Taken From: DrugScope, DPIC
Prepared by: Marguerite Scheid and Megan Karnes, University of
Cincinnati PharmD Candidates
Cincinnati Drug and Poison Control Center
Edited by: Ohio Resource Network
AWOL, Alcohol WithOut Liquid, is a new concept that has recently reached the
United States in which users get intoxicated through inhaling an alcoholic mist.
The inhalation device has been termed AWOL, a play on the military term for Absent
Without Leave. It originally appeared in Europe and Asia. The product is marketed by
Spirit Partners, Inc. and was introduced to the United States in August 2004, at the
Trust Lounge in New York City's Meat-Packing District.
These machines are now available for sale and distribution on the internet and
dealerships are being established in Florida, California, and New York. A single
user AWOL machine can be purchased for approximately $300.
AWOL consists of two components: an oxygen generator and a hand-held vaporizer. Tubes
from the generator attach to the vaporizer. The user chooses an 80-proof spirit
(i.e. vodka, whiskey), which is poured into the "diffuser capsule". Oxygen bubbles then
pass through the diffuser capsule and mix with the alcohol. A hand-held vaporizer
produces a fine alcoholic mist which is inhaled. The device is similar to a
nebulizer machine that is used for asthmatic breathing treatments.
AWOL promotes a sense of well being and a mild euphoria similar to consumption of
traditional alcoholic drinks. The continual inhalation of this mist over a 20 minute
period is equivalent of taking one-half to one shot of distilled spirits.
Purchasers are encouraged to allow the use of the machine no more than twice in a 24 hour
period to avoid over consumption.
Besides being a new way to consume alcohol, marketers advertise AWOL as a way to
achieve the euphoric effects of alcohol while reducing calories and carbohydrates.
Through inhalation, the alcohol enters the bloodstream through the lungs rather than the
stomach. It is important to remember, however, that distilled spirits are
carb-free and there is no need to inhale them to avoid the carbs.
The marketers of AWOL also claim that using their device reduces the occurrence of
hangovers. Hangovers are thought to be caused by direct physiological effects of alcohol
on the brain, including inhibition of the release of vasopressin (anti-diuretic hormone)
which leads to increased urine output from the kidneys possibly causing dehydration and
electrolyte imbalance. The main metabolite of ethanol, acetaldehyde, and possibly fusel
oils contained in distilled spirits are also likely to play a role in hangover
production. The only real difference between drinking alcohol and using the
AWOL device is the means of getting the drug into the body. Once the alcohol enters
the bloodstream, it affects the body in the same way as drinking alcohol.
AWOL just bypasses oral absorption in favor of absorption via the lungs. It makes
just as much sense to claim that injecting alcohol directly into a vein reduces the
likelihood of getting a hangover.
Opponents of AWOL fear that it might lead to an increase in alcohol misuse, drunken
driving, and underage drinking. The possible health and safety risks of inhaling
alcohol vapors are unknown and many legislators are pushing to ban alcohol inhalation
machines. Michigan has made it illegal to possess, sell or use an AWOL machine, and as of
January 2007 sixteen other states have banned the device.
Another concern of AWOL opponents is that inhaled alcohol vapor may be absorbed into
the body more quickly through the blood vessels in the nose and the lungs, creating a
more intense effect. Some even go so far as to claim that the practice of inhaling
alcohol vapor could cause brain damage. However, there does not seem to be any good
evidence that AWOL would be worse for the brain than similar amounts of normally ingested
alcohol. Additionally, the possible local effects of inhaled alcohol on the lungs
are still unknown. It does seem reasonable to expect lung problems. Alcohol
is irritating to the stomach and therefore is likely to be irritating to the lungs as
well. Finally, inhaling alcohol may bypass a drinker's normal
methods of preventing overdrinking like the feeling of satiety associated with the liquid
form. When consuming alcohol traditionally, drinkers are able to titrate their
intake based on the feeling of stomach fullness. Inhaling the alcohol would
eliminate this feeling, potentially leading to over consumption.
Marketers have stated, "We are not aware of any current evidence to suggest that use
of the AWOL machine in accordance with the advice and instructions poses particular risks
to the user over and above the risks that may be posed by consuming an equivalent amount
of alcohol in an equivalent time period in a more traditional way."
There is no reason to think that this new route of administration for alcohol will be
safer or in any way better than the oral route. Marketers’ statements about current
evidence and use in accordance with the advice and instructions are without substance.
Once in widespread use, there is no reason to believe that the recommendation to use the
product no more than twice in 24 hours will be followed. Current evidence of safety
for an untested product not in wide use is of no real value, and allows the willing to be
guinea pigs in what is no more than an uncontrolled trial.
References
Alcohol Without Liquid. Wikipedia...http://www.wikipedia.org/ Accessed January 29, 2007
Alcohol Without Liquid: Has Science Gone AWOL? Drinking Report for Addiction Medicine.
2:2. March 1, 2006.
AWOL USA. Spirit Partners Inc. 2004. http://www.awolusa.com/
Campbell, Lynn. Opposition mounts to
alcohol inhalers. Des Moines Register, February 21, 2005
Diageo. Diageo Supports Ban on
"Alcohol Without Liquid" (AWOL) Machine. Diageo press release, January 26, 2005.
Suffolk County, NY: Ch. 214, Art
II. AWOL machines and Alcohol Vapor Devices.
Several recent literature reports
describe intoxication after misuse/abuse of hand sanitizer gels. These products
typically contain 60-95% ethanol along with a smaller percentage of isopropyl alcohol
(rubbing alcohol), water and other ingredients. These products are in widespread
use among the general public, in hospitals and even in prisons.
Two reports of abuse of hand
sanitizer gels in prisons have been published in the last several months. In a
letter to the editor in the New England Journal of Medicine, a normally calm prisoner was
found "red-eyed", "loony", "combative and intoxicated". The patient had been
seen by guards and other inmates drinking from an available gallon jug of a hand
sanitizer containing 62% ethanol by weight (approximately 70% by volume – 140
proof). His blood alcohol was measured at 335mg%. No other sources of alcohol were
available. He recovered uneventfully with supportive care. A second
letter in the same journal describes a similar intoxication in an individual who drank an
isopropyl alcohol based hand sanitizer gel while he was a patient in a hospital
Findings of hand sanitizer abuse
among prison inmates were also presented at the most recent North American Association of
Clinical Toxicology Annual meeting in early October 2006. This report describes
inmates using ordinary table salt to "break" the gel and produce "drinkable"
alcohol. The process involves placing about 4 ounces of hand sanitizer gel in a
sock, sprinkling a teaspoonful of table salt onto the gel and then straining the mixture
through the sock. The investigators used the recipe and within seconds,
produced a cloudy liquid that contained about 70% ethanol and 2% isopropyl alcohol by
volume. These investigators further surveyed prison staff in their state. Ethanol
containing hand sanitizer gel was readily available to inmates at 22% of the
institutions. 94% of prison staff were unaware of the abuse potential of these
products.
DPIC has received calls from prison
nurses and other health care providers about prisoners who have ingested disinfectant
sprays to get high. Some of these products contain as much as 80% ethanol. Using
the salt and filtering the liquid through a sock, clean or otherwise lends an air of
bartending to the procedure, but is an unnecessary step. Squirting the product
directly into the mouth will work, and is only a trifle less elegant. Perhaps most
surprising to a pharmacist and poison control specialist are the associated survey
results indicating that correction facility staff were unaware of the potential for abuse
of gel hand sanitizers.
References
Doyon S, Welsh C. New England
Journal of Medicine 2007 356(5) 529-530 Intoxication of a Prison Inmate with Ethyl
Alcohol-Based Hand Sanitizer
Emadi A, Coberly L. New England
Journal of Medicine 2007 356 (5) 530 – 531 Intoxication of a Hospitalized Patient
with and Isopropanol-Based Hand Sanitizer
Roche KM, Barko IR et al. Clinical
Toxicology 2006 44(5) 633-634 (Abstract) Hand Sanitizer Abuse
Vodka soaked tampons
Another rather odd ethanol
administration technique is the practice of soaking tampons in vodka and inserting them
vaginally. The practice is typically employed by teenage girls in the hope getting high
while avoiding detection by parents. Less commonly teenage boys and girls may
insert vodka soaked tampons rectally. Some of the attraction of the practice is
undoubtedly related to teenage sexuality, although there are no studies that address
this. Its chief attractions are likely to be the transportability of the dosage
form, and the abusing teen's perceived ability to deceive authority – parents,
others. The use of vodka soaked tampons is not particularly new and has never really had
a large following. There are good reasons that this practice has not become more
prevalent. However, DPIC has received several recent calls about this alcohol abuse
technique. It is possible that the form of alcohol abuse may be increasing.
A proposed benefit of the method
touted on the internet is that the abuser is able to get high while avoiding the stomach
upset associated with oral intake. It is true that vaginal or rectal administration of
alcohol will minimize the stomach irritation commonly associated with drinking.
However, putting what amounts to harsh chemicals – ethanol is an irritant solvent -
into the vagina or rectum trades brief exposure to the relatively protected
gastrointestinal tract for a more prolonged contact with the much more sensitive vaginal
or rectal mucosa. Considering the burning sensation typically associated with oral
ingestion of vodka, it is likely that vodka soaked tampons would cause significant
vaginal or rectal discomfort. In addition to the initial burning sensation, the
defatting and drying action of ethanol is likely to lead to prolonged discomfort and the
potential for bleeding during normal functioning.
Internet sites also suggest that
using vodka soaked tampons to get high prevents the smell of alcohol on the breath thus
further reducing the risk of parental detection. This idea is just not true. Alcohol is
partially eliminated from the body through the lungs. There is a constant ratio of
alcohol between blood alcohol concentration and the concentration of ethanol in expired
air. This is the basis of the breathalyzer test used during DUI arrests. Blood
alcohol sufficient to cause inebriation will be detectable in exhaled breath.
Absorption of medicines and
nutrients in the gastrointestinal tract occurs via passive diffusion across the
intestinal wall. The absorptive surface of the intestinal wall is very large due to
the presence of hair-like microvilli. It has been estimated that the absorptive area of
the small intestine is roughly equivalent to that of a football field. Absorption
of medicines or alcohol across the rectal and vaginal mucosa also depends on passive
diffusion but the surface area available is quite small. A few medicines meant to
treat systemic symptoms are available as rectal suppositories. However, absorption
via this route is less reliable than that associated with the oral route.
Systemic absorption of drugs across
the vaginal mucosa is known to occur, but medical literature documenting this is very
sparse. Ethanol is soluble in both water and fats so it is likely to be well
absorbed across the vaginal mucosa. However vaginal absorption of medicines in
general depends upon both the thickness of the vaginal mucosa and the composition of the
vaginal secretions, both of which vary over the course of the menstrual cycle. This is
one of the reasons that most medicines applied vaginally are used to treat topical
conditions of the vaginal mucosa, like yeast infections rather than systemic
conditions.
Pharmaceutical preparations meant
for vaginal use must be non-irritating and thick enough to remain in the vaginal
canal. As such they are always thickened creams, gels or suppositories. Even
these thickened products are poorly accepted because they are messy and tend to
leak. It is unlikely that even the most absorbent tampons would hold vodka
sufficiently to prevent leakage. Leakage is messy, reduces the amount of alcohol
available for absorption and increases the likelihood of detection by alert
parents.
References
Tampons: A new, dangerous way for
teenage girls to drink http://www.lehman.edu/provost /provostoffice/MLJ_211/mariacas
trowebpage/tampons.htmaccessed 3/28/07
Pizzute C: Self Administered alcohol (vodka) enema causing severe colitis: Case
Report and Review (letter) Gastrointestinal Endoscopy 2006 63(7) 1087-88
Hussain A, Ahsan F:. The vagina as a route for systemic drug delivery. J Control
Release. 2005 Mar 21;103(2):301-13. Review.
2007 By the Cincinnati Drug and Poison Information Center (DPIC) and the Cincinnati
Board of Health
Editors: Rob Goetz, PharmD, DABAT
Editorial Board: Earl Siegel, PharmD, Marc Lowy, MA, Rob Goetz, PharmD,DABAT
The Drug and Poison Information Center is a service of Cincinnati Children’s
Hospital Medical Center and is also supported by:
Hamilton County Mental Health and Recovery Services Board, the Ohio Department of
Alcohol & Drug Addiction Services, Health Resources Services
Administration, Ohio Department of Health, University of Cincinnati
Medical Center, Butler County Alcohol and Drug Services Board, , Akron
Children’s Hospital Medical Center and the Member Hospitals Systems
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