (.%) with an apparent rate of elimination of less

than .g/mL/h, probably due to the driver not being in the post-

absorptive state. Twenty-one drivers had a high rate of alcohol elimina-

tion. Their mean BAC was .g/mL (range .–.g/mL).

Their mean rate of alcohol elimination was .g/mL/h and ranged

from . to .g/mL/h.

With only a single blood sample available from each drun ken driver,

which is usually the case in forensic situations, the elimination r ate of

alcohol is unknown. In criminal trials when beyond a rea sonable doubt

is required, it is advisable to work with a range of values to give the sus-

pect the benef‌its of the doubt . Experience from hundreds of controlled

drinking experiments has shown th at the vast majority of individuals as

well as drunken drivers eliminate alcohol from the bloodstream at a rate

between . g/L/h and . g/L/h. In alcoholics during detoxif‌ication,

the elimination rate of alcohol might be considerably faster, as high as

. g/L/h in some individuals.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, .,  .. . “Disappearance Rate of Alcohol from the

Blood of Drunk Drivers Calculated from Two Consecutive Samples;

What Do the Results Really Mean?” Forensic Science International, :

–,  ( tables,  references)

Abstract: A study was conducted of , double blood samples taken

from suspected impaired dr ivers in the Netherlands from February 

to September . The blood was collected in Vacutainers containing

NaF and analyzed by ADH. In  cases (%) of the total database, the

BAC was increasing. A more detailed ana lysis was conducted on ,

double blood samples in which the time interval between the collections

of the samples was between  and  minutes. The rate of elimin ation

varied from . to .g/mL/h with a mean of .g/mL/h,

and the mean rate of alcohol elimination tended to increase with in-

creasing BAC (especially in drivers with a BAC > . g/ mL). At

BACs .g/mL, the rate of alcohol elimin ation in drivers ranged

between . and .g/mL/h.

Table. Range of Elimination Rates of Arrested Drinking Drivers

Range of Elimination Rate s (g/ mL/h) No. of Drivers (%)

.– .   ( .)

.– .   (. )

.–.  ( .)

.–.   (.)

.+  (.)

Source: Adapted from Neuteboom a nd Jones ().

The extremely high elimination, highes t . mg/mL/h as well as  other

drunk drivers with values above . mg/mL/h can hardly represent the

rate of hepatic metabolism of alcohol in human beings. T he results cer-

tainly ref‌lect the change in BAC over the time period st udied but this

might be inf‌luenced by ongoing distribution and equilibration of al cohol

between blood and tissue water. The high average BAC of drunk drivers

suggests an over-representation of problem drinkers and alcoholics .

Reference Number: 

, ..,  .. . “Comparing Roadside with Subsequent

Breath Alcohol Analyses and Their Relevance to the Issue of Retro-

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

grade Extrapolation.” Forensic Science International, : –, 

( table,  f‌igures,  references)

Abstract: Seven law enforcement ocers in Seattle tested  suspected

drivers with an Intoximeter Alco-Sensor III (preliminary breath test 

[PBT]) at the roadside. The arrested drivers were then tested on a BAC

DataMaster (two tests, – minutes apart) between  and  minutes

later (mean  minutes). An additional test was conducted with the Alco-

Sensor III after the evidentia l test (PBT). All BrACs were truncated to

two decimal places. No PBT test results were more tha n .g/mL

greater than PBT. If .g/m L/h was added to the PBT results,

there was a slight overestimation of PBT by .g/mL. This over-

estimation disappeared when there wa s a long time between test results.

There was certainly no evidence that indiv iduals were on the ascending

portion of their concentration time cur ves at the time of driving. As a

result, forensic breath alcohol analysis employing duplicates alo ng with

other appropriate quality control procedures appears to p rovide very

good estimations of BrAC values when conducted within  h of driving.

Reference Number: 

, .. “Ethanol Distribution Ratios between Urine and Capillary

Blood in Controlled Experiments and in Apprehended Drinking Driv-

ers .” Journal of Forensic Sciences, : – ,  ( tables,  f‌igures, 

references)

Abstract: Eighty healthy male subjects cons umed . , ., or .g/kg

of ethanol as neat whiskey withi n , , or  minutes, respectively, a fter

a -hour fast. Capillary blood samples were collected every – min-

utes for – hours, and urine was collected every  mi nutes. BACs and

UACs were determined by an ADH procedure. Additionally,  drink-

ing drivers provided two urine samples and one capill ary blood sample.

The mean UAC/BAC ratio varied between .: and .: when the BACs

were > .g/mL. The mean UAC/BAC ratio was not dependent on

the age of the individual (bet ween  and  years). In only  drivers

(.%) was the UAC/ BAC ratio ≤ .:, indicating that these drivers were

still in the absorpt ion phase.

Despite these limitations, UAC/BAC ratios provide useful evidence to

pinpoint the phase of ethanol metabolism at th e time of sampling. If the

  Wigmore on Alcohol

Reference Number: 

UAC/BAC ratio is less than unity, or not more than ., this suggests,

but does not prove, the existence of a rising BAC. If the UAC/BAC ratio

exceeds . this suggests that the subjec t was in the postabsorptive

stage at the time of sampling Moreover, if the concentration of alcohol

in two successive voids  to  min apart shows a decreasing concen-

tration by . mg/mL or more, then the bulk of the dose of alcohol was

probably consumed at least  h earlier.

Reference Number: 

, ..,  .. . “Relationship between Blood and Urine

Alcohol Concentrations in Apprehended Drivers Who Claimed Con-

sumption of Alcohol after Driving with and without Supporting Evi-

den ce.” Forensic Science International, : –,  ( tables, 

f‌igure,  references)

Abstract: A study was conducted of the UACs and BACs of  drivers

who claimed a drink a fter driving (hip f‌lask) without any supporting

evidence and  drivers who had supporting evidence of a drink after

driving (e.g., eyewitnesses, empty bottle). Two urine samples and a blood

sample were collected from each driver and analyzed by headspace GC.

A drink af ter driving was determined if the f‌irst UAC was close to or

less than the BAC and the second UAC increased by .g/mL or

more. The mean UAC/BAC ratio was .: in drivers with supporting

evidence and . in drivers without supporting evidence. In  of the 

drivers (%) with supporting evidence, the UAC was less than or simil ar

to the BAC, so a drink af ter driving could have occurred. In none of the

drivers without supporting evidence was the UAC/BAC ratio less than

.:, which indicates no post-of‌fence drinking of alcohol.

Long experience from investigating claims of post-of‌fence drinking

leads us to conclude that in the vast majority of ca ses this lacks any

substance and is simply a last resort by DUI A [driving under the inf‌lu-

ence of alcohol] of‌fenders to evade justice. Unless suppor ting evidence

exists (eye witnesses, police report etc) of post of‌fence drinking, th e

courts are encouraged to ignore this defence argum ent.

Reference Number: 

, .,  .. . “Status of Alcohol Absorption in Drinking

Drivers Killed in Trac Accidents.” Journal of Forensic Sciences, : –,

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

 ( table,  references)

Abstract: A study of the heart BACs and UACs of  drivers killed

within  minutes of an MVC was conducted in the state of Maryland

over a -year period. Peripheral blood samples were also collected, and

their alcohol concentration was compared with heart BACs. The aver-

age peripheral BAC–heart BAC ratio was .:. The alcohol concentra-

tions were determined by headspace GC. The BACs ranged from .

to .g/mL (mean .g / mL). The mean UAC/BAC ratio

was .:. Eleven of the  cases (.%) had a UAC/BAC ratio of .:,

which indicates a rising BAC at the time of death. The remaining UAC/

BAC ratios indicated a plateau or a post-absorptive phase at the time of

the fatal motor vehicle collision (FMVC).

Table. Range of Postmortem BACs and Percent of Fatally Injured

Drivers with a BAC/UAC Ratio

BAC Range (g/ mL) Percent of BAC/UAC Ratios 

.–. .

.–. . 

.–. .

.–. .

.+ .

Source: Adapted from Levine and Sm ialek ().

Based on the above study the following conclusions can be of‌fe red: )

less than % of ethanol drinking drivers were in the absorptio n phase at

the time of their fatal accident; ) over % of ethanol drinking drivers

were in the plateau or post-absorptive phases at the time of their fatal

accident; ) these data are consistent with studies from living individuals

which indicate that only a small number of drivers are in the absorpti ve

phase at the time of a particular event; and ) these data are consistent

with alcohol concentrations found in living drivers in Mar yland.

. BACK CALCULATIONS OF DRINKING DRIVERS

Much unnecessary arg ument has occurred in courts regarding the back

calculation or extrapolation of BAC to an earlier time in arrested drink-

ing drivers. The use of a plateau to allow for the variability of breath

alcohol analysis (, ) to prevent the possibility of a falsely high

eBAC () as well a s the use of a range of possible rates of elimination

  Wigmore on Alcohol

Reference Number: 

are warranted. A proposed “steepling” ef‌fect or zigzag pattern of BAC

has been found to be due to typical breath sa mpling variability and does

not exist from a pharmacokinet ic point of view (, ).

Reference Number: 

, .. “Blood Alcohol in Automobile Drivers: Measurement and In-

terpretation for Medicolegal Purposes. I. Ef‌fect of Time Interval be-

tween Incident and Sample Acquisition.” Quarterly Journal of Studies

on Alcohol, : –,  ( tables,  f‌igures,  references)

Abstract: Eighteen drinking drivers had their BrACs determined at the

roadside using a Breathalyzer collection unit (a CaCl absorption t ube)

and then later at a police station using a breathalyzer. The BrAC in the

CaCl tube was determined by GC. The time inter val between the road-

side test and the Breathalyzer result ranged f rom  to  minutes (mean

 minutes). The roadside BrACs ranged from . to .g/mL

(mean .g/mL). The Breatha lyzer results ranged from . to

.g/mL (mean .g/mL). The mean dif‌ference between

the roadside BrACs and the Breathalyzer results was .g/ mL.

In addition,  subjects consumed alcohol over a period of time and

had Breathalyzer tests conducted and BACs determined from blood

samples. The mean rate of alcohol elimination in  subjects a s deter-

mined by BrAC was .g/ mL/h and as determ ined by BAC was

.g/mL/h. A n interval of up to  hours was found in which the

BrACs did not change by more than .g/ mL. The Breathalyzer

results should not be reported to three decimal places a s the accuracy of

the instrument is not sucient for this pur pose.

The conclusion from the above example is that if a BAC in an auto-

mobile driver is determined at any time within  hr following an inci-

dent, that BAC is not practically dif‌ferent from what it was at the time

of the incident. Furthermore, in medicolegal c ases a BAC determined in

excess of  hr following an incident should not be considered equivalent

to the BAC at the time of the incident.

Reference Number: 

, . “The Rate of Disappearance of Blood Alcohol in Drunken Driv-

ers .” Blutalkohol, : –,  ( table,  f‌igure,  references)

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Abstract: Blood samples were collected  hour apart from  drink-

ing drivers in Copenhagen between  and . The BACs were

determined by the Widmark, ADH, and GC methods. The decrease

in BAC ranged between  and .g/mL/ h, and the average was

.g/mL/h. An increase in BAC was not observed in any dr iver.

After deduction of these two hour s, a possible surplus time is used for

backward calculation applying . promille as the BAC-fall per hour.

The above mentioned time deduction and th e low BAC f all rate ensure

that the possibility of obtaining a too high BAC value by the backwa rd

calculation is virtually eliminated.

Reference Number: 

-, ., . , . , . , .. ,  ..

. “Ethanol Kinetics: Extent of Error in Back Extrapolation

Procedures.” British Journal of Clinical Pharmacology, : –, 

( tables,  f‌igures,  references)

Abstract: Twenty-four male subjects consumed .g/kg of alcohol with-

in  minutes. Venous blood samples were collected from an indwell-

ing venous catheter at , ., ., ., , ., ., , , , , , , , and 

hours after alcohol was consumed. Plasm a alcohol concentrations were

determined by GC. The mean pea k PAC was .g/ mL, and the

mean time to peak was  hour. The mean rate of alcohol elimination

was .g/mL/h. Back extrapolation starting at  a nd  hours post-

consumption was conducted using ., ., a nd .g/ mL/ h as

rates of elimination. When .g/mL/h was used, the back extrapo-

lation resulted in an underestimation of PAC in the majority of subjects.

Using the PAC at  hours, the mean error was −.g/mL calcu-

lated to  hours and −.g/mL for the calculation to  hour.

Table. Mean Dif‌ference (eBAC−BAC) Using Dif‌ferent Elimination

Rates with Increasing Back Calculation Time

Elimination Rate (g/ mL/ h)  h  h  h

. − . − . − .

. .  +. − .

. +. + . + .

Source: Adapted from Al-La nqawi et al. ().

  Wigmore on Alcohol

Reference Number: 

Thus for the majority of the population the use of an e limination rate of

 mg/L/h [. g/L/h] for back extrapolation would underestimate

the true blood alcohol concentration and therefore would be unlikely

to result in invalid prosecution. From this study, it may be concluded

that the accuracy and precision of the back extrapolation p rocedure

depends on the rate of elimination assumed.

Reference Number: 

, .., .. ,  .. . “Backtracking Booze with

Bayes—The Retrospective Interpretation of Blood Alcohol Data.”

British Journal of Clinical Pharmacology, : –,  ( tables, 

f‌igures,  references)

Abstract: An application of Bayes’ theorem to back calculate BAC using

dif‌ferent rates of absorption, volume of distribution (Vd), and elimina-

tion rates is presented. The best mathematical model is zero order elim-

ination and f‌irst order absorption rates. This mathematical model is

applied to a famous British case involving a fata l motor vehicle accident

(FMVA) in which the accused had a BAC of .g/mL at . hours

after t he collision.

In the simple case without continuing absorption th e variability in the

predicted blood ethanol concentration at the time of the i ncident was

low. The proportion of the area below  mg/% [.g/mL] was

small and, therefore, the likelihood of making a conviction in er ror is

small. However, when the model was extended to include ethanol ab -

sorption which continues after the cessation of drinki ng, the possibility

of the blood ethanol concentration at time t(a) being below the legal

limit ceases to be negligible.

Reference Number: 

, ..,  .. . “Estimation of Blood Alcohol Concen-

trations after Social Drinking.” Journal of Forensic Sciences, : –,

 ( tables,  f‌igures,  references)

Abstract: Twenty-four male subjects (ages – years) consumed .–

.g/kg of ethanol over .–. hours, at least  hour after consum-

ing lunch. A blood sample was collected immediately prior to drin king

(BAC), .–. hours after drinking stopped (BAC), and .–.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

hours after drin king stopped (BAC). BACs were determined by head-

space GC. BAC ranged between . and . g/  mL (mean

.g/mL), and BAC ranged between . and .g/mL

(mean .g/mL). Back calculations were conducted in which the

BAC was estimated from the BAC. The mean time di f‌ference between

these two blood samples was . hours. BAC was withi n the estimated

range %, %, and % of the time using elimination rates of .–

., .–., and .–.g/mL/h, respect ively. Forward

calculations were conducted using Widmark, Watson et al., Lewis, and

Forrest methods. The forward calculations of Forrest and Watson et al.

use an % v/v water factor of blood rather than % v/v, probably due to

confusion about w/w and v/v units.

Table. Percent Correct Estimation of BAC and BAC*

Rates of

Elimination

(g/ mL/h)

% Correct Using

Back-Calculation

from BAC to BAC

% Correct Using

Widmark Forward

Calculation to BAC

% Correct Using

Watson et al. Forward

Calculation to BAC

.–.   

.–.   

.– .   

* Estimation of BAC using back ca lculation from BAC or forward calculation to

BAC using Widmark or Watson et al. for mulas and dif‌ferent rates of elimination.

Source: Adapted from Stowell and Stowell ().

Considering that BAC was measured approximately one hour af ter

drinking stopped, when absorption an d equilibration of alcohol may

not have been complete, these results are surprising. They sug gest that

back estimations up to a relatively short time after cess ation of drinking,

may not be subject to gross errors after a perio d of social drinking. This

conclusion is supported by other studies involving even shor ter period

of social drinking.

Reference Number: 

, .. “Considering Measurement Variability when Performing

Retrograde Extrapolation of Breath Alcohol Results [Letter].” Journal

of Analytical Toxicology, : –,  ( f‌igure,  references)

Abstract: A statistical and theoretical discussion of BAC back calcula-

tion from two breath alcohol results is presented. For the calculation,

the SD of the duplicate breath samples should be taken into account.

  Wigmore on Alcohol

Reference Number: 

If the BrACs were . and . g/mL, the mean BrAC would be

.g/ mL. The SD of duplicates using , dupl icate results in a

f‌ield study was ±.g/mL. Therefore, no increase in the back calcu-

lation would occur before . hours.

If the driving incident occurred only  hour prior to breath alcoho l an-

alysis, and all of the other relevant assumptions are [sic] valid, then one

would expect the BrAC at the time of the incident to be measurably

the same as the BrAC at the time of the analysis. Their values would b e

considered random variables from the same distribution.

Reference Number: 

, .. “Employing Simulated Data to Illustrate an Important

Cause of the ‘Steepling’ Ef‌fect in Breath Alcohol Analysis.” Medicine,

Science and the Law, : –,  ( table,  f‌igure,  references)

Abstract: A statistica l evaluation of the alleged steepling ef‌fect of BrACs

was conducted using multiple breath samples. If the mean of the BrACs

is employed rather than single measurements, the steepling ef‌fect is

much reduced. If blood rather than breath samples were used, the ef‌fect

would be reduced even further.

Interpreting this phenomenon as originating from some other biological

cause (pyloric spasms, etc.) is cautioned agains t unless total analytical

variability is accounted for. Certainly, other biological factors contrib-

ute to the total variability as well, but one must keep in mind th e inf‌lu-

ence of data collection and treatment.

Reference Number: 

, .., . , . ,  .. . “Physiological

Variations in Blood Ethanol Measurements during the Post-absorptive

State.” Journal of the Forensic Science Society, : –,  ( table,

 f‌igures,  references)

Abstract: Nine subjects (ages – years) consumed .g/ kg of etha-

nol over  minutes. When the postabsorptive state was determined

by BrAC, and at least  hours after the end of drinking,  consecu-

tive samples of venous blood were drawn at -minute intervals into

Vacutainers with a catheter. Six males (ages – years) were given

.g/kg of ethanol IV, and arterial BACs were determined with a cath-

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

eter implanted in the radial a rm. BACs were determined by headspace

GC. The rate of eliminat ion of alcohol from venous blood varied from

. to .g/ mL/h and from arterial blood varied from . to

.g/mL/h. No zigzag pattern (i.e., steepling ef‌fect) was observed

from the venous samples drawn at -minute intervals, a nd most varia-

tions were less than .g /mL. Variations of .–.g /mL

occurred in subjects who had techn ical problems with the catheter.

A zigzag concentration time prof‌ile of ethanol was demonstrated when

end-expired air was used as the biolog ical specimen for analysis of ethanol.

There were inter- and intra-subject variations in the amplitude of the sp ik-

ing, being most pronounced during the absorpti on phase. Making a long

series of  to  successive end-exhalations at – min intervals m ust

prove tiresome for the volunteer subjects. Som e might have unintention-

ally changed their breathing technique between successive breaths, e .g.,

by hypo- or hyper-ventilation, to generate sucient vital capacit y for the

forced exhalation maneuver. This could easily account for some of the

breath to breath variation in concentration of ethanol reported.

. WIDMARK OR FORWARD CALCULATIONS

The calculations to estimate the amount of alcohol in the body from a

BAC are commonly known as Widmark (or forward) calculat ions, named

after the Swedish scientist E.M .P. Widm ark. His research on alcohol was

published mainly in the s and s in German. T he equation is as

follows:

A = p × C × r

where A is the amount of alcohol absorbed and distributed in the body

(in grams), p is the body weight (in kilograms), C is the BAC (in grams

per kilogram), and r is the reduction or Widmark fac tor (rat io of alcohol

in the body to the alcohol in the blood), approximately . for men and

. for women.

By adding a range of elimination rates and the time since the start

of drinking to the equation, the amount of alcohol consumed can be es-

timated. By rearranging the equation, one can calculate C or BAC from

a drinking scenario. Widmark equations tend to underestimate the

amount consumed and overestimate the BAC (–). The overesti-

mation of BAC is substantial when there is prolonged drink ing ().

  Wigmore on Alcohol

Reference Number: 

Another problem with calculating BAC from a dri nking scenario

is that alleged dri nking patterns from drinki ng drivers are notoriously

unreliable (correlation coecient [r] = .–.) and of little scien-

tif‌ic value (–). In addition, the uncertain volume of hand-poured

drinks m akes accurate BAC calculations dicult ().

Reference Number: 

, ... “The Estimation of Widmark’s Factor.” Journal of the For-

ensic Science Society, : –,  ( table,  references)

Abstract: Widmark r values tend to be lower in females than in males

and lower in obese persons. To directly measure r, the subject should be

given dose of .g/kg of alcohol in a –% v/v solution on an empty

stomach, and the dose should be consumed within  minutes. Frequent

blood or breath samples should be taken at -minute intervals for the

next  hours. The technique gives only an estimate of r at the time of

the testing; r = body ethanol concentration/blood ethanol concentra-

tion. In health, the water content of the blood is relatively constant at

%; hence, r = TBW/body weight × .. The total body water may be

estimated by TBW = . × (body weight − body fat). The body fat can

be estimated from the sum of ski n-fold thickness measured at four sites

using standard calipers. Total body water and, hence, r may be estimat-

ed by the equations of Watson et al.

Whilst estimates of Widmark ’s factor from weight and height will be

particularly unreliable in individuals of grossly un usual physique, no mat-

ter what equations are used, such estimates will still be useful aids in t he

preparation of reports for the cour ts concerning “hip f‌lask” defences.

Reference Number: 

, .., .. ,  . . “An Evaluation of the Reliability of

Widmark Calculations Based on Breath Alcohol Measurements.” Jour-

nal Forensic Sciences, : –,  ( table,  f‌igures,  references)

Abstract: Sixty-one male and  female subjects consumed .g/kg or

.g/kg, respectively, within  minutes. BrACs were determined with

a BAC Verif‌ier DataMaster II at , , , , and  minutes. Widmark

calculations to esti mate the alcohol consumption were conducted based

on an r value of . for males and . for females and a rate of alcohol

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

elimination of .g/mL/h. In seven of the  subjects (%), a dif-

fusion drop or plunge was observed.

This study shows that under the conditions described ab ove, Widmark’s

formula usually underestimates the actual ethan ol dose when BrACs

were employed. When  min and  min BrACs are used, the %

conf‌idence limits for calculated vodka dose were from  to  mL below

the actual dose. Thus one can state wit h a high level of conf‌idence that

the calculated dose at these times does not overestimate the tru e dose,

and may in fact underestimate it by as much as  mL of vodka.

Reference Number: 

, ..,  .. . “Guidelines for Estimating the Amount

of Alcohol Consumed from a Single Measurement of Blood Alcohol

Concentration: Re-evaluation of Widmark’s Equation.” Forensic Sci-

ence International, : –,  ( tables,  f‌igures,  references)

Abstract: A study was conducted of  male subjects (ages − years)

who consumed between . and .g/kg of alcohol within − min-

utes after an overnight fast. Capillary or venous blood samples were

collected every − minutes, and the BACs were determined by an

enzymatic method. T he mean Vd was . L/kg, and the mean rate

of elimination was . g/ mL/h. Widmark ’s equation was used

to estimate the amount consumed from the BACs obtained at , , and

 hours post-drinking. The est imated amount consumed was within

±%, ±%, and ±% for the , , and  hours post-drink ing BAC (at

% conf‌idence interval [CI]).

For most practical purposes Widmark ’s equation provides a fast and re-

liable way to estimate the quantity of alcohol consumed provided that

the limits of uncertainty are considered. M uch can be said for using the

simplest pharmacokinetic model when t his is supported by extensive

empirical results, such as those presente d here.

Reference Number: 

, .., .. ,  .. . “Predictions of Blood Alcohol

Concentrations in Human Subjects. Updating the Widmark Equation.”

Journal of Studies on Alcohol, : –,  ( f‌igures,  references)

  Wigmore on Alcohol

Reference Number: 

Abstract: Equations are derived for expressing the relationship between

alcohol intake and BAC in terms of TBW and blood water fraction.

These equations are more exact tha n Widmark’s, and if used in con-

junction with regression equations to calcu late TBW give more accurate

predictions of BAC. Data from various drinking experiments were em-

ployed to compare BACs estimated from the classic Widmark equation

and from using TBW.

Table. Comparison of Accuracy Range of the Widmark and TBW*

Equations with Measured BAC in Drinking Subjects

Accuracy Range

(%)

Percent Correct Using Wid mark Percent Correct Using TBW*

±  

±  

±  

*Equation from Watson et al.

Source: Adapted from Watson et al. ().

Hence not only does the Widmark equation overestimate the blo od

alcohol level in most cases, but it also predict s C values much less pre-

cisely, particularly in women.

Reference Number: 

, .., .. ,  .. . “The Course of the Blood-Al-

cohol Curve after Consumption of Large Amounts of Alcohol under

Realistic Conditions.” Canadian Society Forensic Science Journal, :

–,  ( tables,  f‌igure,  references)

Abstract: A review and appreciation of a German ar ticle by Zink and

Reinha rdt (Blutalkohol, : –, ) is presented. Twelve male sub-

jects (mean age  years) consumed large doses of alcohol (.–.g /kg)

in a social setting over – hours. The total amount of alcohol con-

sumed was equivalent to .–. L (– f‌l. oz.) of % v/v liquor.

Venous blood samples were collected every – minutes, and SACs

were determined by GC and enzymatic methods. The mean time to

peak BAC was  minutes after the la st drink. The rate of elimination

of alcohol was .g/mL/h (range .–.g/mL/h). Wid-

mark’s r value ranged from . to . (mean .). The overestimation

in BAC using typical Widma rk calculations ranged from  to %. No

steepling ef‌fect was observed.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Table. Comparison of Measured BAC and eBAC* Showing the

Greatest BAC Overestimations

BAC Curve No. Equivalent Liters

of % v/v Alcohol

Consumed

Drinking

Time (h)

Maximum

Observed BAC

(g/ m L)

eBAC Range from

Widmark Equation

(g/ m L)

. . .  .– .

. . .  .– .

. . . . – .

. .  . . –.

 . . .  .–. 

 . . . . –. 

* Using the Widmark equatio n and rates of elimination of .–.g/mL/h.

Source: Adapted from Jones et al . ().

Whatever the mechanism, the fact remains that after prolon ged heavy

drinking, a considerable quantity of alcohol fails to reach th e systematic

circulation and this needs to be considered when Widmark calcu lations

are made. The rate of alcohol elimination when this is calculated from t he

slope of the BAC curve in the post-absorptive phase (.g/kg/h in th e

Z&R [Zink and Reinhardt] study) underestimates a person’s overall elimina-

tion capacity. Z&R suggested that a Widmark factor of . and a lower limit

of . should be used when the dose of alcohol ingested exceeds .g/kg.

Reference Number: 

, ..,  ... . “Are Retrospectively Reconstructed Blood Al-

cohol Concentrations Accurate? Preliminary Results from a Field Study.”

Journal of Studies on Alcohol, : –,  ( f‌igure,  references)

Abstract: BrACs were determined with an Alco-Sensor IV and compared

with eBACs from  drink ing subjects (% male) near a university cam-

pus. The eBACs were determined from drinking scenarios obtained via

telephone interviews the next day. The National Highway Trac Safety

Administration equation was employed, which uses a rate of alcohol elim-

ination of .g/ m L/h. The dif‌ference between the eBAC and the BrAC

ranged from −. to +. g/mL. The correlation between BrAC and

eBAC decreased with increasing BrAC. At a BrAC . g/ mL, t he

correlation w as r = ., and when the BrAC was > .g/mL, r = ..

The observation that eBACs become less accurate when h igher BACs

are estimated is consistent with the f‌indings of Sommer s and colleagues

  Wigmore on Alcohol

Reference Number: 

(, ) in two samples of hospitalized patients. At higher BACs a

person must recall more drinks an d estimate longer time periods. The

encoding of more frequent events or temporal monitoring may be af-

fected by increasing cognitive impairment due to intoxication.

Reference Number: 

, .., .. , .. , . ,  . .

“Nurse, I Only Had a Couple of Beers: Validity of Self-Reported Drink-

ing before Serious Vehicular Injury.” American Journal of Critical Care,

: –,  ( tables,  references)

Abstract: A -month study was conducted of  female and  male non-

alcohol-dependent patients injured in a motor vehicle accident (MVA) with

an admission BAC as determined by GC > .g/ mL. There were 

drivers,  passengers, and six un known passenger/drivers. Of the  pa-

tients, seven male patients (%) with a BAC > .g/ mL denied having

consumed alcohol. The BACs ranged between . and .g/ mL

(mean .g/mL). Sucient information was obtained from the self-

reported drinki ng pattern of  male and  female patients to determine

an eBAC based on a rate of alcohol elimination of .g/mL/ h. For

all patients, the correlation between the measu red BAC a nd the eBAC w as

r = .. Drivers underreported drinking more often tha n non-drivers did,

and male patients underreported dri nking more often than fema le patients

did. For all patients, the eBAC was on average . g/mL lower than

the actual BAC. For male dr ivers t he eBAC was on average .g/mL

lower than the actual BAC, and for female drivers it was .g/mL

lower. Patients with an admission BAC > .g/mL were more likely

to underreport drink ing than were drivers with lower BACs. All drinking

histories were obtained when the patient was sober and not at admission.

Table. Mean Dif‌ferences in eBAC* Minus the Actual BAC in

Patients Injured in an MVC

Patient Characteristic Mean Dif‌fere nce (eBAC−Actual BAC) (g/ mL)

Male driver −.

Male non-driver −.

Female driver −.

Female non-driver +.

All patients − .

* From self-reported drinkin g.

Source: Adapted from Sommer s et al. ().

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

We found that most subjects were not trying to conceal their dr inking

entirely but rather were either unable or unwilling to describe the e xact

quantity and frequency of alcohol consumption. Possibl y, the subjects

did not understand the concept of a standard drink . If they underesti-

mated the number of standard drinks contain ed in their serving of al-

cohol, they would have underreported their drinki ng. In addition, some

subjects may have underreported the ir drinking because they could not

remember their drinking patterns bec ause of confusion from the injury

or because of alcohol intoxication itself. Because of these fac tors, we

do not think that the data support the hypothe sis that underreporting

was a function of fear of prosecution alone.

Reference Number: 

, .., .. ,  .. . “A Comparison of Blood

Alcohol Concentrations Estimated from Drinking Histories of Driv-

ers Charged with Over  and Their Intoxilyzer C Results.” Can-

adian Society of Forensic Science Journal, : –,  ( table, 

f‌igures,  references)

Abstract: Two hundred and thirty self-reported drinking scena rios

from arrested drin king drivers in Ontario between  and  were

obtained and compared to the f‌irst or the lowest Intoxilyzer C

result. There were  male (%) and  female drivers. Beer was re-

ported to have been consumed by % of the male drivers and % of

the female drivers. Wine was reported to have been consumed by % of

the female drivers and .% of the male drivers. eBACs were calculated

using the Widmark formula (r = . for men and . for women). The

Intoxilyzer results ranged from . to . g/ mL. The eBACs

ranged from  to .g/mL (mean .g/ mL) and from 

to .g/mL (mean .g/ mL) using a rate of alcohol elim-

ination of . and .g/ mL/h, respectively. The eBACs were

more than .g/mL lower than the Intoxilyzer result in % and

% of the reported drinking scenarios, when a rate of elimination of

.g/ mL/h or .g/mL/h were employed, respectively. The

correlation coecients (r) were . and . using rates of elimination

of . a nd .g/mL/h, res pectively.

Estimated BACs based on submitted drinking scena rios from drivers

charged with an over  of‌fence were signif‌icantly lower than a measured

  Wigmore on Alcohol

Reference Number: 

BAC using an approved breath testing instrument, the Intoxilyzer C .

We suggest that this discrepancy lies not with the Intoxilyzer C , but

is due to an unreliability of self-reported drinking scenari os in these cases.

Whether this stems from memory l oss, decreased attention, carry-over of

a pre-existing BAC, misrepresentation or misu nderstanding of the amount

of alcohol consumed (due to non-standard size drinks being ingested) is

unknown. It is also possible that a combination of these facto rs could

result in a signif‌icantly underestimated eBAC calculated from a drink ing

scenario in a single case.

Reference Number: 

, .. “Are a Blood Alcohol Concentration of  mg/dL and Min-

imal Signs of Impairment Reliable Indications of Alcohol Dependence?”

Medicine Science and the Law, : –,  ( references)

Abstract: A -year-old woman was involved in a minor trac accident

in Sweden at approximately : p.m. and was arrested for impaired

driving. After she could not provide an acceptable breath sample into

the Intoxilyzer , two blood samples were collected. The reported

BAC was .g/ mL. Since the woman cla imed she had only had

one and a half glasses of wine at lunch, the BAC was determined in the

second blood sample (which conf‌irmed the f‌irst alcohol analysis). A de-

oxyribonucleic acid (DNA) prof‌ile of the blood samples was conducted

that matched the DNA prof‌ile of the driver. A lower court dismissed the

charges against t he woman as the defense expert stated that in tests

conducted  months later, the woman had no biochemical markers of

excessive alcohol consumption. A higher court convicted the woman

when, in addition to the blood results, the def‌icient BrAC result stored in

the Intoxilyzer was equivalent to .g/mL.

The lower court justices seem to have chosen to ignore a golden rule in

DUI litigation, namely that what the suspect says he or sh e has drunk is

not reliable evidence.

Reference Number: 

, . “A Survey of Hand-Poured Measures of Spirit.” Science and

Justice, : –,  ( tables,  f‌igure)

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Abstract: Fifty-one male and  female members of the general public

were asked to pour a single ( mL) and double ( mL) shot of spirits

into three dif‌ferent types of gla sses. The three types of glasses were a

tall slender glass, a broad short tumbler, and a stemmed wine gla ss. The

volume poured ranged from  to  mL for the single shot and –

mL for the double shot. On average, more volume was poured into the

board short glass ( mL and  mL) than the tall slender glass ( mL

and  mL for the single and double shot pours, respectively).

Given the often uncertain volume of hand -poured drinks in cases re -

garding Blood Alcohol Calculations it is hoped th at this work will help

those involved in carrying out such calculations to re ach informed opin-

ions as to the feasibility of some individuals’ recollec tions.

. EFFECTS OF OTHER DRUGS

Other drugs ty pically do not have a signif‌icant ef‌fect on the phar maco-

kinetics of alcohol, especially when the tests a re conducted under real-

istic drink ing conditions (–). Among the reasons for the lack of

ef‌fect of other drugs on alcohol pharmacokinetics a re the following:

• Alcohol is a simple drug that is dist ributed through the TBW and

has a general ef‌fect (i.e., it is not bound to a specif‌ic carr ier protein

or receptor).

• Alcohol is at a concentration in the blood of –,× that of

most other dr ug concentrations.

Some of the alleged ef‌fects of various dr ugs occurred only in vitro or

with anima l studies (). Various “sobering-up” preparations such as

fructose or other sugars (, , ), B vitamins ( ), energy

drinks (), and oxygenated water () have been shown to be in-

ef‌fective at signif‌icantly increasing the rate of alcohol elimination. The

ADH inhibitor (-methylpyrazole) commonly used for the treatment of

methanol poisoning can lower the rate of alcohol elimination ().

Reference Number: 

, .., . , .. , .. , .. , . ,

 ... . “Lack of Ef‌fect of H-Receptor Antagonists on

the Pharmacokinetics of Alcohol Consumed after Food at Lunchtime.”

  Wigmore on Alcohol

Reference Number: 

British Journal Clinical Pharmacology, : –,  ( table,  f‌igure,

 references)

Abstract: Twenty-four healthy male subjects (ages – years) were ad-

ministered a placebo or ranitidine ( mg four times daily), cimetidine

( mg four times daily), or famotidine ( mg four times daily). After

a -day administration of the drug or placebo, the subjects cons umed 

g of ethanol with a stand ard lunch. The ethanol dosage was between .

and .g/kg. Frequent blood samples were collected by an indwelling

cannula. T he BACs were determined by GC. There were no signif‌icant

dif‌ferences in maximum BAC between the use of a ny drug and the pla-

cebo (range .–.g/mL).

The absence of any pharmacokinetic interaction with any of the thre e

drugs studied support s the view that these widely used agents do not

have any signif‌icant interaction with alcohol.

Reference Number: 

, ., . , . , . , . , . ,

 . . “Interaction of H-Receptor Antagonists (Cimetidine

and Ranitidine) and High Blood Alcohol Concentrations. Experiment-

al Investigations.” Blutalkohol, : –,  ( tables,  f‌igures, 

references)

Abstract: Twelve m ale subjects (ages – years) consumed cimetidine,

ranitidine, or placebo and consumed .g/ kg of ethanol within  min-

utes. The alcohol was consumed after a standard breakfast. Frequent

blood samples were collected, and the BACs were determined in dupli-

cate by GC. Various psychomotor tests were conducted. The mean peak

BACs were ., . , and .g/mL for placebo, cimetidine, and

ranitidine, respectively. The mean rates of ethanol elim ination were

., ., and .g/ mL/h for placebo, cimetidine, and raniti-

dine, respe ctively.

There is neither an ef‌fect of HRA [H receptor antago nist] on the kinetics

of alcohol nor an ef‌fect of alcohol on the kinetics of HR A. Neither cimet-

idine nor ranitidine af‌fect the psychomotor func tion of healthy sober

male volunteers. With maximum blood alcohol concentrations of more

than . promille [.g/ mL], no additional def‌iciencies of psycho-

motor tests are demonstrable that cann ot be explained from the alcohol.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Reference Number: 

, ..,  ... . “Omeprazole, Ranitidine and Cimetidine

Have no Ef‌fect on Peak Blood Ethanol Concentrations, First Pass

Metabolism, or Area under the Time-Ethanol Curve under Real-Life

Conditions.” Alimentary Pharmacology Therapeutics, : –, 

( tables,  f‌igures,  references)

Abstract: Twelve fema le and  male subjects were administered  mg

of ranitidine,  mg of cimetidine, or  mg of omeprazole nightly for

 weeks. The subjects then consumed .g/ kg of ethanol as beer (.%

v/v alcohol) over  hour, .g/kg of ethanol IV, and de-alcoholized beer

immediately after the consumption of a sta ndard meal with or without

prior drug administration. Frequent blood samples were collected via

an indwelling catheter, and BACs were determined by GC. The mean

peak BACs were .g/mL (control), .g/mL (cimetidine),

.g/mL (ranitidine), and .g/mL (omeprazole).

Under these real-life conditions, the concomitant admin istration of

cimetidine, ranitidine, or omeprazole is unlikely to have any signif‌ic ant,

physical, social or forensic implications since they do not signif‌ic antly

change ethanol elimination.

Reference Number: 

, ., . ,  . . “Ethanol Elimination in Man

under the Inf‌luence of Frequently Prescribed Beta Receptor Blockers.”

Blutalkohol, : –,  ( tables,  f‌igures,  references)

Abstract: Four female and seven male subjects consumed . g /kg of

ethanol over  minutes after the consumption of a standard meal.

Blood was collected from an indwelling cannula in the vein of an arm

every  minutes, and the BACs were determined by the ADH and GC

methods. The same drinking procedure was repeated on four occa-

sions with pindolol ( mg), propranolol ( mg), atenolol ( mg), or a

placebo. There were no signif‌icant ef‌fects of the three β-blockers on the

BAC curve. The mean rate of elimin ation was .g/mL/h for pla-

cebo and .g/mL/h for β-blockers. During t he absorption phase,

simulta neous ingestion of β-blocker and ethanol sometimes produced

a major drop in systolic and diastolic blood pressure; several subjects

complained of a feeling of giddiness, and one subject collapsed.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, .., .. ,  .. . “Ef‌fect of -Methyl-

pyrazole on Ethanol Elimination Rate and Hepatic Redox Changes in

Alcoholics with Adequate or Inadequate Nutrition and in Nonalcohol-

ic Controls.” Metabolism, Clinical and Experimental, : –,  (

table,  f‌igures,  references)

Abstract: Nine non-alcoholics, six alcoholics with adequate nutrition,

and seven alcoholics with inadequate nutrition were administered

.g/kg of alcohol IV within  minutes. Three hours later,  mg/kg of

-methylpyrazole (-MP) was injected IV and an additional .g /kg of

alcohol was administered. Blood samples were collected every  min-

utes for the duration of the experiment. Blood alcohol, acetaldehyde,

lactate, pyruvate, and galactose concentrations were measured. The

mean rate of alcohol elimination was approximately ., ., and

. mg/dL/h in controls, alcoholics with adequate nutrition, and a lco-

holics with poor nutrition, respectively. After -MP administ ration, the

mean elimination rates decreased to ., ., and .g/mL/h,

respectively. In two alcoholics with poor nutrition, -MP decreased the

alcohol elimination rate by only % and %.

In conclusion, the present results indicate that the contribution of a

non-ADH pathway is pronounced in chronic alcoholics with inadequate

nutrition, probably due to the secondary d ecrease in hepatic ADH ac-

tivity caused by their def‌icient diet. T he net ef‌fect is that redox [oxi-

dation-reduction]-related metabolic changes in t he liver are especially

diminished in chronic alcoholics with inadequate nutrition.

Reference Number: 

, ., .. , .. , .. , .. , .. ,

 .. . “Kinetic Interactions between -Methylpyrazole

and Ethanol in Healthy Humans.” Alcoholism: Clinical and Experiment-

al Research, : –,  ( tables,  f‌igures,  references)

Abstract: Three groups of four fasting m ale subjects consumed either

a placebo drug or , , or  mg/kg of -MP (respectively) on two oc-

casions. One hour later .g/kg (group ) or .g/ kg (groups  and )

were consumed. Frequent venous blood samples were collected, and

BACs were determined by GC. The mean rate of alcohol elimination was

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

., ., and .g/ mL/h for the placebo drug and ., .,

and .g/mL/ h after ,  and  mg/kg -MP for each group,

respectively.

Table. Mean Alcohol Elimination Rate after Various Doses of -MP

-MP Dose

(mg/kg)

Mean Alcohol Eliminat ion Rate

after Placebo

(g/ mL/h)

Mean Alcohol Eliminat ion Rate

after -MP

(g/ mL/h)

 . .

 . .

 . . 

Source: Adapted from Jacobsen et al. ( ).

In conclusion, these studies have shown that doses of -MP shown to

be safe in healthy humans will inhibit human ADH activit y in vivo. Thus,

the metabolism of methanol, and ethylene gl ycol to their toxic metab-

olites should be prevented by these levels of -MP, which should be

therapeutic in these poisonings.

Reference Number: 

, .., . , . , . , . , . ,

 . . “The Interaction of the Lipase Inhibitor Orlistat with

Ethanol in Healthy Volunteers.” European Journal Clinical Pharmacol-

ogy, : –,  ( tables,  f‌igure,  references)

Abstract: Orlistat is an i nhibitor of GI lipases and therefore inhibits the

absorption of dietary fat. T hirty healthy male subject s (ages – yea rs)

were divided into three equal groups. One received  mg orlistat da ily

for  days and placebo alcohol, one received  mg orlistat daily for

 days and alcohol, and the other received placebo orlistat and alcohol.

The subjects consumed . g of alcohol diluted with orange juice to 

mL in three equal doses, before, during a nd after standa rd meals. Fre-

quent blood samples were collected, and the SACs were determined by

GC. The mean peak SACs for orlistat and orlistat placebo groups were

virtua lly identical (.–.g/ mL).

In conclusion, inhibition of dietary fat absorption du ring short-term

treatment ( days) with orlistat was not altered by the concomitant in-

gestion of a social amount of ethanol. Short ter m treatment with orli-

stat had no signif‌icant inf‌luence on ethanol phar macokinetics.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, ., . ,  .. . “Acute Ef‌fects of Maproti-

line, Doxepin and Zimeldine with Alcohol in Healthy Volunteers.” Ar-

chives International Pharmacodynamics, : –,  ( tables, 

f‌igures,  references)

Abstract: Nine male and three female subjects (ages – years) were

administered  mg of maprotili ne,  mg of doxepin,  mg of zimeld-

ine, or placebo with alcohol or alcohol placebo at -week intervals. The

dose of alcohol was g/kg and was consu med within  minutes. Blood

samples were collected at . and . hours after alcohol consumption,

and BACs and plasma drug concentrations were determined. BrACs

were also determined with an A lcolmeter AE-D. Various psychomotor

tests were conducted. The mean BACs at . hours did not statistically

dif‌fer among drug treatments a nd pl acebo (i.e., .–.g/mL).

In conclusion, maprotiline in a single dose seems to be fairly safe in situ-

ations where special psychomotor skills are required (e.g., car driving).

This holds true for doxepin as well, although it is subjectively clea rly

sedative. On the other hand, the addition of alcohol leads to a p oten-

tially dangerous interaction, and in this situation maprotiline t akes a

slight advantage over doxepin, probably because of its slower absorp -

tion, which yields a f‌latter plasma concentration vs time cur ve.

Reference Number: 

, ., . , . , . -,  . -

. “Ciprof‌loxacin Decreases the Rate of Ethanol Elimination in

Humans.” Gut, : –,  ( tables,  f‌igures,  references)

Abstract: Eight healthy male subjects (ages – years) were adminis-

tered .g/kg of ethanol IV before and after ora l ingestion of  mg

of ciprof‌loxacin twice daily for  week. Ciprof‌loxacin is an antibiotic

that concentrates in the intestinal mucosa. Frequent blood samples

were collected via an indwelling catheter, and BACs were determined

by headspace GC. Fecal samples were also collected. T he mean rate

of alcohol elimination was . g / mL/h before treatment and

. g/mL/h a fter treatment. The mean decrea se in the alcohol

elimination rate after a ntibiotic use was .% (range .–.%).

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

In conclusion ciprof‌loxacin treatment decreases the ethanol elimination

rate by .% in man, with a concomitant decrease in faecal ADH activ-

ity and acetaldehyde production in vitro. Due to a lack of evidence that

ciprof‌loxacin interferes with hepatic ethanol metabolism, our f‌indings

can be explained by the reduction in aerobic and facult ative anaerobic

bacteria in the lumen and mucosal surf aces of the human large intes-

tines. The f‌indings suppor t evidence of the signif‌icant role of colonic

bacteria in extrahepatic ethanol metabolism and acetaldehyde produc-

tion in man.

Reference Number: 

, ., .. ,  .. . “Impact of Gastric Empty-

ing on the Pharmacokinetics of Ethanol as Inf‌luenced by Cisapride.”

British Journal of Clinical Pharmacology, :  –,  ( f‌igures, 

references)

Abstract: Ten male subjects (ages – years) consumed .g /kg of al-

cohol on an empty stomach (after a -hour fast);  hour after a meal; or

 hour after a meal after treatment with  mg of cisapride three times

a day for  days. The alcohol was consumed within  m inutes, and mul-

tiple venous blood samples were collected via an indwelling catheter.

BACs were determined by headspace GC. Acetaminophen (. g) was

also admini stered to determine the rate of gastric empty ing. Cisapride

is used in the treatment of gastroesophagea l ref‌lux disease (GERD) and

promotes gastric emptying. The mean m aximum BACs (Cmax) were .,

., and .g/mL for fasting, food, and food with cisapride, re-

spec ti vel y.

In conclusion, our study demonstrates that taking th e drug cisapride

causes a small increase in both Cmax and AUC [area under the drug

concentration-time curve] when ethanol (. g/kg) was ingested  h

after eating a meal. The mechanism appear s to be accelerated gastric

emptying and more rapid saturation of metab olizing enzymes and thus

a diminished f‌irst-pass metabolism. The increa ses in peak BAC and AUC

after cisapride treatment were not remarkable and w as [sic] less than

that observed when ethanol was consume d on an empty stomach. This

example of drug-alcohol interaction probably lacks clinical or forensic

signif‌icance, and the ethanol-induced per formance decrements will be

more pronounced when alcohol is consumed on an empty stomach.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, .., .-. , . ,  .  . “Interaction of

Alcohol and Transdermally Administered Scopolamine.” Journal of Clin-

ical Pharmacology, : –,  ( tables,  f‌igures,  references)

Abstract: Six male and six fema le subjects (ages – years) were ad-

ministered a placebo or scopolamine tra nsdermally v ia a patch and al-

cohol calculated to obtain a BAC of either . or . g/mL. The

alcohol was consumed within  minutes, and f requent blood and urine

samples were collected. The BACs were determined by an ADH method.

Various psychomotor tests were conducted. The mean peak BACs were

.g/mL with scopolamine and .g/mL with placebo, and

.g/mL with scopolamine and .g/ mL with placebo, re-

spectively, for the low and high alcohol doses. The mean rate of alcohol

elimination was not af‌fected by scopolam ine and was . g/mL/h

for the low dose of alcohol and .g/ m L/h for the high dose.

In conclusion, TTS [transdermal therapeutic system]-scopolamine did

not signif‌icantly potentiate the ef‌fect of an acute dose on CRT and CFFF

[critical f‌licker fusion frequency]. There was no ef‌fect of T TS-scopola-

mine on alcohol elimination or of alcohol on scop olamine elimination.

Reference Number: 

, ., . ,  .. . “A Comparative Study of the Inter-

actions of Alcohol with Amitriptyline, Fluoxetine and Placebo in Nor-

mal Subjects.” Progress in Neuro-Psychopharmacology and Biological

Psychiatry, : –,  ( tables,  f‌igures,  references)

Abstract: Six male and six fema le subjects were administered a placebo,

amitriptyline (– mg), or f‌luoxetine (– mg) for  days. On day

, the subjects consumed vodka with in  hour to produce a calculated

BrAC of approximately . g/  mL. BrACs were measured by an

Alcolmeter AE-M,  hour after the end of drinking. Various psycho-

motor tests were conducted. The mean BrACs were ., ., and

.g/ mL after placebo, amitriptyline, or f‌luoxetine treatments,

which is not statistical ly signif‌icant.

We conclude that amitriptyline and f‌luoxetine in the doses used in this

study dif‌fer very little in their ef‌fec ts on physiological or psychomotor

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

activity before alcohol. Subjecti ve ratings did show some dif‌ferences

and in general amitriptyline was less-well tol erated than either f‌luox-

etine or placebo. After alcohol, signif‌icant ef‌fec ts were found with most

measures but these were mostly consistent with the ef‌fe cts of alcohol.

Reference Number: 

, .., .. , .. , . ,  .. . “Inter-

action of Sted-eze, Nikethamide, Pipradrol, or Ammonium Chloride

with Ethanol in Human Males.” Alcoholism: Clinical and Experimental

Research, : –,  ( tables,  f‌igures,  references)

Abstract: Six male subjects (ages – years) consumed .g/kg of al-

cohol within  minutes at  hours after a l ight breakfast and either four

tablets of Sted-eze or a placebo. Each tablet of Sted-eze contains  mg

of vitamin B,  mg of vitamin B,  mg of niacin, and  g of yeast.

BrACs were determined by a Breathalyzer in duplicate on f‌ive occasions.

Various psychomotor tasks were conducted. In addition, eight male sub-

jects (ages – years) consumed .g/kg of alcohol under identical con-

ditions and then consumed either . mg of pipradrol,  g of ammonium

chloride, or . g of nikethamide. BrACs were again determined by a

Breathalyzer, and various psychomotor tests were conducted. Pipradrol

is an amphetamine-related stimulant. Nikethamide is a powerful cen-

tral nervous system (CNS) stimula nt, similar to strychni ne. Ammonium

chloride induces diuresis. The mean peak BrACs were approximately

.g/mL under all conditions.

These results indicate that none of the tested dr ugs represent ef‌fective

sobering agents at the doses employed.

Reference Number: 

, ., .. ,  .. . “Ef‌fect of Methylene

Blue on the Disposition of Ethanol.” Alcohol and Alcoholism, : –

,  ( f‌igures,  references)

Abstract: Eleven male subjects (ages – years) consumed .g /kg

of alcohol with and without prior administration of  mg of methyl-

ene blue (, , , and  hour prior to alcohol consumption). Frequent

blood samples were collected via an indwelling catheter, and PACs were

determined by headspace GC. Blood lactate a nd pyruvate concentrations

  Wigmore on Alcohol

Reference Number: 

were also determined. Methylene blue has been shown to increase al-

cohol elimination in rats and hepatocyte cultures. The mean pea k

PACs were virtually identical with and without prior administration of

methylene blue (approximately .g/mL). The mean rate of alco-

hol elimination was .g/ mL/ h and .g/ mL/h w ithout

and with prior admini stration of methylene blue, respectively.

In summary, whereas methylene blue stimulates the oxidation of eth anol

to CO in isolated hepatocytes and intac t rats, no ef‌fect of methylene

blue on the disposition of ethanol and its met abolic consequences could

be demonstrated in humans, possibly bec ause the dose of methylene blue

that can be safely administered to humans is too low to be ef‌fec tive.

Reference Number: 

, .., .. ,  . . “Failure to Demonstrate an Increased

Removal of Alcohol from the Blood Stream by Fructose.” Medicine Sci-

ence and the Law, : –,  ( f‌igure,  references)

Abstract: A rapid infusion of .g/kg of ethanol was a dministered to 

controls and to  patients who were also given  g of fructose IV. No

signif‌icant increase i n the rate of elimination of alcohol was detected with

fructose. The mean rate of alcohol elimination was .g/ mL/ h

without fructose and .g/mL/ h with fructose. Fructose may al-

ter the absorption of alcohol consumed orally and may thus give some

benef‌it. This amount of ethanol in fused caused an appreciable incidence

of sickness and headache. Fructose caused retrosterna l pain and a con-

striction in the chest, which was f rightening to patients.

Studies of blood ethanol levels after rapid infusion of .g/kg failed to

demonstrate any signif‌icant increase in the rate of removal of alcoho l

from the blood by  g fructose given intravenously.

Reference Number: 

, ., . , . , . , . , . ,

 . . “Inecacy of Oxygenated Drinking Water in Accel-

erating Ethanol Elimination in Humans.” Life Sciences, : –,

 ( table,  references)

Abstract: In liver slices and perfused rat livers (in vit ro), the alcohol elimina-

tion rate had been shown to increase with increa sing oxygen concentration.

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

It was therefore tested whether oxygenated water could increase the rate of

alcohol elimination in humans. Ten male and three female subjects (ages

– years) were divided into three groups and after a -hour fast were ad-

ministered .g/kg of alcohol IV in saline, and dran k  mL of either water

or oxygenated water every – minutes. Subjects in the third group were

administered alcohol IV in % glucose and dran k fruit juice or oxygenated

fruit juice every  minutes. Blood samples were collected every  min-

utes and analyzed by GC. Elimination rates were calculated using linear

regression. The mean elimin ation rates for the three conditions were .,

., and .g/mL/h for control (non-oxygenated) and ., .,

and .g/mL/h for oxygenated conditions, respectively.

Oxygenated drinks did not increase th e elimination rate of ethanol in

humans.

Reference Number: 

, ., . ,  . . “Ethanol Elimination in Man under the

Inf‌luence of Hepatoprotective Silibinin.” Blutalkohol, : –, 

( f‌igure,  references)

Abstract: Twenty-six healthy subjects of both sexes consumed either

brandy or vodka to obtain BACs of between . and .g/mL .

Three weeks later, the subjects consumed the same a mount of alcohol

but were given a single therapeutic dose of . g of silibinin. Silibinin is

a biof‌lavonoid used to treat chronic alcoholic liver damage. BACs were

determined six times over  hours from f‌ingertip blood analyzed by

GC. The rate of alcohol elimination was .g/ mL/h before and

.g/mL/h after silibini n treatment.

Although the biof‌lavonoid silibinin is known as a hepatoprotec tive agent

in the prevention of chronic alcoholic liver damage, it can be stated that

silibinin has no inf‌luence on acute alcohol elimination in spite of the

biochemical hypothesis and considerations. Th erefore, it is not suitable

nor recommended to administer silibinin as a sobering- up drug.

Reference Number: 

, .., .. ,  . ’. “A Natural Sobriety Enzyme:

A Party Pill or Snake Oil?” Veterinary and Human Toxicolog y, : –,

 ( f‌igures,  references)

  Wigmore on Alcohol

Reference Number: 

Abstract: Five male and three female subjects consumed four to six 

mL ( f‌l. oz.) beers ad libitum over  minutes. The BACs and BrACs

were determined  minutes after the last drink. T he BrACs were de-

termined by the Intoxilyzer  and the BACs by GC. One-half of the

subjects ingested  capsules of Alco-Zyme with a glass of water, and

the other half consumed only water. Forty minutes later, the BACs and

BrACs were determined again. The BACs and BrACs correlated well,

with a coecient of determination of r= .. There were no dif‌ferences

in BrACs or BACs with or without Alco-Zyme. In addition, an in vitro

study showed no reduction in the aqueous alcohol concentration when

Alco-Zyme was added to the solution.

Alcozyme fails to meet its expressed and implied claim s to accelerate

ethanol metabolism or to produce sobriety after consuming ethanol.

Reference Number: 

, .., ..  , . ,  ...  -.

“Ef‌fects of Energy Drink Ingestion on Alcohol Intoxication.” Alcohol-

ism: Clinical and Experimental Research, : –,  ( table, 

f‌igures,  references)

Abstract: Twenty-six male subjects (mean age  years) consumed . or

.g/kg of alcohol after a standa rd meal with and without the consump-

tion of the energy drink Red Bull (. mL/kg). BrACs were determined

with an Alco-Sensor IV. Subjective ef‌fects of alcohol and various psycho-

motor tests were determined. The mean peak BrACs were .g/mL

(no energy drink) and .g/mL (energy drin k) at the low alcohol

dose, and .g/mL and .g/m L, respectively, at the higher

alcohol dose.

Table. Comparison of the Mean Maximum BrAC with Alcohol*

Alone or Alcohol* and Energy Drink

Condition Mean Maximum BrAC (g/

mL) at .g/kg Alcohol Dose

Mean Maximum BrAC (g/

mL) at .g/kg Alcohol Dose

Alcohol alone . . 

Alcohol and

energy drink

. .

* At alcohol doses of . and .g/kg.

Source: Adapted from Ferreira et al. ().

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

When compared with the ingestion of alcohol alone, the inges tion of

alcohol plus energy drink signif‌ica ntly reduced subjects’ perception of

headache, weakness, dry mouth , and impairment of motor coordina-

tion. However, the ingestion of the energy drink did not signif‌icantly

reduce the def‌icits caused by alcohol on objective motor coordin ation

and visual reaction time. The ingestio n of the energy drink did not alter

the breath alcohol concentrations in either group.

Reference Number: 

, ., . , . , . , . ,  . .

“Another Soberade on the Market: Does Outox Keep Its Promise?”

Wiener Klinische Wochenschrift, (–): –,  ( tables,  f‌ig-

ures,  references)

Abstract: Fourteen female and  male subjects (ages – years)

consumed beer, wine, and vodka ad libitum over  hours (average dose

.g /kg) and  mL of either placebo or Outox. The second drink-

ing session was conducted under identical conditions to the f‌irst. Outox

contains fructose a nd citric, malic, ascorbic, and car minic acids. Blood

and urine samples were collected, and the alcohol concentrations were

determined by headspace GC. BrACs were also determined using an Al-

cotest  MK III-A. The mean BACs were .g/mL (placebo) a nd

.g/ mL (Outox). The mean rates of alcohol elimination were

.g/mL/h (placebo) and .g/ mL/h (Outox).

In addition signif‌icant variances in the decrease of alcohol concentr a-

tion were observed among the volunteers, the refore individuals cannot

be sure if and to what extent Outox can possibly diminish their pe r-

sonal alcohol concentration. Consequently the claim of Outox being a

soberade cannot be proven from a scientif‌ic point of view.

. EFFECTS OF TRAUMA

The ef‌fects of trauma and its clinical treatment on the pharmacokin-

etics of alcohol are described in this sect ion. Since alcohol distributes

throughout TBW (approximately  L) and not just the blood volume

(approximately  L), the transfusion of blood () or other f‌luids

(, ) has no signif‌icant ef‌fect on BAC. The use of activated or

superactivated charcoal does not af‌fect BAC (, ).

  Wigmore on Alcohol

Reference Number: 

Studies of the elimination rates of patients being treated in hospita l

have shown that trauma patients generally eliminate alcohol at higher

rates. The elimination rate is decreased substantially if blood f‌low to

the liver is restricted (). Burn patients with hypermetabolism may

eliminate alcohol at a higher rate (). If blood samples are collected

from the arm receiving intravenous inf usions, the blood sample may be

diluted and cause an apparent decrease in the BAC ().

Reference Number: 

, .,  . . “The Course of the Blood Alcohol Curve in Men

after Blood Loss and Infusion of a Blood Substitute.” Acta Medicinae

Legalis et Socialis, : –,  ( f‌igures)

Abstract: A series of  tests was conducted on  male subjects (ages

– years). The subjects consumed an average of  mL of % v/v al-

cohol and  mL of beer within  hours, while eating bread rolls. BACs

were determined in blood and ranged from . to .g /mL. In 

subjects,  mL of blood was removed; in  subjects this was increa sed

to  mL. The amount of blood removed was % of the body weight,

equivalent to –% of the total blood volume. The removed blood was

infused back into the subjects severa l hours later. Also, in some subjects,

 mL of a blood volume substitute (Sterofundin) was infused after

the blood removal. None of the above conditions af‌fected the course of

the BAC curve. The rate of elimination of alcohol was determined to

be .–. g/mL/h, with a mea n of . g/ mL/h. Some

subjects were unaccustomed drin kers, and this large amount of alcohol

frequently caused nausea and vomiting, which produced long BAC pla-

teaus and absorption blockade.

Reference Number: 

, ., .  ,  . . “Intravenous Saline Has No Ef‌fect on Blood

Ethanol Clearance.” Journal of Emergency Medicine, : –,  (

f‌igures,  references)

Abstract: Five female and f‌ive male subjects (ages – years) con-

sumed .g/kg of eth anol after at least a -hour fast. Four days later,

the subjects consumed the same dose of etha nol but were administered

 L of saline IV. The rate of elimination of alcohol was determined by

breath samples collected every  minutes. The BrACs were determined

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

by an Alco-Sensor III. Linea r regression was used to determine the rate

of elimination. The rate of alcohol elimin ation was .g/mL/h

without saline IV and .g/mL/h wit h saline IV.

In summary, use of IV f‌luid therapy in alcohol-intoxicated patients is

commonplace and has several potential justif‌ications. Nevertheless

routine treatment of all intoxicated patients with IV f‌luids is potentially

dangerous since many of these patients may in reality be overhydrated,

hypophosphatemic, or have underlying alcohol-induced cardiomyop-

athy. Intoxicated patients who require f‌luid or nutritive replenishments

may be able to receive such replenishment by mouth. This study addi-

tionally demonstrates that IV f‌luids do not accelerate physiologic etha-

nol clearance rate.

Reference Number: 

, .., . , . ,  . . “Does Alcohol

Absorb to Activated Charcoal?” Human Toxicolog y, : –,  (

table,  f‌igure,  references)

Abstract: Alcohol poisoning is a common cause of morbidity and mor-

tality in industrialized countr ies. Alcohol is rapidly absorbed from the

gut and is absorbed poorly on activated charcoal; however, in , dogs

that were given ethanol at the same time as activated charcoal had sig-

nif‌icantly reduced BACs. In the abstracted study, eight healthy men

consumed  g of ethanol mixed with orange or pineapple juice in the

early morning on an empty stomach. T hirty minutes after consumption,

subjects also consumed either  g of activated charcoal as a slurry or

an equivalent volume of water. Blood samples were taken at , , ,

and  minutes and then every hour for  hours. PAC was measured

by GC. The mean elimination rate was .g/mL/h with charcoal

and .g/mL/h w ithout charcoal. There were no signif‌ica nt dif-

ferences in AUC with and without charcoal.

Table. Maximum PAC in Subjects with and without

Administration of Activated Charcoal

Subject

Number

Maximum PAC without

Activated Charcoal ( g/ mL)

Maximum PAC with Activated

Charcoal (g/ mL)

. .

. .

. .

  Wigmore on Alcohol

Reference Number: 

Subject

Number

Maximum PAC without

Activated Charcoal ( g/ mL)

Maximum PAC with Activated

Charcoal (g/ mL)

. .

. .

. .

. .

. .

Mean . .

Source: Adapted from Hulten et al. ( ).

Activated charcoal has no place in the treatment of alcohol poisoning.

Reference Number: 

, .., .. , .. , .. ,  . . “The Ef-

fect of Superactivated Charcoal and Magnesium Citrate Solution on

Blood Ethanol Concentrations and Area under the Curve in Humans.”

Clinical Toxicology, : –,  ( tables,  f‌igure,  references)

Abstract: Nine male subjects (ages – years) consumed .g/kg wit h-

in – minutes after a standard break fast. Blood samples were col-

lected via a heparin lock at ., , ., , , and  hours after ingestion,

and the BACs were determined by GC. One week later under identical

conditions, the subjects consumed  g of superactivated charcoal a nd

 mL of .% magnesium citrate solution at  hour after consump-

tion of alcohol. One subject consumed a second dose of the solution at 

hours. The mean peak BACs were .g/mL for the control group

and .g/mL for the superactivated charcoal group.

SAC [superactivated charcoal] showed a statistically signif‌icant ef‌fe ct

in decreasing the blood ethanol concentration at the  hour d etermina-

tion. It did not signif‌icantly af‌fect AUC or time to peak etha nol concen-

tration. Our data support s not using SAC [superactivated charcoal] or

AC [activated charcoal] in situations where ethanol is the lone ingested

substance.

Reference Number: 

, .,  . . “Rate of Clearance of Ethanol from the

Blood of Intoxicated Patients in the Emergency Department.” Journal

of Emergency Medicine, : –,  ( tables,  references)

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Abstract: A study was conducted of  intoxicated patients admitted to

an inner-city hospital in the United States; at least three blood samples

were collected from each patient. Forty-f‌ive percent of those admitted

had head and/or other trauma. The blood samples were collected on

average  hours apart (range .–. hours). The SACs were determined

by an enzymatic procedure. Two patients were excluded because a large

bolus ingestion of alcohol within  minutes prior to admission caused

the SACs to increase with time. T he mean rate of alcohol elimination

was .g/mL/h (range .–.g/mL/h).

We have determined the rate of ethanol clearance in an intoxicated

unselected population presenting to an inner cit y ED to be . ± .

mg/dL/h [. ± .g/mL]. While  mg/dL/h is a reproducible

mean, the ED physician should also keep in mind that the variation in

clearance rate is considerable (SD . mg/dL/h [.g/ mL/h]

in our study) and that only .% of the population will have clear-

ances between . and . mg/dL/h [. and .g/mL/h].

Therefore, if an accurate prediction of the rate of clearance is required,

it will be necessary to draw a second ethanol level af ter several hours

have elapsed. We f‌ind no justif‌ication for the measurement of liver, pan-

creatic or biliary function test s as a predictor of ethanol clearance in

these patients.

Reference Number: 

, .., . , . ,  . . “Ethanol Elimination

Rates in an ED Population.” American Journal of Emergency Medicine, :

–,  ( tables,  f‌igure,  references)

Abstract: A study of  intoxicated patients in which multiple breath

samples were collected over a period of .– . hours was conducted.

The BrACs were determined using an Intoxilyzer . The initial BrACs

were between . and .g /mL. The mean rate of elimination

for chronic alcohol users was .g/mL/h. The mean rate of elim-

ination for non-chronic alcohol users was .g /mL/h. There were

problems with the Intoxilyzer , and it required factory servicing.

The Intoxilyzer  was not suited for the rigors of daily ED use.

The rate of ethanol elimination in an ED population is . (% CI, .

to .) mg/dL/h, [.–.g/mL/h] corresponding closely to

  Wigmore on Alcohol

Reference Number: 

rates reported for other populations. Alt hough some clinical factors

have a statistical ef‌fect on elimination rate, their clinic al signif‌icance

appears small, and the prediction of ethan ol elimination was not shown

to be enhanced by consideration of other parameters.

Reference Number: 

, .., . , . , . , .-. ,  .-.

. “Arterial and Venous Alcohol Elimination in Ten Patient s with

Polytrauma/Shock.” Blutalkohol, : –,  ( table,  f‌igures,

 references)

Abstract: A study was conducted of the venous and arteria l BACs of  pa-

tients admitted to hospital with multiple injur ies and suf‌fering from hem-

orrhagic shock. Patients received up to  L of Ringer’s lactate solution and

 L of plasma IV. Blood samples were collected every hour, and BACs were

determined by GC and ADH methods. The mea n rate of alcohol elimina-

tion from venous and arterial blood was .g/mL/ h. BAC plateau s

occurred in one patient with total hepatic fai lure who died and in one

patient whose hepatic blood supply was interrupted during an operation.

There was a f‌lattening of the BAC cur ve at BACs less than .g/mL.

Back calculations of BAC can be conducted in patients who have multiple

injuries and hemorrhagic shock and are given f‌luids IV.

Table. Hourly Venous and Arterial BACs of Three Patients Who

Suf‌fered Polytrauma at – Hours after Admission to

Hospital

Cause of Injury in Pat ients,

and IV Fluids Administered

    Mean Venous

(Arterial) Rate of

Alcohol Elimination

(g/ mL/h)

Suicide attempt with a knife

 mL of Ringer’s lactate

at scene, additional ,  mL

of Ringer’s lactate,  unit s of

fresh frozen plasma,  units of

erythrocyte concentrates

.

(.)

.

(.)

.

(.)

.

(.)

. (.)

MVC, trapped in car

, mL of Ringer’s lactate ,

 mL of plasma

.

(.)

.

(.)

.

(.)

.

(.)

. (.)

Absorption, Distribution, and Elimination of Alcohol  

Reference Number: 

Cause of Injury in Pat ients,

and IV Fluids Administered

    Mean Venous

(Arterial) Rate of

Alcohol Elimination

(g/ mL/h)

Fall from f‌irst storey of a building

 units of fresh frozen plasma,

 erythrocy te concentrates,

, mL of Ringer’s lactate

.

(.)

.

(.)

.

(.)

.

(.)

. (.)

Source: Adapted from Kleeman n et al. ().

Reference Number: 

, .., . , . ,  .. . “The Ef‌fect of

Hypermetabolism Induced by Burn Trauma on the Ethanol-Oxidizing

Capacity of the Liver.” Critical Care Medicine, : –,  (

table,  f‌igures,  references)

Abstract: Eight burn patients (ages – years) suf‌fering from burns

to –% of the total body surface area and nine healthy ma le subjects

(ages – years) were administered .–.g/kg of alcohol IV over 

hour. Frequent blood samples were collected from the cubital vein, and

SACs were determined by headspace GC. None of the patients had a

history of heavy alcohol consumption or liver disease. T he alcohol was

administered daily for the f‌irst week post-burn. The elimination rate

was calculated from the ratio of grams per kilog ram of alcohol admin-

istered and the time to a  SAC (assuming a zero-order elimin ation rate).

The mean rate of eliminat ion in the burn victims was .g/mL/h

(range .–.g/ mL/h) in the f‌irst day after the burn and in-

creased to .g/ mL/h (range .–. g/ mL/h) on day .

The rate of elimination in control subjects ranged between . and

.g/  mL/h (mean . g/ mL/h). After severe burn injur y,

oxygen consumption has been found to be increased in as soon as –

hours, reaching peak values – days post-burn. In addition, protein ca-

tabolism, urea genesis, lipolysis, a nd gluconeogenesis are increased, and

there is an extensive loss of water from the burned areas .

We conclude that the increased elimination of ethanol in burn patients

mainly ref‌lects an increased act ivity in the mitochondrial electron trans-

port chain. Clinically the elimination of ethano l may serve as a measure

of the oxidative metabolic capacity of the liver.

  Wigmore on Alcohol

Reference Number: 

Reference Number: 

, ., .. ,  . . “Dilution of Blood Collected for Med-

icolegal Alcohol Analysis by Intravenous Fluids.” Journal of Analytical

Toxicology, : –,  ( table,  references)

Abstract: Two case reports are presented of blood samples diluted by IV

in which there was admini stration of f‌luids in inebriated trauma victi ms.

In one case, a -year-old female driver had a BAC of .g /mL

in one blood sample and .g/mL in another. The second blood

sample was diluted, and the hemoglobin (Hb) concentration had de-

creased from . to .g/m L. In the second case, a -year-old in-

jured snowmobile driver had a BAC of .g/mL in a f‌irst sample,

which was reduced to .g /mL in a second. The Hb concentra-

tions were . and .g/mL, respectively.

The two reported cases show th e possibility of the dilution of the blood

sample by IV f‌luids, resulting in the lowering of the actual BAC . In order

to minimize this phenomenon blood samples sh ould be collected dis-

tally from the IV infusion or from the other arm.

Author	James G. Wigmore
Pages	1-74

Absorption, Distribution, and Elimination of Alcohol

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