The pharmacology of ethanol involves both pharmacodynamics (how it affects the body) and pharmacokinetics (how the body processes it). In the body, ethanol primarily affects the central nervous system, acting as a depressant and causing sedation, relaxation, and decreased anxiety. The complete list of mechanisms remains an area of research, but ethanol has been shown to affect ligand-gated ion channels, particularly the GABAA receptor.
After oral ingestion, ethanol is absorbed via the stomach and intestines into the bloodstream. Ethanol is highly water-soluble and diffuses passively throughout the entire body, including the brain. Soon after ingestion, it begins to be metabolized, 90% or more by the liver. One standard drink is sufficient to almost completely saturate the liver's capacity to metabolize alcohol. The main metabolite is acetaldehyde, a toxic carcinogen. Acetaldehyde is then further metabolized into ionic acetate by the enzyme aldehyde dehydrogenase (ALDH). Acetate is not carcinogenic and has low toxicity, but has been implicated in causing hangovers.'Is coffee the real cure for a hangover?' by Bob Holmes, New Scientist, Jan. 15 2011, p. 17. Acetate is further broken down into carbon dioxide and water and eventually eliminated from the body through urine and breath. 5 to 10% of ethanol is excreted unchanged in the breath, urine, and sweat.
History
Beginning with the Gin Craze, excessive drinking and drunkenness developed into a major problem for public health. In 1874, Francis E. Anstie's experiments showed that the amounts of alcohol eliminated unchanged in breath, urine, sweat, and feces were negligible compared to the amount ingested, suggesting it was oxidized within the body. In 1902, Atwater and Benedict estimated that alcohol yielded 7.1 kcal of energy per gram consumed and 98% was metabolized. In 1922, Widmark published his method for analyzing the alcohol content of fingertip samples of blood. Through the 1930s, Widmark conducted numerous studies and formulated the basic principles of ethanol pharmacokinetics for forensic purposes, including the eponymous Widmark equation. In 1980, Watson et al. proposed updated equations based on total body water instead of body weight. The TBW equations have been found to be significantly more accurate due to rising levels of obesity worldwide.
Pharmacodynamics The principal mechanism of action for ethanol has proven elusive and remains not fully understood. Identifying molecular targets for ethanol is unusually difficult, in large part due to its unique biochemical properties. Specifically, ethanol is a very low molecular weight compound and is of exceptionally low potency in its actions, causing effects only at very high (millimolar mM) concentrations. For these reasons, it is not possible to employ traditional biochemical techniques to directly assess the binding of ethanol to receptors or ion channels. Instead, researchers have had to rely on functional studies to elucidate the actions of ethanol. Even at present, no binding sites have been unambiguously identified and established for ethanol. Studies have published strong evidence for certain functions of ethanol in specific systems, but other laboratories have found that these findings do not replicate with different neuronal types and heterologously expressed receptors. Thus, there remains lingering doubt about the mechanisms of ethanol listed here, even for the GABAA receptor, the most-studied mechanism.
In the past, alcohol was believed to be a non-specific pharmacological agent affecting many neurotransmitter systems in the brain, but progress has been made over the last few decades. It appears that it affects ion channels, in particular ligand-gated ion channels, to mediate its effects in the CNS. In some systems, these effects are facilitatory, and in others inhibitory. Moreover, although it has been established that ethanol modulates ion channels to mediate its effects, ion channels are complex proteins, and their interactions and functions are complicated by diverse subunit compositions and regulation by conserved cellular signals (e.g. signaling lipids).
Alcohol is also converted into phosphatidylethanol (PEth, an unnatural lipid metabolite) by phospholipase D2. This metabolite competes with PIP2 agonist sites on lipid-gated ion channels. The result of these direct effects is a wave of further indirect effects involving a variety of other neurotransmitter and neuropeptide systems. This presents a novel indirect mechanism and suggests that a metabolite, not the ethanol itself, could cause the behavioural or symptomatic effects of alcohol intoxication. Many of the primary targets of ethanol are known to bind PIP2 including GABAA receptors, but the role of PEth needs to be investigated further.
List of known actions in the central nervous system Ethanol has been reported to possess the following actions in functional assays at varying concentrations:
GABAA receptor: positive allosteric modulator (primarily of δ subunit-containing receptors) NMDA receptor: negative allosteric modulator AMPA receptor: negative allosteric modulator Kainate receptor: negative allosteric modulator Glycine receptor: positive allosteric modulator Serotonin 5-HT3 receptor: positive allosteric modulator Opioid receptor: endogenous positive allosteric modulator Muscarinic acetylcholine receptor: positive allosteric modulator. Nicotinic acetylcholine receptor: positive allosteric modulator Glycine reuptake inhibitor Adenosine reuptake inhibitor L-type calcium channel: channel blocker GIRK: channel opener Voltage-gated calcium channel Dihydropyridine-sensitive L-type Ca2+ channels BK channel modulation G-protein-activated inwardly rectifying K+ channels Brain medulla: Decreased levels of nitric oxide Mesolimbic pathway: Increased levels of dopamine and endogenous opioids, secondary to other actions
Many of these actions have been found to occur only at very high concentrations that may not be pharmacologically significant at recreational doses of ethanol, and it is unclear how or to what extent each of the individual actions is involved in the effects of ethanol. Some of the actions of ethanol on ligand-gated ion channels, specifically the nicotinic acetylcholine receptors and the glycine receptor, are dose-dependent, with potentiation or inhibition occurring dependent on ethanol concentration. This seems to be because the effects of ethanol on these channels are a summation of positive and negative allosteric modulatory actions.
GABAA receptors
Ethanol has been found to enhance GABAA receptor-mediated currents in functional assays. Ethanol has long shown a similarity in its effects to positive allosteric modulators of the GABAA receptor like benzodiazepines, barbiturates, and various general anesthetics. Some of these effects include anxiolytic, anticonvulsant, sedative, and hypnotic effects, cognitive impairment, and motor incoordination. In accordance, it was theorized and widely believed that the primary mechanism of action of ethanol is GABAA receptor positive allosteric modulation. However, other ion channels are involved in its effects as well. Although ethanol exhibits positive allosteric binding properties to GABAA receptors, its effects are limited to pentamers containing the δ-subunit rather than the γ-subunit. Ethanol potentiates extrasynaptic δ subunit-containing GABAA receptors at behaviorally relevant (as low as 3 mM) concentrations, but γ subunit receptors are enhanced only at far higher concentrations (> 100 mM) that are in excess of recreational concentrations (up to 50 mM).
GABAA receptors containing the δ-subunit have been shown to be located exterior to the synapse and are involved with tonic inhibition rather than its γ-subunit counterpart, which is involved in phasic inhibition. The δ-subunit has been shown to be able to form the allosteric binding site which makes GABAA receptors containing the δ-subunit more sensitive to ethanol concentrations, even to moderate social ethanol consumption levels (30mM). While it has been shown by Santhakumar et al. that GABAA receptors containing the δ-subunit are sensitive to ethanol modulation, depending on subunit combinations receptors could be more or less sensitive to ethanol. It has been shown that GABAA receptors that contain both δ and β3-subunits display increased sensitivity to ethanol. One such receptor that exhibits ethanol insensitivity is α3-β6-δ GABAA. It has also been shown that subunit combination is not the only thing that contributes to ethanol sensitivity. Location of GABAA receptors within the synapse may also contribute to ethanol sensitivity.
Ro15-4513, a close analogue of the benzodiazepine antagonist flumazenil (Ro15-1788), has been found to bind to the same site as ethanol and to competitively displace it in a saturable manner. In addition, Ro15-4513 blocked the enhancement of δ subunit-containing GABAA receptor currents by ethanol in vitro. In accordance, the drug has been found to reverse many of the behavioral effects of low-to-moderate doses of ethanol in rodents, including its effects on anxiety, memory, motor behavior, and self-administration. Taken together, these findings suggest a binding site for ethanol on subpopulations of the GABAA receptor with specific subunit compositions via which it interacts with and potentiates the receptor.
Calcium channel blocking
Research indicates ethanol is involved in the inhibition of L-type calcium channels. One study showed the nature of ethanol binding to L-type calcium channels is according to first-order kinetics with a Hill coefficient around 1. This indicates ethanol binds independently to the channel, expressing noncooperative binding. Early studies showed a link between calcium and the release of vasopressin by the secondary messenger system. Vasopressin levels are reduced after the ingestion of alcohol. The lower levels of vasopressin from the consumption of alcohol have been linked to ethanol acting as an antagonist to voltage-gated calcium channels (VGCCs). Studies conducted by Treistman et al. in the aplysia confirm inhibition of VGCC by ethanol. Voltage clamp recordings have been done on the aplysia neuron. VGCCs were isolated and calcium current was recorded using patch clamp technique having ethanol as a treatment. Recordings were replicated at varying concentrations (0, 10, 25, 50, and 100 mM) at a voltage clamp of +30 mV. Results showed calcium current decreased as concentration of ethanol increased. Similar results have shown to be true in single-channel recordings from isolated nerve terminal of rats that ethanol does in fact block VGCCs.
Studies done by Katsura et al. in 2006 on mouse cerebral cortical neurons, show the effects of prolonged ethanol exposure. Neurons were exposed to sustained ethanol concentrations of 50 mM for 3 days in vitro. Western blot and protein analysis were conducted to determine the relative amounts of VGCC subunit expression. α1C, α1D, and α2/δ1 subunits showed an increase of expression after sustained ethanol exposure. However, the β4 subunit showed a decrease. Furthermore, α1A, α1B, and α1F subunits did not alter in their relative expression. Thus, sustained ethanol exposure may participate in the development of ethanol dependence in neurons.
Other experiments done by Malysz et al. have looked into ethanol effects on voltage-gated calcium channels on detrusor smooth muscle cells in guinea pigs. Perforated patch clamp technique was used having intracellular fluid inside the pipette and extracellular fluid in the bath with added 0.3% vol/vol (about 50-mM) ethanol. Ethanol decreased the current in DSM cells and induced muscle relaxation. Ethanol inhibits VGCCs and is involved in alcohol-induced relaxation of the urinary bladder.
Rewarding and reinforcing actions