**3.5 Alcohol Use:**

Definition of alcohol

Chemical composition of alcohol

Sources of alcohol and average consumption per capita

Pharmacological effects of alcohol

Symptoms, signs and performance effects of alcohol consumption

FAA alcohol testing program for aviation personnel

FAA regulations concerning the use of alcohol

Rehabilitation of the alcoholic pilot

**[Definition of alcohol]{.underline}:**

A clear, colorless liquid rapidly absorbed from the gastrointestinal
tract and distributed throughout the body. It has bactericidal activity
and is used often as a topical disinfectant. It is widely used as a
solvent and preservative in pharmaceutical preparations. The chemical
formula of alcohol is C~2~H~5~OH

**[One drink equals one 12-ounce bottle of beer or wine cooler, one
5-ounce glass of wine, or 1.5 ounces of 80-proof distilled
spirits.)]{.underline}**

**Alcohol is the product of the fermentation of
[starches](http://www.1uphealth.com/health/carbohydrates_info.html) and
[sugars](http://www.1uphealth.com/health/carbohydrates_info.html). It is
a colorless, volatile, flammable liquid. Beer, wine, and distilled
liquors (such as whisky, vodka, rum, and gin) are common dietary sources
of alcohol**.

Humans can be exposed to ethanol by ingestion of foods, flavorings,
beverages, in pharmaceuticals. Indkustrial exposures include the
manufacture of ethanol, use as a solvent, or release as a product of
fermentation, decomposition or combustion (including cigarette smoking).

The proportion of 12- to 20-year-olds who drink was estimated to be
50.0% using data from the YRBS (Youth Risk Behavior Survey: The National
Center on Addiction and Substance Abuse at Columbia University) the
proportion of adults aged 21 or older who drink was estimated to be
52.8%. The estimated total number of drinks consumed per month was 4.21
billion; underage drinkers consumed 19.7% of this total. The amount of
adult drinking that was excessive (\>2 drinks per day) was 30.4%.
Consumer expenditure on alcohol in the United States in 1999 was \$116.2
billion; of that, \$22.5 billion was attributed to underage drinking and
\$34.4 billion was attributed to adult excessive drinking. These data
suggest that underage drinkers and adult excessive drinkers are
responsible for 50.1% of alcohol consumption and 48.9% of consumer
expenditure.

**[PHARMACOLOGICAL EFFECTS OF ALCOHOL]{.underline}**

Some characteristic features of persons consuming and abusing alcohol
are:

Craving\--A strong need, or urge, to drink.

Loss of control\--Not being able to stop drinking once drinking has
begun.

Physical dependence\--Withdrawal symptoms, such as nausea, sweating,
shakiness, and anxiety after stopping drinking

Tolerance\--The need to drink greater amounts of alcohol to get
\"high.\"

At a blood level of 20-99 mg/100 ml the following physiologic effects
can be noted:

Reduced visual acuity (flicker-fusion test)

Decreased sense of smell and taste.

Elevated threshold for pain

Decreased sensitivity of cornea of eye

Decreased sensitivity to local heating of skin

Changes in mood, personality, and behavior

Dizziness

Reduced sense of fatigue

Mild euphoria

Self satisfaction

Release of inhibitions

Loud, profuse speech

Impaired mental activity (Subtraction test, reading comprehension tests)

The threshold level that impairs automobile driving skill is about 35
mg/100 ml/dl)

**At blood alcohol levels of 100-199 mg/100 ml** staggered gait, marked
impairment on mental tests, marked impairment of driving ability, and
lengthened reaction time are also seen.

**At 200-299 mg/100 ml** nausea and vomiting, diploplia, marked ataxia,
and extreme clumsiness can be experienced.

**At 300-399 mg/100 ml/dl** hypothermia, cold, clammy skin, loss of
ability to speak, amnesia, anesthesia, and heavy breathing appear and
there is a change in cerebral blood flow, metabolism, vascular
resistance, and cerebral oxygen uptake is much reduced. Cerebral oxygen
uptake is much reduced.

**When blood levels surpass 400 mg/100 ml** a deep coma is possible. If
the coma persists fo 8 to 10 hr, or if blood levels ae high enough,
shock and circulatory collapse may develop, causing death.

In severe acute intoxication patients are stuporous or comatose. Skin is
cold & clammy, body temp is low, respirations are slow & noisy, pupils
may be normal or dilated and heart rate is accelerated. If this
condition persists for 8 or 10 hr. hypostatic pneumonia or increased
intracranial pressure may ensue.

Alcohol ingestion impairs glottic reflexes, and alcoholics are
predisposed to pneumonias and lung abscesses from aspiration of
oropharyngeal bacteria. Intoxication also increases the frequency of
sleep apnea and may result in respiratory failure from oversedation.

Acute alcohol ingestion can lead to alterations of either mechanical
function or electrophysiologic properties of the heart, whereas chronic
consumption can lead to progressive cardiac dysfunction and congestive
cardiomyopathy.

In modest doses, alcohol has the potential of producing atrial or
ventricular arrhythmias. There are reports of patients with no evident
heart disease developing arrhythmias as a result of acute alcohol
ingestion. This sequence of events, (i.e., cause and effect), has been
referred to as the \"holiday heart\" syndrome.

Pathologic effects of ethanol on hematopoietic tissue can result
directly from ingestion or from secondary nutritional deficiencies or
hepatic disease. The clinician will often confront an array of
overlapping syndromes in the alcoholic patient which involve
abnormalities of erythrocytes, leukocytes, and platelets.

The acute and chronic effects of alcohol ingestion on pancreatic
structure and function can lead to acute necrotizing, acute edematous,
acute relapsing, chronic relapsing, and painless pancreatitis.

Four cases of chronic alcoholic patients who developed oscillopsia
(illusory movement of the environment) with downbeat nystagmus,
associated with ataxia of gait and cerebellar atrophy have been
reported.

Alcohol intereferes with several aspects of folic acid
metabolism/transport as well as its normal pattern of storage and
hepatic release. Other effects include thrombocytopenia and
vacuolization of RBC and WBC precursors, depressing the leukocyte
migration into inflamed areas which may, in part, account for the poor
resistance of alcoholics to infection.

*Fetal alcohol syndrome, though not the subject of this piece, is
noteworthy inasmuch as the abnormality consists of CNS dysfunction (such
as low IQ and micrencephaly), slowness in growth, a characteristic
cluster of facial abnormalities, such as short palpebral fissures,
hypoplastic upper lip and short nose, and a variable set of major and
minor malformations. These patients are more susceptible to life
threatening as well as minor infectious diseases due to, it is believed,
impairment of their immune system.*

**ALCOHOL WITHDRAWAL:**

In patients with severe physical dependence, three somewhat distinct
withdrawal states occur. The **tremulous syndrome, seizure disorder and
delirium tremens** can occur with considerable overlapping Tremulousness
usually appears within a few hours after the last drink, and can be
accompanied by nausea, weakness, anxiety and sweating. There is often a
purposive behavior directed at obtaining alcohol or a suitable
substitute. Cramps, vomiting, hyperreflexia, along with prominent
tremors that may be so dramatic that a person would be unable to lift a
glass can develop. The individual may see things, at first only when the
eyes are closed, but later even when the eyes are open. At first the
patient remains oriented but tonic/clonic seizures can occur, albeit
less common during alcohol withdrawal than with barbiturate withdrawal.
Within 24-48 hours, tremulousness reaches its peak. Seizures are more
likely to occur after 24 hours from the last drink. Insight is lost, the
individual becomes progressively weaker, more confused, disoriented and
agitated. At this stage, around the third day, the picture of withdrawal
is that of delirium tremens, or "DTs". Hyperthermia is common in DTs and
exhaustion and cardiovascular collapse may occur. If the patient
survives, recovery usually occurs within 5-7 days.

**THE METABOLIC EFFECTS**

Metabolic effects are due to the direct action of ethanol or its
metabolites. Ethanol causes hyperglycemia or hypoglycemia, depending on
whether glycogen stores are adequate, inhibits protein synthesis and
results in a fatty liver with elevations in serum triglyceride levels.
Increases in high density lipoprotein cholesterol after alcohol
ingestion may explain the lower risk of myocardial infarction and death
from coronary disease after moderate drinking. Increases in serum
lactate, resulting from the increased NADH/NAD+ ratio, and
hyperurecemia, most likely the result of an increase in the turnover of
adenine nucleotides, are common transient effects of ethanol ingestion.
Causes of vitamin deficiencies in alcoholism are decreased dietary
intake, decreased intestinal absorption, and alterations in vitamin
metabolism. Ethanol decreases thiamine absorption and decreases the
enterohepatic circulation of folate. Acetaldehyde increases the
degradation of pyridoxal 5\'-phosphate by displacing it from its binding
protein and making it susceptible to hydrolysis by membrane bound
alkaline phosphatase.

Cirrhosis of liver, that occurs in 8% of chronic alcoholics in contrast
to 1% of abstainers and temporate drinkers may be in part due to
malnutrition.

Moderate amount of alcohol may stimulate or depress respiration,
ventilatory response to carbon dioxide is always depressed. With a large
amount (\>400 mg/dl) can produce dangerous or lethal respiratory
depression which can be fatal.

**EFFECTS IN THE GENITOURINARY SYSTEM:**

Low doses result in behavioral disinhibition. As the dose increases,
sexual response is impaired, resulting in failure of erection in males
and reduced vaginal vasodilation and delayed orgasm in females. Chronic
use has been associated with an 8% rate of impotence, one-half of which
was irreversible despite abstinence from alcohol. The chronic effects
are probably the result of both neurological and endocrine effects.
ethanol, in addition, has been shown to reduce testosterone levels and
increased luteinizing hormone levels. The chronic effects are
independent of liver disease.

**OTHER SPECIAL CIRCUMSTANCES TO BE CONSIDERED IN ALCOHOL CONSUMPTION**

For most adults, moderate alcohol use\--up to two drinks per day for men
and one drink per day for women and older people\--causes few if any
problems. **However**, **there are** c**ertain people at risk IF THEY
consume alcohol:**

Women who are pregnant or trying to become pregnant

People who plan to drive or engage in other activities that require
alertness and skill (such as using high-speed machinery)

People taking certain over-the-counter or prescription medications

People with medical conditions that can be made worse by drinking.

Recovering alcoholics.

Research shows that the risk for developing alcoholism does indeed run
in families. The genes a person inherits partially explain this pattern,
but lifestyle is also a factor. Currently, researchers are working to
discover the actual genes that put people at risk for alcoholism. Your
friends, the amount of stress in your life, and how readily available
alcohol also are factors that may increase your risk for alcoholism

Alcohol\'s effects do vary with age. Slower reaction times, problems
with hearing and seeing, and a lower tolerance to alcohol\'s effects put
older people at higher risk for falls, car crashes, and other types of
injuries that may result from drinking.

More than 150 medications interact harmfully with alcohol. These
interactions may result in increased risk of illness, injury, and even
death. Alcohol\'s effects are heightened by medicines that depress the
central nervous system, such as sleeping pills, antihistamines,
antidepressants, anti-anxiety drugs, and some painkillers. In
addition, medicines for certain disorders, including diabetes, high
blood pressure, and heart disease, can have harmful interactions with
alcohol.

Older people also tend to take more medicines than younger people.
**Mixing alcohol with over-the-counter or prescription medications can
be very dangerous**, **even fatal**. More than 150 medications interact
harmfully with alcohol.

In addition, alcohol may complicate many of the medical conditions
common in older people, including high blood pressure and ulcers.
Physical changes associated with aging can make older people feel
\"high\" even after drinking only small amounts of alcohol.

**Medical Surveillance:**

On physical examination, look for chronic irritation of mucous membranes
and signs of chronic alcoholism. Ethanol can readily be determined in
blood, urine, and expired air.

The determination of ethanol in blood, breath, or urine, sampled during
or just after the work period, can provide a useful index to workplace
exposures. The blood ethanol concentration should not exceed 200-300
mg/l in exposed workers. Pre-exposure specimens should be taken to rule
out nonoccupational sources of ethanol..

***[AVIATION FACTORS:]{.underline} GENERAL AIRCRAFT ACCIDENTS (FAA
\<40mg% (0.04)***

United Kingdom: 1345 fatalities \>50mg/% (0.05) ethanol with 8.7%, drugs
1.2% (50% within 18 min of take off, 50% with \<100 hours PIC.

US: 18% of fatal accidents, ethanol found but study considered only half
of those actually impaired

Dade County: Profiling the pilot in an ethanol related accident: single
engine, private trip, afternoon or early evening

**[FAA alcohol testing program for aviation personnel]{.underline}**

**If there is a verified positive drug test result acquired under an
anti-drug program or internal program of the U. S. DOT or any other
Administration within the U. S. DOT or misuse of a substance that the
Federal Air Surgeon, based on case history and appropriate, qualified
medical judgment relating to the substance involved finds that:**

**Makes the person unable to safely perform the duties or exercise the
privileges of the airman certificate applied for or held; or may
reasonably be expected, for the maximum duration of the airman medical
certificate applied for or held, to make the person unable to perform
those duties or exercise the privileges.**

**Use of a substance in which use was physically hazardous (e.g.
DUI/DWI) if there has been any other time an instance of the use of the
substance (including alcohol) also in a situation in which the use was
physically hazardous.**

**\[In 1989, the Department of Transportation in conjunction with the
FAA mandated an extensive urine drug testing program within the airline
industry. At the end of one year 2872 applicants tested positive under
these rules for a positive finding rate of 0.17%. 32,157 applicants were
also tested including those applying for DOT positions, with a positive
rate of 2.82%. Only two of the main drugs of abuse, that is marijuana
and cocaine (not alcohol) were tested\].**

**[FAA regulation concerning the use of alcohol]{.underline}**

**No substance abuse within the preceding [two years]{.underline}
defined as: use of a substance ("substance" includes alcohol) in which
that use was physically hazardous, if there had been any other time an
instance of the use of the substance also in a situation which that use
was physically hazardous.**

**"Substance dependence" means a condition in which a person is
dependent on a substance, other than tobacco or ordinary
xanthine-containing (e.g. caffeine) beverages as evidenced by:**

**Increased tolerance**

**Manifestation of withdrawal syndrome**

**Impaired control of use or**

**Continued use despite damage to physical health or impairment of
social, personal or occupational functioning**

Rehabilitation of the alcoholic pilot

Pilots drifting towards alcohol abuse can be detected earlier than
previously, due mainly to the acceptance of alcoholism as a treatable
disease. The fact that pilots are not summarily terminated from flying
encourages staff not to "cover" for the affected colleagues. Cooperation
of liaison between managements, unions, and staff combined with peer
pressure is a prerequisite for early detection and counseling of
alcoholic pilots. (Canadian study, Aviation Space Environmental
Medicine; July, 1983, 54(7):592-4).

Based on the data available from the National Council on Alcoholism and,
as mentioned above, encouraged by the "disease" status of the alcoholic
pilot, a responsive multidisciplinary approach was started b y United
Airlines in 1968 at their Maintenance Ops Center in San Francisco.
Again, as in the Canadian example above, the cooperation of management,
union and the medical department worked together to assist flight crews
to:

Identify, including intervention

Refer for treatment in a specialty hospital embracing the principles of
AA (Alcoholics Anonymous)

Follow-up monthly for 2 years

Recertification, when appropriate and if qualified.

(Aviation Space Environmental Medicine, Schwartz et al, May, 1978,
49(5):729-31).

For those individuals who are not working for commercial carriers, as
above, appropriate documentation, therapy and abstinence for at least 2
years is required. (See above)

*The above information has been taken from several sources. The
references can be obtained by way of the NIH's National Library of
Medicine database, more specifically the HSDB, or Hazardous Substances
Data Bank via [www.nlm.nih.gov](http://www.nlm.nih.gov/) In addition**,
Guide for Aviation Medical Examiners**, 1999 edition was also used as a
source of information.*.