Jonathan Ameli, MD
with Jason Hack, MD
Adsorbing ethanol to bulked sugar compounds called cyclodextrins that contain a hydrophobic cavity creates Powdered Alcohol (Palcohol), or anhydrous ethanol.
Mark Phillips of Lipsmark LLC, an Arizona entrepreneur, is the inventor of Palcohol. In April of 2014, his patent application was approved, but then rejected by the TTB (Alcohol and Tobacco Tax and Trade Bureau) due to a labeling error. Interestingly, a previous patent for ‘Alcohol-Containing Powder’ by William Mitchell of General Foods does exist dating back to 1974 . Nevertheless, on March 10, 2015, the patent for Palcohol was legitimately approved by the TTB. On March 12, 2015, several states banned powdered alcohol even before its official release scheduled for the summer of 2015. In a statement from March 13, 2015, the FDA (Food and Drug Administration) had not yet approved Palcohol, but they did not foresee any ‘legal basis to block market entry of the product.’
Palcohol is marketed as an ‘instant cocktail’ and includes several flavors. Each packet of powder contains 15 grams of ethanol, which is about equal to a standard drink after adding liquid.
Powdered alcohol has been criticized as a substance that will allow underage drinkers to gain easier access to ethanol. Senator Charles Schumer (D-NY) has stated Palcohol is the ‘Kool-Aid of teen binge drinking,’ and has led a campaign against the substance by introducing a bill that would ban it nationwide.
Powdered alcohol has been assessed as a hazardous substance likely because ethanol abuse is so prominent. NJ Assemblyman, Paul Moriarty said, ‘we have enough problems with alcohol and I don’t think we need a new delivery system.’
The consequences of alcohol abuse are rampant in North America, and internationally. Even household products such as mouthwash (about 20% alcohol by volume / ABV), cologne (40-60% ABV), and hand sanitizers (60-70% ABV) have been reported as abused substances. Alcohol-related visits to the Emergency Department (ED) are plentiful. At Rhode Island Hospital’s ED, there are at least 2300 alcohol intoxication visits per year, and this does not include alcohol-related visits that are combined with other diagnoses such as motor vehicle accident, or acute pancreatitis. On a national level, alcohol in combination with other drugs results in about 520,000 ED visits per year, and this is likely a gross underestimation. In a study that combined data from several emergency rooms in Australia and New Zealand at a single point of time at 2am on a weekend, about 15% of the total ED visits were related to alcohol. Finally, according to a 2011 study, almost 32.5% of trauma visits to Level 1 trauma centers in the US were correlated with alcohol intoxication. According to the CDC, all-cause alcohol-related mortality results in approximately 300 deaths per year in the state of Rhode Island, and about 88,000 deaths per year nationally. Finally, excessive alcohol consumption cost the United States about $223.5 Billion in 2006, or about $1.90 per drink.
Since anhydrous ethanol is in a powdered form, there has been concern that it may be snorted. Mark Phillips, the creator of Palcohol, has stated this is impractical because ‘it would take you an hour to ingest the equivalent of one drink,’ and that ‘it really burns.’ But as emergency physician, Dr. Ryan Stanton stated: ‘I’ll be interested to see what people do to make this dangerous…because I’m sure somebody will figure out a way to make this dangerous.’ Adolescents may be tempted to obtain attention and respect among their peers by engaging in physically dangerous activities. For example, the ‘pass-out challenge’ was popularized in 2012, and involved placing pressure on the trachea in order to induce brief euphoric hypoxia. Another challenge called the ‘cinnamon challenge,’ involves ingesting a scoop of cinnamon without liquid, obviously leading to choking, and aspiration. This does not prove that Palcohol will be snorted as the next Internet challenge, but the discussion alone on Palcohol’s website as well as the media attention on the subject of snorting will likely ignite some curious minds.
In addition, snorting any substance has been shown to be deleterious to the nasal mucosa. Cocaine snorting has been shown to induce nasal septal perforation and necrosis due to its vasoconstrictive effects. Many illicit substances are laced with adulterants such as borax and talcum powder that are very irritable to the delicate mucosa. In a case-series from 2013, even heroin snorting had been shown to be associated with orofacial lesions such as ulceration and necrosis, but this may be due to heroin being cut with various adulterants.
There is also the argument that powdered alcohol will be easier to sneak into public places where alcohol is prohibited. But as Mark Phillips states: ‘the bag is too big to conceal,’ and you could sneak almost four nips of vodka to occupy the same space in the Palcohol bag. On the other hand, the powder could be transferred to another instrument, such as a pocket.
Finally, there is the argument that powdered alcohol can be used to spike another person’s drink. Mark Phillips states that this is impractical because it would take more than 60 seconds to dissolve the powder in any drink whereas you could just pour a nip of vodka into it instead.
There could be real benefits to powdered alcohol. For one, it is an interesting product, and technically, it is legal under federal law since it is just ethanol and sugar in powdered form. Furthermore, we exist in a post-prohibition society, and we hold well-established rights as Americans in regards to ethanol consumption. Finally, anhydrous ethanol theoretically could be used for industrial (windshield wiper fluid, emergency fuel) and healthcare (anti-septic) purposes. Of course, flammability, weight when added to water, and other physical properties of powdered alcohol must be taken into consideration.
In conclusion, powdered alcohol, or Palcohol, is a unique vehicle of delivery for ethanol that has not yet been released in the United States. Ethanol in liquid form has been proven for decades to be one of the most dangerous, and easily abused intoxicating substances. Alcohol is also very safe when used in moderation. Whether the powdered form of the ethanol is hazardous for our youth, chronic alcoholics, and the general public, is up for heated debate.
According to combined 2011 and 2012 NSDUH (National Survey on Drug Use and Health) data, approximately 27 million young adults aged 18 to 25 drank alcohol in the past year (9 million of those aged 18 to 20), and this was much more common in comparison to ‘any illicit drug use,’ marijuana, or prescription pain relievers. In addition, according to a literature review of several studies completed in emergency departments, 15% of traumatic injuries tested positive for ethanol by saliva. This study included ages from 10 to 21 years old. Ethanol in liquid form is already accessible to the youth, and has the potential for abuse.
The peak absorption time for ethanol is about 30 to 120 minutes. Ethanol enhances GABA and blocks NMDA resulting in a global inhibitory response of the central nervous system. Elimination is mostly via the liver using alcohol dehydrogenase (ADH) as the main enzymatic pathway although alcoholics tend to recruit the CYP2E1 minor pathway to a higher extent resulting a faster metabolism of ethanol (ie: 30-40 mg/dl per hour vs. 15-20 mg/dl per hour in novice drinkers). Chronic alcoholism can result in cirrhosis, gastrointestinal bleeding, pancreatitis, hypoglycemia, poor nutrition and electrolyte abnormalities leading to atrial fibrillation, holiday heart cardiomyopathy, Wernicke-Korsakoff syndrome, and alcoholic ketoacidosis.
On a cellular level, several factors contribute to disease in alcoholics including protein synthesis inhibition, and a surplus of toxic metabolites such as acetaldehyde and reactive oxygen radicals. The NADH:NAD+ ratio is increased, which impairs gluconeogenesis and fatty acid metabolism leading to several metabolic derangements.
The Emergency Department evaluation for alcohol intoxication is a difficult task because the blood alcohol level (BAL) has not been shown to compare accurately with clinical signs of alcohol intoxication, especially with chronic alcoholics[11, 12]. Regardless, a BAL 50-100 usually results in an increase in talkativeness and relaxation, a BAL > 100 leads to ataxia and lack of coordination, a BAL > 200 usually leads to amnesia, dysarthria, diplopia, and finally, a BAL > 400 can result in respiratory depression, coma, and death. Blood alcohol levels can be higher with fewer clinical effects in chronic alcoholics. The use of the HII score (Hack-Impairment Index) is a 0-20 numeric scale used to assess the degree of impairment from alcohol intoxication by physical exam that does not rely on the BAL. The HII score includes components such as speech, cognition, gross motor function, nystagmus, and coordination, and it drops in a predictable manner over time.
The ED management of acute alcohol intoxication is mainly supportive. This includes monitoring for respiratory depression, preventing aspiration events, and in most cases, administering large volumes of crystalloid (if there are no contraindications), replacing nutrients such as thiamine, and behavioral control as needed. Always consider ruling out other etiologies for altered mental status such as head trauma even with a highly positive BAL.