Absorption, distribution, and elimination of alcohol

AuthorJames G. Wigmore
Pages1-23
1

Absorption, Distribution, and Elimination
of Alcohol
The absorption, distribution, and elimination of alcohol, the focus of
this chapter, are also known a s the pharmacokinetics of alcohol. Phar-
macokinetics is basical ly the study of what the body does to a drug: how
the drug is absorbed, dis tributed, and metabolized by the various organs
of the body. Although the pharmacokinetics of alcohol has been d ivided
into the separate topics of absorption, distribution, and elimination, it
should be emphasized that these processes occur nea rly simultaneously
in the body.
When the absorption of alcohol is greater than the eli mination,
the blood alcohol concentration (BAC) increases. When absorption is
slowed down, such as with the ingestion of food, and absorption is equa l
to elimination, a plateau occurs in which the BAC apparently does not
change. When absorption is less tha n elimination, a decrease in the BAC
occurs that is basica lly linear until all the alcohol has been eliminated
from the body.
Absorption > Elimination → BAC Increases
Absorption = Elimination → BAC Plateaus
Absorption
If there is rapid absorption of alcohol from quick oral drink ing or
intravenous infusion, then distribution may lag behind absorption and
result in a signif‌icantly higher alcohol concentration in the arterial
blood than the venous blood (arteriovenous [AV] lag).
2The Abridged Wigmore on Alcohol
Reference Number: 
The typical drinking patter ns and pharmacokinetics of drinki ng
drivers are also discussed in this chapter, as well as the extrapolation
or back calculations of the BAC of the drin king driver to an earlier time.
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.
1.01 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: 10101
, ..,  . . “The Absorption of Ethyl Alcohol from
the Gastro-Intestinal Tract as a Dif‌fusion Process.” Acta Physiologica
Scandinavia, /: –, / ( tables,  f‌igures,  references)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol3
Reference Number: 
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, .. “The Simultaneous Emptying and Absorption of Ethanol from
the Human Stomach.” Digestive Diseases, : –,  ( tables,
 f‌igures,  references)
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, ., . , . , . , . ,  . .
“Gastric Emptying and Gastrointestinal Absorption of Alcohol Ingested
with a Meal.” Digestive Diseases and Sciences, : –,  ( f‌ig-
ures,  references)
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, .., .. ,  . . “Distribution of Ethanol in the
Human Gastrointestinal Tract.” American Journal of Clinical Nutrition,
: –,  ( f‌igures,  references)
Reference Number: 10105
, .. ., .. , .. ,  .. . “Gastric
Emptying in the Acutely Inebriated Patient.” Journal of Emergency
Medicine, : –,  ( tables,  references)
Reference Number: 10106
, ..,  .. . “The Ef‌fect of Food on Alcohol Absorption
and Elimination Patterns.” Journal of Forensic Sciences, : –,
 ( table,  f‌igures,  references)
Reference Number: 10107
, ., . ,  . . “Ef‌fects of Meal Composition
on Blood Alcohol Level, Psychomotor Performance and Subjective
State after Ingestion of Alcohol.” Appetite, : –,  ( tables,
 f‌igures,  references)
Reference Number: 10108
, ..,  . . “Evaluation of Blood-Ethanol Prof‌iles after Con-
sumption of Alcohol Together with a Large Meal.” Canadian Society of
4The Abridged Wigmore on Alcohol
Reference Number: 
Forensic Science Journal, : –,  ( tables,  f‌igures,  refer-
ence s)
Reference Number: 10109
, ., . , . ,  . . “The Ef‌fects of Carbon
Dioxide in Champagne on Psychometric Performance and Blood-
Alcohol Concentration.” Alcohol and Alcoholism, : –,  (
table,  f‌igures,  references)
Reference Number: 10110
, .,  .. . “Alcohol Concentration and Carbonation
of Drinks: The Ef‌fect on Blood Alcohol Levels.” Journal of Forensic and
Legal Medicine, : –,  ( tables,  f‌igures,  references)
Reference Number: 10111
, .., .. , .. , .. ,  . .
“The Inf‌luence of Temperature on Alcohol Absorption Rates in Humans.”
Military Medicine, : –,  ( f‌igure,  references)
Reference Number: 10112
, .,  .  . “The Ef‌fects of Salty and Nonsalty Food
on Peak Breath Alcohol Concentration and Divided Attention Task
Performance in Women.” Substance Abuse, : –,  ( table,
 references)
Reference Number: 10113
, .., .. , ..  ., . , . ,  ..
. “Comparison of Blood Alcohol Concentrations after Beer and
Whi skey.” Alcoholism: Clinical and Experimental Research, : –,
 ( table,  f‌igure,  references)
Reference Number: 10114
, ., . ,  .. . “Faster Absorption of Etha-
nol and Higher Peak Concentration in Women after Gastric Bypass
Sur gery.” British Journal of Clinical Pharmacology, : –,  (
table,  f‌igure,  references)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol5
Reference Number: 
Reference Number: 10115
, .., . ,  . . “Blood Ethanol Levels following
Rapid Intravenous Infusion.” Quarterly Journal of Studies on Alcohol :
–,  ( f‌igures,  references)
Reference Number: 10116
, ..,  .. . “Intravenous Injection of Alcohol by Drug
Injectors: Report of Three Cases.” Alcohol and Alcoholism, : –,
 ( references)
Reference Number: 10117
, .., .. ,  .. . “An Unusual Form of Fatal
Ethanol Intoxication.” Journal of Forensic Sciences, : –, 
( f‌igure,  references)
Reference Number: 10118
, .., . ,  .. . “Alcohol-Based Hand Sanitizer:
Can Frequent Use Cause an Elevated Blood Alcohol Level?” American
Journal of Infection Control, : –,  ( references)
Reference Number: 10119
, .. “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)
Reference Number: 10120
, .. “Inhalation of Ethanol Vapour: A Case Report and Experimental
Test Involving the Spraying of Shellac Lacquer.” Journal of the Forensic
Science Society, : –,  ( f‌igure,  references)
Reference Number: 10121
, ..,  .. . “Experimental Inhalation of Ethanol Va-
pou r.” Medicine, Science and the Law, : –,  ( tables,  f‌igures,
 references)
6The Abridged Wigmore on Alcohol
Reference Number: 
Reference Number: 10122
, .,  .. . “Blood Alcohol Concentrations following
the Inhalation of Ethanol Vapour under Controlled Conditions.” Jour-
nal of the Forensic Science Society, : –,  ( tables,  f‌igure,
 references)
Reference Number: 10123
, ., . ,  . . “Drunken by a Bath in Champagne?
Error: No Relevant Ethanol Absorption through Intact Skin.” Blutalko-
hol, : –,  ( table,  f‌igures,  references)
Reference Number: 10124
, .., .. ,  .. . “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)
1.02 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.
The distribution of alcohol throughout the body after it is consumed
orally is as follows:
Stomach/small intestines → Liver → Right side of heart → Lungs → Left
side of heart → Body tissues (including th e brain) → 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
Chapter 1: Absorption, Distribution, and Elimination of Alcohol7
Reference Number: 
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 c ases.
Reference Number: 10201
, ...,  . . “Comparison of DO and Ethanol Dilutions
in Total Body Water Measurements in Humans.” Clinical Investigator,
: –,  ( tables,  f‌igures,  references)
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, .., .. ,  .. . “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)
Reference Number: 10203
, .., . ,  .. . “Overshoot of Ethanol in the
Blood after Drinking on an Empty Stomach.” Alcohol and Alcoholism,
: –,  ( tables,  f‌igures,  references)
Reference Number: 10204
, .., . ,  .-. . “Magnitude and Time-Course
of Arterio-venous Dif‌ferences in Blood-Alcohol Concentration in
Healthy Men.Clinical Pharmacokinetics, : –,  ( tables,
 f‌igures,  references)
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, .., . ,  .. . “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)
8The Abridged Wigmore on Alcohol
Reference Number: 
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, .,  .. . “Ethanol in Human Brain by Magnetic
Resonance Spectroscopy: Correlation with Blood and Breath Levels,
Relaxation, and Magnetization Transfer.” Alcoholism: Clinical and Ex-
perimental Research, : –,  ( tables,  f‌igures,  refer-
ence s)
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, .., . , .. , . , . , . ,
 .. . “Spectroscopic Imaging of the Uptake Kinetics
of Human Brain Ethanol.” Magnetic Resonance Medicine, : –,
 ( table,  f‌igures,  references)
1.03 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:
CHCHOH → CHCHO → CHCOOH → CO+ HO
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 t he rates of alcohol elimination
over time, a single drink ing test conducted to determine an individual ’s
precise rate of alcohol elimin ation is not forensica lly appropriate ().
Chapter 1: Absorption, Distribution, and Elimination of Alcohol9
Reference Number: 
Reference Number: 10301
, ., . , . , .. ,  . . “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)
Reference Number: 10302
, ..,  . . “Kinetics of Ethanol and Methanol in
Alcoholics during Detoxif‌ication.” Alcohol and Alcoholism, : –,
 ( table,  f‌igures,  references)
Reference Number: 10303
, .., .. , .. , .. ,  .. . “Inter- and
Intra-subject Variability in Ethanol Pharmacokinetic Parameters: Ef-
fects of Testing Interval and Dose.” Forensic Science International, :
–,  ( tables,  f‌igures,  references)
Reference Number: 10304
, .., . , . , . ,  .. .
“Eating a Meal Increases the Clearance of Ethanol Given by Intrave-
nous Infusion.” Alcohol and Alcoholism, : –,  ( table, 
f‌igures,  references)
Reference Number: 10305
, ., . , . , . , . , . , 
.-. . “Ethanol Elimination Rates in Men and Women in Con-
sideration of the Calculated Liver Weight.” Alcohol, : –, 
( table,  f‌igure,  references)
Reference Number: 10306
, ., . , . , . ,  .. . “A Re gress ion
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)
10The Abridged Wigmore on Alcohol
Reference Number: 
Reference Number: 10307
, .. “Dietary Inf‌luences on Ethanol Metabolism.” Drug-Nutrient
Interactions, : –,  ( tables,  f‌igure,  references)
Reference Number: 10308
, .,  . . “On the Ef‌fect of Muscular Exercise on the
Metabolism of Ethyl Alcohol.” Scandinavian Archives of Physiology, :
–,  ( tables,  f‌igures,  references)
Reference Number: 10309
, .., .. , .. ,  . . “Observations on the
Metabolism of Alcohol in Man.” British Journal of Nutrition, : –,
 ( tables,  references)
Reference Number: 10310
, .., . ,  . . “Measurement of Total Body
Water in Patients on Maintenance Hemodialysis Using an Ethanol Di-
lution Technique.Nephron, : –,  ( tables,  f‌igures, 
references)
Reference Number: 10311
, ..,  .. . “Pharmacokinetics of Ethanol in Patients with
Renal Failure before and after Hemodialysis.Forensic Science Inter-
national, : –,  ( table,  f‌igures,  references)
Reference Number: 10312
, .,  .. . “Liver Disease, Hepatic Alcohol Dehydro-
genase Activity, and Alcohol Metabolism in the Human.” Gastroenter-
ology, : –,  ( tables,  f‌igures,  references)
Reference Number: 10313
, .. “The Ef‌fect of Liver Disease on the Rate of Ethanol Metab-
olism in Man.” Gastroenterology, : –,  ( table,  f‌igure, 
references)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol11
Reference Number: 
Reference Number: 10314
, .. “First-Pass Metabolism of Ethanol in the Human Stomach: A
Negligible Reaction.” Biochemical Archives, : –,  ( table,
 references)
Reference Number: 10315
, .-., .-. , .-. , .-. , .-. , .-. ,  .-. .
“No Sex and Age Inf‌luences on the Expression Pattern and Activities
of Human Gastric Alcohol and Aldehyde Dehydrogenases.” Alcohol-
ism: Clinical and Experimental Research, : –,  ( tables, 
f‌igures,  references)
Reference Number: 10316
, ., . , . ,  .-. . “The Inf‌luence of
Luteal and Follicular Phases on Major Pharmacokinetic Parameters
of Blood and Breath Alcohol Kinetics in Women.” Alcohol, : –,
 ( tables,  f‌igures,  references)
1.04 PHARMACOKINETICS OF DRINKING DRIVERS
The pharmacoki netics of drinking drivers can be determined by the fol-
lowing:
Observations or sur veys of actual dri nking patterns
Real istic laborator y drink ing tests of consu mption of alcohol over
a period of hours
Multiple blood samples from drink ing drivers
Multiple breath samples from drinking drivers over a prolonged
period of time
Blood and urine sa mples from drinking d rivers
Postmortem blood and urine samples from drinking 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 cour t.
This allows for the forensic validity of presumptions, or time of testing
laws and the back calculations of BAC.
12The Abridged Wigmore on Alcohol
Reference Number: 
Reference Number: 10401
, ..,  .. . “Drinking Establishment, Driving Risk, and
Ethno-pharmacology.” Proceedings of 35th International Congress on
Alcohol and Drug Dependence (Vol. ), Oslo, Norway,  ( tables, 
f‌igures,  references)
Reference Number: 10402
, .., . ,  . . “Gender Comparison of Alcohol Exposure
on Drinking Occasions.” Journal of Studies on Alcohol, : –,
 ( tables,  f‌igures,  references)
Reference Number: 10403
, ..,  .. . “Alcohol Accumulation in Humans after
Prolonged Drinking.” Clinical Pharmacology and Therapeutics, : –,
 ( f‌igures,  references)
Reference Number: 10404
, ..,  .. . “Evaluation of Breath Alcohol Prof‌iles
following a Period of Social Drinking.” Canadian Society of Forensic
Science Journal, : –,  ( tables,  f‌igures,  references)
Reference Number: 10405
, .., ..  ,  .. . “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)
Reference Number: 10406
, .. “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)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol13
Reference Number: 
Reference Number: 10407
, .,  .. . “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)
Reference Number: 10408
, ..,  .. . “Comparing Roadside with Subsequent
Breath Alcohol Analyses and Their Relevance to the Issue of Retro-
grade Extrapolation.” Forensic Science International, : –, 
( table,  f‌igures,  references)
Reference Number: 10409
, .. “Ethanol Distribution Ratios between Urine and Capillary
Blood in Controlled Experiments and in Apprehended Drinking Driv-
ers .” Journal of Forensic Sciences, : –,  ( tables,  f‌igures, 
references)
Reference Number: 10410
, ..,  .. . “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)
Reference Number: 10411
, .,  .. . “Status of Alcohol Absorption in Drinking
Drivers Killed in Trac Accidents.Journal of Forensic Sciences, : –,
 ( table,  references)
1.05 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 drin k-
ing drivers. The use of a plateau to allow for the variability of breath
alcohol analysis (, ) to prevent the possibility of a falsely high
14The Abridged Wigmore on Alcohol
Reference Number: 
eBAC () as well as the use of a range of possible rates of elimination
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 pharmacoki netic point of view (, ).
Reference Number: 10501
, .. “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)
Reference Number: 10502
, . “The Rate of Disappearance of Blood Alcohol in Drunken Drivers.”
Blutalkohol, : –,  ( table,  f‌igure,  references)
Reference Number: 10503
-, ., . , . , . , .. ,  ..
. “Ethanol Kinetics: Extent of Error in Back Extrapolation
Procedures.” British Journal of Clinical Pharmacology, : –, 
( tables,  f‌igures,  references)
Reference Number: 10504
, .., .. ,  .. . “Backtracking Booze with
Bayes The Retrospective Interpretation of Blood Alcohol Data.”
British Journal of Clinical Pharmacology, : –,  ( tables, 
f‌igures,  references)
Reference Number: 10505
, ..,  .. . “Estimation of Blood Alcohol Concen-
trations after Social Drinking.” Journal of Forensic Sciences, : –,
 ( tables,  f‌igures,  references)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol15
Reference Number: 
Reference Number: 10506
, .. “Considering Measurement Variability when Performing
Retrograde Extrapolation of Breath Alcohol Results [Letter].” Journal
of Analytical Toxicology, : –,  ( f‌igure,  references)
Reference Number: 10507
, .. “Employing Simulated Data to Illustrate an Important
Cause of the ‘Steepling’ Ef‌fect in Breath Alcohol Analysis.” Medicine,
Science and the Law, : –,  ( table,  f‌igure,  references)
Reference Number: 10508
, .., . , . ,  .. . “Physiological
Variations in Blood Ethanol Measurements during the Post-absorptive
State.” Journal of the Forensic Science Society, : –,  ( table,
 f‌igures,  references)
1.06 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) calculations,
named after the Swedish scientist E.M.P. Widmark. His research on
alcohol was published mainly in the s and s in German . The
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 (ratio 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 ().
16The Abridged Wigmore on Alcohol
Reference Number: 
Another problem with calculating BAC from a drinking scenar io
is that alleged drinking patterns from drinking 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: 10601
, ... “The Estimation of Widmark’s Factor.Journal of the For-
ensic Science Society, : –,  ( table,  references)
Reference Number: 10602
, .., .. ,  . . “An Evaluation of the Reliability of
Widmark Calculations Based on Breath Alcohol Measurements.” Jour-
nal Forensic Sciences, : –,  ( table,  f‌igures,  references)
Reference Number: 10603
, ..,  .. . “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)
Reference Number: 10604
, .., .. ,  .. . “Predictions of Blood Alcohol
Concentrations in Human Subjects. Updating the Widmark Equation.”
Journal of Studies on Alcohol, : –,  ( f‌igures,  references)
Reference Number: 10605
, .., .. ,  .. . “The Course of the Blood-Alcohol
Curve after Consumption of Large Amounts of Alcohol under Realis-
tic Conditions.” Canadian Society Forensic Science Journal, : –,
 ( tables,  f‌igure,  references)
Reference Number: 10606
, ..,  ... . “Are Retrospectively Reconstructed Blood
Alcohol Concentrations Accurate? Preliminary Results from a Field
Chapter 1: Absorption, Distribution, and Elimination of Alcohol17
Reference Number: 
Stu dy.” Journal of Studies on Alcohol, : –,  ( f‌igure, 
references)
Reference Number: 10607
, .., .. , .. , . ,  . .
“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)
Reference Number: 10608
, .., .. ,  .. . “A Comparison of Blood
Alcohol Concentrations Estimated from Drinking Histories of Drivers
Charged with Over  and Their Intoxilyzer C Results.” Can-
adian Society of Forensic Science Journal, : –,  ( table, 
f‌igures,  references)
Reference Number: 10609
, .. “Are a Blood Alcohol Concentration of  mg/dL and Min-
imal Signs of Impairment Reliable Indications of Alcohol Depend-
ence?” Medicine Science and the Law, : –,  ( references)
Reference Number: 10610
, . “A Survey of Hand-Poured Measures of Spirit.Science and
Justice, : –,  ( tables,  f‌igure)
1.07 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 are 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.
18The Abridged Wigmore on Alcohol
Reference Number: 
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 eliminat ion ().
Reference Number: 10701
, .., . , .. , .. , .. , . ,
 ... . “Lack of Ef‌fect of H-Receptor Antagonists on
the Pharmacokinetics of Alcohol Consumed after Food at Lunchtime.”
British Journal Clinical Pharmacology, : –,  ( table,  f‌igure,
 references)
Reference Number: 10702
, ., . , . , . , . , . ,
 . . “Interaction of H-Receptor Antagonists (Cimetidine
and Ranitidine) and High Blood Alcohol Concentrations. Experiment-
al Investigations.” Blutalkohol, : –,  ( tables,  f‌igures, 
references)
Reference Number: 10703
, ..,  ... . “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)
Reference Number: 10704
, ., . ,  . . “Ethanol Elimination in Man
under the Inf‌luence of Frequently Prescribed Beta Receptor Blockers.
Blutalkohol, : –,  ( tables,  f‌igures,  references)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol19
Reference Number: 
Reference Number: 10705
, .., .. ,  .. . “Ef‌fect of -Methyl-
pyrazole on Ethanol Elimination Rate and Hepatic Redox Changes in
Alcoholics with Adequate or Inadequate Nutrition and in Nonalcoholic
Controls.” Metabolism, Clinical and Experimental, : –,  (
table,  f‌igures,  references)
Reference Number: 10706
, ., .. , .. , .. , .. , .. ,
 .. . “Kinetic Interactions between -Methylpyrazole
and Ethanol in Healthy Humans.” Alcoholism: Clinical and Experimen-
tal Research, : –,  ( tables,  f‌igures,  references)
Reference Number: 10707
, .., . , . , . , . , . ,
 . . “The Interaction of the Lipase Inhibitor Orlistat with
Ethanol in Healthy Volunteers.European Journal Clinical Pharmacol-
ogy, : –,  ( tables,  f‌igure,  references)
Reference Number: 10708
, ., . ,  .. . “Acute Ef‌fects of Maprotiline,
Doxepin and Zimeldine with Alcohol in Healthy Volunteers.Archives
International Pharmacodynamics, : –,  ( tables,  f‌igures,
 references)
Reference Number: 10709
, ., . , . , . -,  . .
“Ciprof‌loxacin Decreases the Rate of Ethanol Elimination in Humans.”
Gut, : –,  ( tables,  f‌igures,  references)
Reference Number: 10710
, ., .. ,  .. . “Impact of Gastric Empty-
ing on the Pharmacokinetics of Ethanol as Inf‌luenced by Cisapride.”
British Journal of Clinical Pharmacology, : –,  ( f‌igures, 
references)
20The Abridged Wigmore on Alcohol
Reference Number: 
Reference Number: 10711
, .., .-. , . ,  . . “Interaction
of Alcohol and Transdermally Administered Scopolamine.” Journal of
Clinical Pharmacology, : –,  ( tables,  f‌igures,  refer-
ence s)
Reference Number: 10712
, ., . ,  .. . “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)
Reference Number: 10713
, .., .. , .. , . ,  .. . “Inter-
action of Sted-eze, Nikethamide, Pipradrol, or Ammonium Chloride
with Ethanol in Human Males.” Alcoholism: Clinical and Experimental
Research, : ,  ( tables,  f‌igures,  references)
Reference Number: 10714
, ., .. ,  .. . “Ef‌fect of Methylene
Blue on the Disposition of Ethanol.” Alcohol and Alcoholism, : –,
 ( f‌igures,  references)
Reference Number: 10715
, .., .. ,  . . “Failure to Demonstrate an Increased
Removal of Alcohol from the Blood Stream by Fructose.” Medicine Sci-
ence and the Law, : –,  ( f‌igure,  references)
Reference Number: 10716
, ., . , . , . , . , . ,
 . . “Inecacy of Oxygenated Drinking Water in Accel-
erating Ethanol Elimination in Humans.Life Sciences, : –,
 ( table,  references)
Chapter 1: Absorption, Distribution, and Elimination of Alcohol21
Reference Number: 
Reference Number: 10717
, ., . ,  . . “Ethanol Elimination in Man under the
Inf‌luence of Hepatoprotective Silibinin.Blutalkohol, : –, 
( f‌igure,  references)
Reference Number: 10718
, .., .. ,  . ’. “A Natural Sobriety Enzyme:
A Party Pill or Snake Oil?” Veterinary and Human Toxicology, : –,
 ( f‌igures,  references)
Reference Number: 10719
, .., ..  , . ,  ...  -.
“Ef‌fects of Energy Drink Ingestion on Alcohol Intoxication.” Alcohol-
ism: Clinical and Experimental Research, : –,  ( table, 
f‌igures,  references)
Reference Number: 10720
, ., . , . , . , . ,  . .
“Another Soberade on the Market: Does Outox Keep Its Promise?”
Wiener Klinische Wochenschrift, (–): –,  ( tables,  f‌ig-
ures,  references)
1.08 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 (, ).
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 hypermet abolism may
eliminate alcohol at a higher rate (). If blood samples are collected
22The Abridged Wigmore on Alcohol
Reference Number: 
from the arm receiving intravenous inf usions, the blood sample may be
diluted and cause an apparent decrease in t he BAC ().
Reference Number: 10801
, .,  . . “The Course of the Blood Alcohol Curve in Men
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Chapter 1: Absorption, Distribution, and Elimination of Alcohol23
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