Alcohol intoxication

Alcohol intoxication
Other names: Drunkenness, acute alcohol poisoning, ethanol intoxication, acute alcohol intoxication[1][2]
The Drunkenness of Noah by Michelangelo, 1509
SpecialtyToxicology, psychiatry
SymptomsMild: Mild sedation, decreased coordination[3]
Moderate: Slurred speech, trouble walking, vomiting[3]
Severe: Decreased effort to breathe, coma[3]
ComplicationsSeizures, aspiration pneumonia, injuries, low blood sugar[3][4]
Usual onsetOver minutes to hours[5]
DurationSeveral hours[5]
CausesEthanol (alcohol)[6]
Risk factorsSocial environment, impulsivity, alcoholism[5][7]
Diagnostic methodTypically based on history of events and physical examination[6]
Differential diagnosisHepatic encephalopathy, Wernicke encephalopathy, methanol toxicity, meningitis, traumatic brain injury[6]
TreatmentSupportive care[6]
FrequencyVery common (especially in the Western world)[8]
Deathsc. 2,200 per year (USA)[9]

Alcohol intoxication, also known as drunkenness or alcohol poisoning,[1] is the negative behavior and physical effects due to the recent drinking of alcohol.[6][10] Symptoms at lower doses may include mild sedation and poor coordination.[3] At higher doses, there may be slurred speech, trouble walking, and vomiting.[3] Extreme doses may result in a decreased effort to breathe (respiratory depression), coma, or death.[3] Complications may include seizures, aspiration pneumonia, injuries including suicide, and low blood sugar.[3][4] Alcohol intoxication can lead to alcohol-related crime with perpetrators more likely to be intoxicated than victims.[11]

Alcohol intoxication typically begins after two or more alcoholic drinks.[5] Risk factors include a social situation where heavy drinking is common and a person having an impulsive personality.[5] Diagnosis is usually based on the history of events and physical examination.[6] Verification of events by witnesses may be useful.[6] Legally, alcohol intoxication is often defined as a blood alcohol concentration (BAC) of greater than 5.4–17.4 mmol/L (25–80 mg/dL or 0.025–0.080%).[12][13] This can be measured by blood or breath testing.[5] Alcohol is broken down in human body at a rate of about 3.3 mmol/L (15 mg/dL) per hour.[6]

Management of alcohol intoxication involves supportive care.[6] Typically this includes putting the person in the recovery position, keeping the person warm, and making sure breathing is sufficient.[4] Gastric lavage and activated charcoal have not been found to be useful.[6] Repeated assessments may be required to rule out other potential causes of a person's symptoms.[6]

Alcohol intoxication is very common, especially in the Western world.[8] Most people who drink alcohol have at some time been intoxicated.[5] In the United States acute intoxication directly results in about 2,200 deaths per year,[9] and indirectly more than 30,000 deaths per year.[5] Acute intoxication has been documented throughout history and alcohol remains one of the world's most widespread recreational drugs.[14][15] Some religions consider alcohol intoxication to be a sin.[5][16]

Signs and symptoms

Wine is a Mocker by Jan Steen c. 1663

Alcohol intoxication is the negative health effects due to the recent drinking of ethanol (alcohol).[6] When severe it may become a medical emergency. Some effects of alcohol intoxication, such as euphoria and lowered social inhibition, are central to alcohol's desirability.[17]

Effect by alcohol level

Progressive effects of alcohol[18]
BAC (% by vol.) SI units (mmol/l) Behavior Impairment
0.001–0.029 0.22–6.3
  • May appear normal
  • Subtle effects detected with special tests
0.030–0.059 6.5–12.8
  • Decreased social inhibition
  • Joyousness
  • Mild euphoria
  • Relaxation
  • Increased verbosity
  • Decreased attentional control
0.060–0.099 13.0–21.5
  • Depth perception
  • Glare recovery
  • Peripheral vision
  • Reasoning
0.100–0.199 21.7–43.3
0.200–0.299 43.4–64.9
0.300–0.399 65.1–86.6
0.400–0.500 86.80–108.5
>0.50 >108.5
  • High possibility of death

Pathophysiology

Alcohol is metabolized by a normal liver at the rate of about 8 grams of pure ethanol per hour. 8 grams or 10 ml (0.34 US fl oz) is one British standard unit. An "abnormal" liver with conditions such as hepatitis, cirrhosis, gall bladder disease, and cancer is likely to result in a slower rate of metabolism.[19]

Ethanol is metabolised to acetaldehyde by alcohol dehydrogenase (ADH), which is found in many tissues, including the gastric mucosa. Acetaldehyde is metabolised to acetate by acetaldehyde dehydrogenase (ALDH), which is found predominantly in liver mitochondria. Acetate is used by the muscle cells to produce acetyl-CoA using the enzyme acetyl-CoA synthetase, and the acetyl-CoA is then used in the citric acid cycle.[20]

As drinking increases, people become sleepy, or fall into a stupor. After a very high level of consumption, the respiratory system becomes depressed and the person will stop breathing. Comatose patients may aspirate their vomit (resulting in vomitus in the lungs, which may cause "drowning" and later pneumonia if survived). CNS depression and impaired motor co-ordination along with poor judgment increases the likelihood of accidental injury occurring. It is estimated that about one-third of alcohol-related deaths are due to accidents and another 14% are from intentional injury.[21]

In addition to respiratory failure and accidents caused by effects on the central nervous system, alcohol causes significant metabolic derangements. Hypoglycaemia occurs due to ethanol's inhibition of gluconeogenesis, especially in children, and may cause lactic acidosis, ketoacidosis, and acute kidney injury. Metabolic acidosis is compounded by respiratory failure. Patients may also present with hypothermia.

Mechanism

See also: Alcohol (drug) § Pharmacology

In the past, alcohol was believed to be a non-specific pharmacological agent affecting many neurotransmitter systems in the brain.[22] However, molecular pharmacology studies have shown that alcohol has only a few primary targets. In some systems, these effects are facilitatory and in others inhibitory.

Among the neurotransmitter systems with enhanced functions are: GABAA,[23] 5-HT3 receptor agonism[24] (responsible for GABAergic (GABAA receptor PAM), glycinergic, and cholinergic effects), nicotinic acetylcholine receptors.[25]

Among those that are inhibited are: NMDA,[24] dihydropyridine-sensitive L-type Ca2+ channels[26] and G-protein-activated inwardly rectifying K+ channels.[27]

The result of these direct effects is a wave of further indirect effects involving a variety of other neurotransmitter and neuropeptide systems, leading finally to the behavioural or symptomatic effects of alcohol intoxication.[22]

The order in which different types of alcohol are consumed ("Grape or grain but never the twain" and "Beer before wine and you'll feel fine; wine before beer and you'll feel queer") does not have any effect.[28]

GABAA receptors

See also: GABAA § Ligands
Ethanol binding to GABAA receptor

Many of the effects of activating GABAA receptors have the same effects as that of ethanol consumption. Some of these effects include anxiolytic, anticonvulsant, sedative, and hypnotic effects, cognitive impairment, and motor incoordination.[29] This correlation between activating GABAA receptors and the effects of ethanol consumption has led to the study of ethanol and its effects on GABAA receptors. It has been shown that ethanol does in fact exhibit positive allosteric binding properties to GABAA receptors. However, its effects are limited to pentamers containing the δ-subunit rather than the γ-subunit.[30] 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.[29] 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).[31] 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.[32] It has been shown that GABAA receptors that contain both δ and β3-subunits display increased sensitivity to ethanol.[30] One such receptor that exhibits ethanol insensitivity is α3-β6-δ GABAA.[32] 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.[29]

Diagnosis

See also: Blood alcohol content

Definitive diagnosis relies on a blood test for alcohol, usually performed as part of a toxicology screen. Law enforcement officers in the United States and other countries often use breathalyzer units and field sobriety tests as more convenient and rapid alternatives to blood tests.[33] There are also various models of breathalyzer units that are available for consumer use. Because these may have varying reliability and may produce different results than the tests used for law-enforcement purposes, the results from such devices should be conservatively interpreted.

Many informal intoxication tests exist, which, in general, are unreliable and not recommended as deterrents to excessive intoxication or as indicators of the safety of activities such as motor vehicle driving, heavy equipment operation, machine tool use, etc.

For determining whether someone is intoxicated by alcohol by some means other than a blood-alcohol test, it is necessary to rule out other conditions such as hypoglycemia, stroke, usage of other intoxicants, mental health issues, and so on. It is best if his / her behavior has been observed while the subject is sober to establish a baseline. Several well-known criteria can be used to establish a probable diagnosis. For a physician in the acute-treatment setting, acute alcohol intoxication can mimic other acute neurological disorders, or is frequently combined with other recreational drugs that complicate diagnosis and treatment.

Management

Acute alcohol poisoning is a medical emergency due to the risk of death from respiratory depression or aspiration of vomit if vomiting occurs while the person is unresponsive. Emergency treatment strives to stabilize and maintain an open airway and sufficient breathing, while waiting for the alcohol to metabolize. This can be done by removal of any vomitus or, if the person is unconscious or has impaired gag reflex, intubation of the trachea.[34]

Other measures may include

  • Treat low blood sugar, with intravenous sugar solutions as ethanol induced low blood sugar unresponsive to glucagon.
  • Administer the vitamin thiamine to prevent Wernicke–Korsakoff syndrome, which can cause a seizure (more usually a treatment for chronic alcoholism, but in the acute context usually co-administered to ensure maximal benefit).
  • Apply hemodialysis if the blood concentration is dangerously high (>400 mg/dL), and especially if there is metabolic acidosis.
  • Provide oxygen therapy as needed via nasal cannula or non-rebreather mask.
  • While the medication metadoxine may speed the breakdown of alcohol, use in alcohol intoxication requires further study as of 2017.[6][35] It is approved in a number of countries in Europe, as well as India and Brazil.[35]

Additional medication may be indicated for treatment of nausea, tremor, and anxiety.

Prognosis

A normal liver detoxifies the blood of alcohol over a period of time that depends on the initial level and the patient's overall physical condition. An abnormal liver will take longer but still succeeds, provided the alcohol does not cause liver failure.[36]

People having drunk heavily for several days or weeks may have withdrawal symptoms after the acute intoxication has subsided.[37]

A person consuming a dangerous amount of alcohol persistently can develop memory blackouts and idiosyncratic intoxication or pathological drunkenness symptoms.[38]

Long-term persistent consumption of excessive amounts of alcohol can cause liver damage and have other deleterious health effects.

Society and culture

A 1936 anti-drinking poster.

Alcohol intoxication is a risk factor in some cases of catastrophic injury, in particular for unsupervised recreational activity. A study in the province of Ontario based on epidemiological data from 1986, 1989, 1992, and 1995 states that 79.2% of the 2,154 catastrophic injuries recorded for the study were preventable, of which 346 (17%) involved alcohol consumption.[39] The activities most commonly associated with alcohol-related catastrophic injury were snowmobiling (124), fishing (41), diving (40), boating (31) and canoeing (7), swimming (31), riding an all-terrain vehicle (24), and cycling (23).[39] These events are often associated with unsupervised young males, often inexperienced in the activity, and many result in drowning.[39] Alcohol use is also associated with unsafe sex.

A drunk-driving simulator in Montreal.

Laws on drunkenness vary. In the United States, it is a criminal offense for a person to be drunk while driving a motorized vehicle, except in Wisconsin, where it is only a fine for the first offense.[40] It is also a criminal offense to fly an aircraft or (in some American states) to assemble or operate an amusement park ride while drunk.[41] Similar laws also exist in the United Kingdom and most other countries.

In some countries, it is also an offense to serve alcohol to an already-intoxicated person,[42] and, often, alcohol can be sold only by persons qualified to serve responsibly through alcohol server training.

The blood alcohol content (BAC) for legal operation of a vehicle is typically measured as a percentage of a unit volume of blood. This percentage ranges from 0.00% in Romania and the United Arab Emirates; to 0.05% in Australia, South Africa, Germany, Scotland and New Zealand (0.00% for underage individuals); to 0.08% in England and Wales, the United States (0.00% for underaged individuals) and Canada.[43]

The United States Federal Aviation Administration prohibits crew members from performing their duties within eight hours of consuming an alcoholic beverage, while under the influence of alcohol, or with a BAC greater than 0.04%.[44][45]

In the United States, the United Kingdom, and Australia, public intoxication is a crime (also known as "being drunk and disorderly" or "being drunk and incapable").[46]

In some countries, there are special facilities, sometimes known as "drunk tanks", for the temporary detention of persons found to be drunk.

Religious views

Drunken Immortal by Guo Xu, 1503

Some religious groups permit the consumption of alcohol. Some permit consumption but prohibit intoxication, while others prohibit alcohol consumption altogether. Many Christian denominations such as Catholic, Orthodox, and Lutheran use wine as a part of the Eucharist and permit the drinking of alcohol but consider it sinful to become intoxicated.

In the Bible, the Book of Proverbs contains several chapters dealing with the bad effects of drunkenness and warning to stay away from intoxicating beverages. The book of Leviticus tells of Nadab and Abihu, Aaron the Priest's eldest sons, who were killed for serving in the temple after drinking wine, presumably while intoxicated. The book continues to discuss monasticism where drinking wine is prohibited. The story of Samson in the Book of Judges tells of a monk from the tribe of Dan who is prohibited from cutting his hair and drinking wine.[47] Romans 13:13–14,[48] 1 Corinthians 6:9–11, Galatians 5:19–21,[49] and Ephesians 5:18[50] are among a number of other Bible passages that speak against drunkenness. While Proverbs 31:4, warns against kings and rulers drinking wine and strong drink, Proverbs 31:6–7 promotes giving strong drink to the perishing and wine to those whose lives are bitter, to forget their poverty and troubles.[51]

Some Protestant Christian denominations prohibit the drinking of alcohol[52] based upon Biblical passages that condemn drunkenness,[47] but others allow moderate use of alcohol.[53] In some Christian groups, a small amount of wine is part of the rite of communion.

In the Church of Jesus Christ of Latter-day Saints, alcohol consumption is forbidden,[54] and teetotalism has become a distinguishing feature of its members. Jehovah's Witnesses allow moderate alcohol consumption among its members.

In the Qur'an,[55][56][57] there is a prohibition on the consumption of grape-based alcoholic beverages, and intoxication is considered as an abomination in the Hadith. Islamic schools of law (Madh'hab) have interpreted this as a strict prohibition of the consumption of all types of alcohol and declared it to be haraam ("forbidden"), although other uses may be permitted.[58]

In Buddhism, in general, the consumption of intoxicants is discouraged for both monastics and lay followers. Many followers of Buddhism observe a code of conduct known as the five precepts, of which the fifth precept is an undertaking to refrain from the consumption of intoxicating substances[59] (except for medical reasons).[60] In the bodhisattva vows of the Brahma Net Sūtra, observed by Mahāyāna Buddhist communities, distribution of intoxicants is likewise discouraged, as well as consumption.[61]

In the branch of Hinduism known as Gaudiya Vaishnavism, one of the four regulative principles forbids the taking of intoxicants, including alcohol.

In Judaism, in accordance with the biblical stance against drinking,[47] wine drinking was not permitted for priests and monks[62] The biblical command to sanctify the Sabbath day and other holidays has been interpreted as having three ceremonial meals which include drinking of wine, the Kiddush.[63][64] The Jewish marriage ceremony ends with the bride and groom drinking a shared cup of wine after reciting seven blessings, and according to western "Ashkenazi" traditions, after a fast day. But it has been customary and in many cases even mandated to drink moderately so as to stay sober, and only after the prayers are over.[65]

During the Seder night on Passover (Pesach) there is an obligation to drink 4 ceremonial cups of wine, while reciting the Haggadah. It has been assumed as the source for the wine drinking ritual at the communion in some Christian groups.[66] During Purim there is an obligation to become intoxicated, although, as with many other decrees, in many communities this has been avoided, by allowing sleep during the day to replace it.[67]

In the 1920s due to the new beverages law, a rabbi from the Reform Judaism movement proposed using grape-juice for the ritual instead of wine. Although refuted at first, the practice became widely accepted by orthodox Jews as well.[68]

At the Cave of the Patriarchs in Hebron—the Ibrahimi Mosque as it is called by the Muslims, the Jewish wine drinking rituals during weddings, the Sabbath day and holidays, are a cause for tension with the Muslims who unwillingly share the site under Israeli authority.[69]

Other animals

In the movie Animals are Beautiful People, an entire section was dedicated to showing many different animals including monkeys, elephants, hogs, giraffes, and ostriches, eating over-ripe marula tree fruit causing them to sway and lose their footing in a manner similar to human drunkenness.[70] Birds may become intoxicated with fermented berries and some die colliding with hard objects when flying under the influence.[71][72]

In elephant warfare, practiced by the Greeks during the Maccabean revolt and by Hannibal during the Punic wars, it has been recorded that the elephants would be given wine before the attack, and only then would they charge forward after being agitated by their driver.[73]

It is a regular practice to give small amounts of beer to race horses in Ireland. Ruminant farm animals have natural fermentation occurring in their stomach, and adding alcoholic beverages in small amounts to their drink will generally do them no harm, and will not cause them to become drunk.

See also

References

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  40. ↑ "Wisconsin Legislature: Chapter 346". wisconsin.gov. Archived from the original on 2020-07-25. Retrieved 2020-08-01.
  41. ↑ Texas Penal Code § 49.065 Archived 2011-09-26 at the Wayback Machine
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  45. ↑ "FAR Part 91 Sec. 91.17 effective as of 07/21/2006". faa.gov. Archived from the original on 2021-02-27. Retrieved 2022-03-15.
  46. ↑ "Licensing Act 1872". Acts of the United Kingdom Parliament. Vol. 1872. 1872-08-10. Archived from the original on 2012-08-05. Retrieved 2010-05-08.
  47. 1 2 3 Biblical examples referencing intoxication: "Proverbs 23:21". Net.bible.org. Archived from the original on 2009-06-20. Retrieved 2009-11-03., "Isaiah 28:1". Net.bible.org. Archived from the original on 2009-06-20. Retrieved 2009-11-03., "Habakkuk 2:15". Net.bible.org. Archived from the original on 2009-06-20. Retrieved 2009-11-03.
  48. ↑ "Romans 13:13–14". Archived from the original on 2020-07-26. Retrieved 2020-08-01.
  49. ↑ "Galatians 5:19–21". Archived from the original on 2020-07-25. Retrieved 2020-08-01.
  50. ↑ "Ephesians 5:18". Archived from the original on 2020-07-25. Retrieved 2020-08-01.
  51. ↑ "Proverbs 31: 4–7 NASB—It is not for kings, O Lemuel, It is". Bible Gateway. Archived from the original on 2020-07-26. Retrieved 2020-08-01.
  52. ↑ "On Alcohol Use in America". SBC Resolutions. Southern Baptist Convention. June 2006. Archived from the original on 5 November 2013. Retrieved 7 June 2013.
  53. ↑ "Frequently Asked Questions: Alcohol". LCMS Views – Contemporary Issues. Lutheran Church–Missouri Synod. p. 3. Archived from the original on 10 May 2012. Retrieved 7 June 2013.
  54. ↑ "Doctrine and Covenants 89". Archived from the original on 2020-08-05. Retrieved 2020-08-01.
  55. ↑ "Qur'an: 4:43". Usc.edu. Archived from the original on 2010-12-04. Retrieved 2010-12-04.
  56. ↑ "Qur'an: 2:19". Usc.edu. Archived from the original on 4 December 2010. Retrieved 2010-12-04.
  57. ↑ "Cmje". usc.edu. Archived from the original on 2010-12-04. Retrieved 2010-12-04.
  58. ↑ Yilmaz, Ihsan (2004) [2005-01-31]. "Post-Modern Muslim Legality and its Consequences". Muslim Laws, Politics And Society In Modern Nation States: Dynamic Legal Pluralisms In England, Turkey And Pakistan. Ashgate Publishing. p. 158. ISBN 978-0-7546-4389-0. Archived from the original on 2020-07-25. Retrieved 2020-08-01.
  59. ↑ Gwynne, Paul (2017). "The Buddhist Pancasila". World Religions in Practice: A Comparative Introduction. John Wiley & Sons. ISBN 978-1-118-97227-4. Archived from the original on 2021-08-27. Retrieved 2020-08-01.
  60. ↑ Gombrich, Richard F. (1995). Buddhist Precept and Practice: Traditional Buddhism in the Rural Highlands of Ceylon. Kegan Paul, Trench and Company. p. 298. ISBN 978-0-7103-0444-5.
  61. ↑ Benn, James A. (2005). "Buddhism, Alcohol, and Tea in Medieval China". In Sterckx, R. (ed.). Of Tripod and Palate: Food, Politics, and Religion in Traditional China. Springer Nature. p. 226. ISBN 978-1-4039-7927-8. Archived from the original on 2021-08-27. Retrieved 2020-08-01.
  62. ↑ The Talmudic decree set a schedule according to which the priests would take turns staying sober. The practice of becoming a 'biblical' monk, is discussed in a full tractate of the Mishna and Talmud. The Talmud tells of a family 'the sons of Reichab' who never drank wine, although it is not clear if this is considered good or bad.
  63. ↑ The Kiddush is recited today only in the opening meal on Friday night and the main meal during the day. See On the mystery of the missing Kiddush during the third Sabbath meal Archived 2020-07-25 at the Wayback Machine Ruth Foichtwanger Segel, Shabbat Magazine, August 21, 2016 (Hebrew, Makor Rishon website)
  64. ↑ The Pharisees, avoiding the Zadokites' temple-based rituals, had installed many ceremonies which in a way change or contradict the literal meaning of the biblical protocol. These include the ceremony of lighting candles which stay lit during the Sabbath day, eating hot food from a fire lit previously, starting the Sabbath rituals on the night before, and the drinking of wine with the Sabbath meal. See Qimron Sabbath Laws Archived 2021-03-08 at the Wayback Machine Vered Noam, Department of Hebrew Culture Studies, Tel Aviv University (Dead Sea Discoveries Archived 2017-01-31 at the Wayback Machine, Brill Institute)
  65. ↑ Menachem Posner: What is Judaism's take on alcohol consumption? Archived 2013-07-27 at the Wayback Machine on Chabad.org
  66. ↑ Was Jesus' last supper a Seder? Archived 2021-04-04 at the Wayback Machine Jonathan Klawans, January 7, 2014 (Biblical Archaeology organization's website)
  67. ↑ The Babylonian Talmud says in Megillah 7b that "Rava said: A person is obligated to become intoxicated on Purim until he is unaware of the difference between 'Cursed be Haman' and 'Blessed be Mordechai.'" This is taken to mean that on the Jewish festival of Purim one is commanded to drink alcohol to the point of intoxication. See Yanki Tauber: Are Jews actually supposed to get drunk on Purim? Archived 2014-01-01 at the Wayback Machine Chabad.org (referring to the Talmudic tractate Megillah (7b)).
  68. ↑ Using grape juice for Kiddush Archived 2021-01-16 at the Wayback Machine (Torahlab website)
  69. ↑ Hebron: Jews and Palestinians share holy site begrudgingly Archived 2018-11-29 at the Wayback Machine, Daniel Estrin, November 10, 2015 (Public Radio International website)
  70. ↑ Drunken animals scene Archived 2020-11-23 at the Wayback Machine (YouTube)
  71. ↑ Katz, Brigit (4 October 2018). "Birds Are Acting Erratically in Minnesota. Blame It on the Alcohol". Smithsonian. Archived from the original on 4 October 2018. Retrieved 5 October 2018.
  72. ↑ Kinde, Hailu; et al. (July 2012). "Strong circumstantial evidence for ethanol toxicosis in Cedar Waxwings (Bombycilla cedrorum)". Journal of Ornithology. 153 (3): 995–998. doi:10.1007/s10336-012-0858-7.
  73. ↑ Hannibal's superweapon: The war elephant Archived 2020-08-05 at the Wayback Machine (HistoryThings.com website)

Bibliography

  • Bales, Robert F. "Attitudes toward Drinking in the Irish Culture". In: Pittman, David J. and Snyder, Charles R. (Eds.) Society, Culture and Drinking Patterns. New York: Wiley, 1962, pp. 157–187.
  • Gentry, Kenneth L., Jr., God Gave Wine: What the Bible Says about Alcohol. Lincoln, Calif.: Oakdown, 2001.
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  • Sigmund, Paul. St. Thomas Aquinas On Politics and Ethics. W.W. Norton & Company, Inc, 1988, p. 77.
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