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EFFECTS OF ALCOHOL ON SOME BIOCHEMICAL PARAMETERS OF ALCOHOLICS IN NSUKKA ENUGU STATE NIGERIA

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ABSTRACT

This work was aimed at finding the effects of alcohol on some biochemical parameters. A total of one hundred and eighty (180) apparently healthy, non-hypertensive  male  alcoholics were used for the study. Forty (40) non-consumers of alcohol were used as control. The activity of alanine aminotransferase (ALT) in the control was 10.50±2.00 IU/L while it was 16.50±1.50 IU/L;  17.50±2.00  IU/L  and  18.31±2.00  IU/L  in  alcoholics  who  showed  preference  for palmwine, beer and distilled spirit respectively. Also, the activity of aspartate aminotransferase (AST) in the control was 9.51±0.35  IU/L while it was 18.44±0.40  IU/L, 19.21±0.19  IU/L,

20.32±0.64 IU/L in alcoholics who showed preference for palmwine, beer and distilled  spirit respectively.  The ALT and AST activities of alcoholic subjects who showed  preference for distilled  spirit  was  significantly  higher  (p  <  0.05)  than  those  who  showed  preference  for palmwine and beer. The activities of alcoholics who showed preference for palmwine was the lowest. Furthermore, the serum total bilirubin concentration of the alcoholics was significantly higher (p < 0.05) compared  with the  control. The serum total bilirubin concentrations  were 18.65±2.10  μmol/l,  19.40±1.50  μmol/l  and  22.75±1.60  μmol/l  for  alcoholics  who  showed preference for palmwine, beer and distilled spirit respectively. The serum total bilirubin of the control  was  8.30  ± 2.00  μmol/l.  The alkaline  phosphatase  (ALP)  activity  of the  alcoholic subjects was significantly higher (p<0.05) compared with the control. The ALP activity of the control was 61.50 ± 30.00 IU/L while the ALP activity was 174.20±2.50 IU/L, 175.10±1.50 IU/L and 177.40±1.00 IU/L in the three categories of alcoholics who showed preference  for palmwine, beer and distilled spirit respectively. Moreover, the urine total protein concentration of the alcoholics was significantly higher (p<0.05) compared with the control. Alcoholics who showed preference for distilled spirit had urine total protein of 153.96±0.43 mg/dl followed by alcoholics  who  showed  preference  for  beer  and  palmwine  who  had  urine  total protein  of 152.74±0.42 mg/dl and 151.34±0.60 mg/dl respectively. The urine total protein of the control was 56.40±0.40 mg/dl. Furthermore, the urine specific gravity, serum urea and creatinine of the alcoholics were significantly higher (p < 0.05) compared with the control. However, the plasma sodium, potassium  and creatinine  clearance  of the alcoholics  were  significantly  lower (p < 0.05) compared with the control. The body mass index (BMI) of the three groups of alcoholics fell within the range of 18.50 to 24.90. The blood pressure of both the alcoholic and control subjects were normal (below 140/90 mmHg). This work therefore shows that chronic alcohol use could induce both hepatic and renal dysfunctions  in the  alcoholics which manifested  in form of adverse variations in some biochemical parameters of prognostic and diagnostic utility.

CHAPTER ONE

INTRODUCTION

Generally, alcohol designates a class of compounds that are hydroxyl derivatives of aliphatic  hydrocarbons.  However,  in this study,  the term alcohol used  without  additional qualifications  refers  specifically  to  ethanol.  A  variety  of alcoholic  beverages have  been consumed  by man in the continuing search for euphoria  producing stimuli. Among some people,  alcohol enjoys  a high status as a social  lubricant that relieves tension,  gives self confidence to the inadequate, blurs the appreciation of uncomfortable realities and serves as an escape from environmental and emotional stress.

Alcohol has been loved and hated at different times by different people. Alcohol has been celebrated as healthful especially to the heart (red wine) and most pleasant to the taste buds;  and  then  dismissed  as  “demon’s  rum”  and  “devil  in  solution”  depending  on  the prevalent view.

In spite of the apparent divergent and sometimes conflicting opinions about alcohol, the  consensus  shared  by drinkers  and  non  drinkers  alike  is  that  excessive  and  chronic consumption of alcohol is a disorder. Like any other chronic disorder, it develops insidiously but follows a predictable course. The first or pre-alcoholic symptomatic phase begins with the use of alcohol to relieve tensions. The second (or prodromal) phase is marked by a range of behaviours including preoccupation with alcohol, surreptitious drinking and loss of memory (Hock et al., 1992). In the third  (or  crucial)  phase,  the individual  loses control over  his drinking.  This  loss  of control  is  the beginning  of the disease  process  of addiction.  The individual starts drinking early  in the morning and stays up drinking till late in the night. Impairment in biochemical activities becomes manifest as the organs of the alcoholic begin to deteriorate.  Other  medical problems  develop by the time the alcoholic  gets into the final (chronic  phase).  Prolonged  intoxications  become  the rule.  Alcoholic  psychosis  develops, thinking is impaired, and fear and tremors become persistent (Klemin and Sherry, 1981). A previously responsible individual may be transformed into an inebriate – stereotype alcoholic.

Fear-instilling  but  thought-  provoking  terms  such  as  the  “coming  epidemic”,  a “miserable  trap”, have been used to show concern for the potential hazard  of  widespread alcoholism.

In its 1978 revision of the international classification of diseases, the World Health Organization defined alcoholism as “a state, psychic and usually also physical, resulting from taking  alcohol,  characterised  by behavioural  and  other  responses  that  always  include  a

compulsion  to  take alcohol  on a continuous  or periodic  basis  in order  to  experience  its psychic effects and sometimes to avoid the discomfort of its absence; tolerance may or may not  be  present.   This  definition   emphasized   the  compulsive   nature  of   drinking,   the psychological  and physical  effects,  and dependence  (“discomfort  of its  absence”)  (WHO,

1978).

The kidney and liver could be particularly vulnerable to the chemical assault resulting from alcohol abuse because they receive high percentage of the total cardiac output. Also, the liver is pivotal in intermediary metabolism; so ingested alcohol must come in contact with the liver and kidney. Alcohol could produce many of its damaging effects by the formation of dangerous, highly reactive intermediates such as acetaldehyde which may lead to glutathione depletion, free radical generation, oxidative stress and cell dysfunction.

Alcohol dehydrogenase in the presence of a hydrogen acceptor nicotinamide adenine dinucleotide   (NAD)   oxidizes   ethanol  to   acetaldehyde.   This   is  the   initial   obligatory biochemical  event  in  alcohol  induced  hepatotoxic  and  nephrotoxic  effects.  Thus,  it  is important to find out in quantitative terms the effects of different types of alcohol drinks on some principal biochemical parameters of diagnostic utility.

1.1       Alcohol

1.1.1    Chemistry of Alcohol

The term ‘alcohol’ refers to a class of compounds that are hydroxy (-OH) derivatives of aliphatic hydrocarbons. There are many common alcohols – methanol or  wood alcohol, isopropyl alcohol,  the antifreeze  diethylene  glycol,  and glycerine.  In  this  study however, when the term alcohol is used without additional qualification,  ethyl alcohol, a liquid also known  as ethanol,  is referred  to.  Alcohol  can  be  considered  as being  derived  from  the corresponding alkanes by replacing the hydrogen atoms with hydroxyl groups. The hydroxyl group is the functional group of alcohols as it is responsible for their characteristic chemical properties.  Monohydric  alcohols  contain  only  one  hydroxyl  group  in  each  molecule. Monohydric  alcohols  form  a  homologues  series  with  the  general  molecular  formular CnH2n+1OH.

All alcoholic beverages arise from the process of fermentation. Indeed, ethanol, the

alcohol in beverages, is the quantitative end product of yeast glycolysis. In the presence of water, yeasts are able to convert the sugar (glucose) of plants into alcohol, as depicted by the following chemical reaction:

C6H12O6     2C2H5OH      +      2CO2 Glucose + Yeast

lAcohol               Carbon dioxide

A wide variety of plants have proved to be useful substrates for the action of yeast, and this is reflected by the different types of beverages used throughout the world.

1.1.2    Alcohol Production

1.1.2.1 Beer Production

Beer  is  generally  considered  to  be  of  two  types,  the  ale  types,  brewed   with Saccharomyces  cerevisiae and the lager type, brewed with Saccharomyces  carlsbergensis. The main ingredients of beer are malted barley, the source of  fermentable  carbohydrates, proteins,  polypeptides,  minerals,  and  hops  the  primary  purpose  of  which  is  to  impart bitterness and the hop characteristic, but which also have anti-microbial properties, yeast and water. The basic processes for the brewing of beer include:

(a) Malting

Malting involves the mobilization  and development  of the enzymes  formed  during germination  of  the  barley  grain.  The  grain  is  permitted  to  germinate  under  controlled conditions  of  moisture  and  temperature,  the  starch/enzyme  balance  then  being  fixed  by kilning at drying temperatures as high as 104oC

(b)   Mashing

During mashing, ground malt is mixed (mashed) with hot water. This serves both to extract  existing soluble  compounds  from the malt and to reactivate  malt enzymes  which complete the breakdown of starch and proteins.

(c)  Wort boiling

Wort  is  drained  from  the  mash  tun  into  a  copper  and  boiled  to  inactivate  malt enzymes. In traditional brewing, hops are added at this stage, the humulones (α-acids) being extracted and chemically isomerized. The resulting iso-humulones have a  greater solubility and contribute the characteristic bitter flavour to beer, while the ‘hop character’ is derived from essential oils. In recent  years, there has been a  tendency to replace hop cones with various  types of  hop pellets,  powders  or extracts  including  pre-isomerized  hop  products which may be added after fermentation.  Boiling  serves two other functions: reducing the

potential for microbiological problems by effectively sterilizing the wort and coagulation of proteins followed by their removal as ‘trub’. Inadequate coagulation may adversely affect the subsequent   fermentation   due  to  interference   with   yeast:substrate   exchange   processes (membrane blocking) and lead to poor quality beer.

(d)  Fermentation

Fermentations are considered to be of two distinct types: the top fermentation used in production of ales, in which CO2  carries flocculated Sacch. cerevisiae to the surface of the fermenting vessel, and the bottom fermentation used in production of lagers, in which Sacch. carlsbergensis  sediments  to the bottom of the vessel.  Differentiation  on  the basis of the behaviour of the yeast is, however, becoming less distinct with the increasing use of cylindro- conical fermenters and centrifuges.

(e) Maturation (Conditioning; Secondary fermentation)

Maturation  may be considered  to  include  all transformations  between  the  end  of primary  fermentation  and  the  final  filtration  of  the  beer.  These  include  carbonation  by fermentation of residual sugars, removal of excess yeast, adsorption of various non-volatiles onto  the  surface  of  the  yeast  and  progressive  change  in  aroma  and  flavour.  During maturation, priming sugar may be added or amyloglucosidase used to hydrolyse dextrins.

1.1.2.2       The Production of Palm Wine

There are two main sources of palmwine  namely: raphia palm particularly Raphia vinifera and Raphia hookeri; and the oil palm: Elaeis guineensis. Palmwine is an alcoholic beverage  produced from the fermenting palm sap. The part tapped is the male inflorescence of a standing oil palm tree. The fermentable sugars present in palm wine are glucose, sucrose, fructose,  maltose,  and raffinose.  The  yeast  species  –  Saccharomyces  spp are responsible mainly  for  the  conversion  of  the  sugars  in  palm  sap  into  alcohol  as  well  as  oxidative fermentation of alcohol to acetic acid.

In  the  fermentation   of  natural  palm  wine,   lactic  acid  bacteria,   Lactobacillus

plantarium, Leuconostoc mentseriodes and Pediococcus cerevisiae are also involved. All of them utilize meyerhof parnas pathway which results in the formation of alcohol as well as organic  acids. The leuconostoc  mesenteriode  is a hetero-fermenter  and  ferments  sugar to produce acetic acid., lactic acid, ethanol and carbondioxide.  Lactobacillus plantarium is a homofermenter  and  ferments  sugars  to  produce  mainly  lactic  acid  and  small  amount  of

alcohol and carbondioxide.  Pediococcus cerevisiae is also a homo fermenter and  produces the same metabolites  as Lactobacillus  plantarium.  Thus, the bacterial flora  of palm wine contribute significantly to the fermentation of sugars to alcohol and the alcoholic constituent of palm wine varies with the species of palm tree from which the wine was tapped.

1.1.2.3    Production of Distilled Spirit

Nature  alone  cannot  produce  spirits  or  hard  liquor  by  the  simple  process  of fermentation.  Yeast  will  continue  to  carry  out  fermentation  until  the  alcoholic  content becomes  high.  The  process  of  distillation  then  helps  to  produce  beverages  with  higher concentration of alcohol in form of distilled spirit.

1.1.3    Absorption, Distribution and Metabolism of Alcohol

1.1.3.1 Absorption

After its ingestion, alcohol is rapidly absorbed into the blood stream from the stomach and small intestines. The rate of alcohol absorption can be delayed by the presence of food or milk in the stomach. It is a common observation that when several drinks are taken on an empty stomach, a far more rapid and profound effect is observed  than when an equivalent amount of alcohol is taken when there is food in the stomach.

1.1.3.2 Distribution

Alcohol gains access to all the tissues and fluids of the body. The concentrations of alcohol in the brain rapidly approach those levels in the blood because of the very rich blood supply to the brain and other organs such as the liver and the kidney. This is of obvious significance,   because   alcohol-induced   dysfunctions   in  several  organs   depend   on  the concentration and duration of exposure of the organs to alcohol.

1.1.3.3 Alcohol Metabolism

Two  major  pathways  of alcohol  metabolism  have been  identified  namely  alcohol dehydrogenase pathway and microsomal ethanol oxidizing system (MEOS).

1.1.3.3.1          Alcohol Dehydrogenase Pathway

The primary pathway for alcohol metabolism involves alcohol dehydrogenase (ADH), a cytosolic enzyme that catalyzes the conversion of alcohol to acetaldehyde. This enzyme is

located mainly in the liver but small amounts are found in other organs such as the brain and stomach.

During conversion of ethanol by ADH to acetaldehyde,  hydrogen ion is transferred from alcohol to the cofactor nicotinamide adenine dinucleotide (NAD+) to form NADH. As a net result, alcohol oxidation generates an excess of reducing equivalents in the liver, chiefly as NADH. The excess NADH production appears to contribute to the metabolic disorders that accompany  chronic  alcoholism  and  to  both  the  lactic  acidosis  and  hypoglycaemia  that

frequently accompany alcohol poisoning.

1.1.3.3.2          Microsomal Ethanol Oxidizing System (MEOS)

This enzyme system, also known as the mixed function oxidase system, uses NADPH

as a cofactor in the metabolism of ethanol and consists primarily of cytochrome P450 2E1,

4A2, and 3A4. At blood concentrations  below 100mg/dl (22 mmol/l), the MEOS  system, which has a relatively high Km for alcohol, contributes little to the metabolism of ethanol. However when large amounts of ethanol are consumed, the alcohol dehydrogenase system

becomes saturated owing to depletion of the required cofactor, NAD+. As the concentration

of ethanol increases above 100mg/dl, there is increased contribution from the MEO system, which does not rely on NAD+ as a cofactor.

During chronic alcohol consumption MEOS activity is induced. As a result, chronic alcohol consumption results in significant increases not only in ethanol metabolism but also in the clearance of other drugs eliminated by the cytochrome P450s that constitute the MEOS system, and in the generation of the toxic by-products of cytochrome P450 reactions (toxins, free  radicals  H2O2).  Metabolism  occurs  mainly  via  the  zinc–containing  enzyme  alcohol dehydrogenase  (ADH).  Other enzyme  systems,  such as the microsomal  ethanol oxidizing system (MEOS) or catalase system are capable of metabolising alcohol.

Oxidation of alcohol by ADH involves  the transfer of hydrogen  via  nicotinamide adenine  dinucleotide  (NAD),  which  is  converted  to  nicotinamide  adenine  dinucleotide reduced (NADH). The result of this oxidation is the metabolite acetaldehyde. The subsequent oxidation of acetaldehyde by aldehyde dehydrogenase also involves the reduction of NAD. Acetaldehyde  is metabolized  to acetate and this is  transformed  in to acetyl coenzyme  A, which is then oxidized by the citric acid cycle to carbon dioxide and water. The rate limiting step in this metabolic process is the oxidation of alcohol to acetaldehyde since acetaldehyde is metabolized faster than it is formed.

1.1.4    Patterns of Alcohol Use and Abuse

Patterns  of  alcohol  consumption  may  range  from  its  occasional  use  to  relieve emotional stress, to periodic “spree” drinking, to extreme cases where the alcoholic has little or no control over the amount of alcohol consumed. Chronic and excessive consumption of alcohol is a health and psycho-social disorder characterized by obsessive pre-occupation with alcohol  and  loss  of  control  over  alcohol  consumption  such  as  to  lead  continuously  to intoxication (Johansson et al., 2003). Chronic abuse of alcohol is typically associated with physical disability, social maladjustments, emotional and occupational impairments.

The hallmarks of excessive and chronic alcohol abuse are:

1.        Psychological dependence

2.        Physical dependence

3.        Tolerance (Martin et al., 2008).

1.1.4.1 Psychological Dependence

Psychological  dependence  is typically characterized  by intense  and  uncontrollable craving   for   alcohol.   The   alcoholics’   desire   for   alcohol   is   intense,   obsessive   and overwhelming. The alcoholics are deeply concerned about how daily activities interfere with drinking than how drinking negatively militate against the  performance  of daily activities. Family, relationships, friends, profession and business are relegated to subordinate roles with full joy. Alcohol consumption becomes the driving and motivating force (Johansson et al., 2003).

1.1.4.2 Physical Dependence

Excessive   and  chronic  consumption  of  alcohol  produces  unequivocal   physical dependence,   with  the  intensity  of  the  syndrome   associated   with   withdrawal  directly proportional to the level of intoxication and its duration. Excessive consumption of alcohol on chronic basis directly or indirectly adversely modifies the physical and mental health of the  abuser.  Intermediate  levels  of  alcohol  consumption  produce  withdrawal  symptoms typified by tremors or “shakes”, anxiety, sleeplessness and gastrointestinal upset.

Delirium tremens is one of the potentially risky withdrawal symptoms experienced by chronic abusers, when physical dependence has set in. Alcoholics that have delirium tremens suffer from restlessness, tremors, weakness, nausea and anxiety few hours after the last drink. Generally, these effects experienced by alcoholics on momentary withdrawal from alcohol serve as an impetus driving them to initiate another drinking bout in order to feel ‘normal’

again; thus, potentiating the physical dependence. The tremors could be so severe that  the alcoholic on resuming drinking finds it difficult to successfully navigate beer bottle or cup to his mouth yet he craves for more alcohol.

In  the  early  stages  of  this  withdrawing  syndrome  after  the  onset  of  physical dependence, the alcoholic is hyperactive and is a victim of auditory and visual hallucinations. The alcoholics could be heard shouting that cockroaches are crawling upon them; they see red lions and they may seriously believe that they are being attacked by dangerous animals or people. They are completely disoriented.

Progressively,   the   alcoholic   becomes   weaker,   agitated   and   confused.   These syndromes  coupled  with exhaustion  and fever  are called  ‘tremulus delirium’.  In  physical dependence the intensity of the syndromes associated with withdrawal as typified by tremulus delirium is related to the duration and level of alcohol abuse. Physical  dependence could develop from ethanol induced alterations in membrane components and functions (Cargiulo, 2007).

1.1.4.3 Tolerance

Alcoholics usually exhibit increased resistance to the intoxicating effects of alcohol and are often sober at blood alcohol concentrations that could be deadly in naïve occasional drinkers. Indeed, chronic alcohol abusers can readily ingest quantities of alcohol that would severely intoxicate the occasional drinker (Chiaochicy and Shijium, 2008).

Ethanol can cross the blood- brain barrier and enter the brain quickly. Blood alcohol level is almost always directly proportional to the concentration of alcohol in  brain tissue (Oscarberman and Marinkovit, 2003). However, despite increasing levels of alcohol in the blood, alcoholics usually exhibit decreasing response to the intoxicating effect of alcohol.

This  phenomenon   known   as  tolerance   could   be  explained   in  part  by   these mechanisms: first, tolerance could develop consequent upon alterations in the absorption rate, distribution, metabolism and elimination of alcohol from the body (Rottenburg, 1986). The resultant effect of these alterations is a reduction in the  duration and intensity of alcohol’s effects on the body tissues most remarkably the brain.

The second mechanism  involves alterations in the properties or function of  tissues rendering  them  less  vulnerable  to  effects  of alcohol  (Wilson  et al., 1984).  Tolerance  to alcohol  could  develop  as  a result  of  adaptive  alterations  in the  central  nervous  system.

Alcohol changes many specific membrane dependent processes such as Na+, K+ ATPase and

adenylyl  cyclase  process  in  the  cell  precipitating  ethanol-induced  alterations  in  neural

functions. It has been observed that after chronic exposure to alcohol, cellular  membranes often develop resistance to the fluidizing effect of alcohol (Goldstein, 1986). Ethanol-induced alterations  also  occur  in  membrane  components  and  functions   such  as  alterations  in membrane lipids, receptors, phosphatidylinositol,  GTP binding proteins, second messengers and neuro-modulator (Reynolds et al., 1990). Alterations in ion channels and transporters are also some of the ethanol induced  changes in human  cell membranes  related  to tolerance (Chastain, 2006).  Putting these observations in a functional perspective, it is salient to point out the fact that these adaptive changes in membrane components are exquisite phenotypic markers for genetic predisposition to alcoholism and its attendant problems (Das et al., 2008).

1.1.5    Aetiology/Causes of Alcohol Abuse

1.1.5.1 Biochemical basis

(a) Monoaminergic System

The enzyme monoamine oxidase (MAO) is the major degradative enzyme for both catecholamines  and  indoleamines.  It  has  been  shown  that  reduced  platelet  monoamine oxidase concentrations are closely associated with a remarkable predisposition to alcoholism (Patsenka,  2004)  and  psychiatric  vulnerability.  It  has  also  been  proposed  that  a  weak monoaminergic system causes predisposition to alcohol abuse (Raddtz and Parini, 1995).

Available evidence is becoming overwhelming in support of the view that sub class of alcoholics exists where genetic considerations are of etiological significance. These imposing factors appear to be reflected in low platelet monoamine oxidase (MAO). Low concentrations of platelet monoamine oxidase reflect a disturbance in the serotoninergic system (Chastain,

2006). Thus, the biochemical basis of alcoholism seems to involve combined aberrations in

some transmitter system. In essence, these aberrations have far reaching effects which are reflected in neuro-physiological, psychosocial and personality abnormalities.

(b) Tetrahydroisoquinolines

Biologically active chemicals called tetrahydroisoquinolines  are formed during  alcohol metabolism (Antkiewez et al., 2000). Catecholamines could also condense with aldehydes via a Pictet-Spengler  reaction  to  form  1,4-Disubstituted  tetrahydroisoquinoline  (Raddatz  and Parini,  1995).  Tetrahydroisoquinoline   such  as   tetrahydropapaveroline   changes  drinking behaviour from alcohol rejection to alcohol acceptance (Nappi and Vass, 1999).

The   Picket-Spengler    reaction   provides    a   useful    route   for   the   synthesis    of tefrahydrolsoquinoline  (TIQ). Many tetrahydroisoquinoline  are formed from  dopamine and

carbonyl  compounds  (phenylpyruvic  acids,  aldehydes  and  ketones)  two  catecholamine norepinephrine or epinephrines could also react resulting in the formation of diastereomeric

Fig. 1: 1,4-disubstituted TIQ occur in form of two diastereomers and their optical isomers

Furthermore,   ethanol   or   its   first   oxidation   product   acetaldehyde   can   induce catecholamines to undergo an unusual form of metabolism  that results in the  formation of

1,2,3,4-  tetrahydroisoquinoline.  Tetrahydroisoquinoline  compounds  have  biochemical  and neuropharmacological  properties.  They possess abilities to interact with  catecholaminergic and  dopaminergic   systems.   They  also   exert   a  potent  influence   on  Ca2+   binding  in synaptosomes  in  a  similar  manner  to  morphine  and  ethanol.  T1Qs  have  biochemical

associations with ethanol and is deeply involved in the aetiology of alcoholism (Raddtz and

Parini, 1995).

Patsenka (2004) showed that excessive and chronic consumption of alcohol by human alcoholics  could  be  caused  by  metabolic  abnormalities  that  result  in  the  formation  of tetrahydroisoquinolines. He reasoned that because drinking generates tetrahydroisoquinolines and   tetrahydroisoquinolines   stimulate   drinking,   the  positive   feedback   loop   could  be responsible  for  the  obsessive,  uncontrolled  and  habitual  drinking  by  alcoholics.  Thus, tetrahydroisoquinolines could be involved in the mediation of voluntary ethanol consumption habit  that  often  degenerates  to  heavy  intoxication,  physical  dependence  and  tolerance (Chastain, 2006).



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