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Prohibition or Permission? Either Way, EDs Brace for Palcohol

Shaw, Gina

doi: 10.1097/01.EEM.0000469319.61765.09
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Patients with alcohol-related diagnoses already account for a fair number of emergency department visits, but now experts fear that number might spike with the introduction of an enticing new product: powdered alcohol, or Palcohol.

Those patients with at least one alcohol-related diagnosis accounted for approximately 3.5 percent of all emergency department visits in 2010, a number that crept steadily upward over the previous five years, according to a report from the National Institute on Alcohol Abuse and Alcoholism. (http://1.usa.gov/1PFdRmq.)

Whether that influenced the federal Alcohol and Tobacco Tax and Trade Bureau's waffling about the new product is unknown, but the TTB first approved the concentrated powder, which contains at least 55 percent alcohol by weight and 10 percent by volume, in April 2014, only to reverse its decision that same month, and then once again change its ruling by granting approval a year later.

The four powdered alcohol products come in airtight packages in a variety of flavors: cosmopolitan, margarita, rum, and vodka. Tuck the pouch in your purse or picnic basket, take it along anywhere you go, and just add water for an impromptu party. That's the idea, anyway. National Public Radio called it Country Time lemonade for grownups.

Palcohol is not even on the market yet, but the company is expected to start selling it this summer. At least 10 states have already banned it, with bills pending in dozens of others. U.S. Sen. Charles Schumer (D-NY) introduced an amendment in March to the federal Alcohol Administration Act with the Sober Truth on Preventing Underage Drinking Reauthorization (STOP) Act (S. 728) that would ban the production, sale, distribution, or possession of powdered alcohol nationwide.

One of the leaders behind a ban on powdered alcohol enacted in Maryland in March is emergency physician and Baltimore City Health Commissioner Leana Wen, MD. “We're trying to preempt this because we know it's going to cause significant harm. In the ED, we've all treated teens who have stopped breathing and died after consuming too much alcohol, or who fall and break limbs, or who don't know how much they've had to drink and drive drunk and injure or kill others. The last thing we need is more dangerous alcoholic products, and emergency physicians should be very concerned about this,” she said.

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In addition to temporary state bans instituted by the Maryland legislature, the Maryland State Licensed Beverage Association, the Maryland Beer Wholesalers Association, and the Licensed Beverage Distributors of Maryland voluntarily agreed to ban the distribution and sale of powdered alcohol.

Not only does Palcohol offer a new and easy avenue for alcohol abuse, but Dr. Wen cautioned that it could make it frighteningly simple to get someone drunk without their knowledge by slipping the powder into a nonalcoholic drink. “Or imagine putting powdered alcohol into vodka shots, and making an existing alcoholic drink even stronger,” she said.

Senator Schumer said he agreed. “This Palcohol can be the Kool-Aid for our kids. Drop one bag or many more in a glass of water, it's very easy to ingest a huge amount of alcohol quickly,” he said.

Potentially, the powder could even be hidden by mixing it with food. The company's website has been amended since last year, but when the product was first announced, it suggested: “Sprinkle Palcohol on almost any dish and give it an extra kick. Some of our favorites are the Kamikaze in guacamole, rum on a BBQ sandwich, Cosmo on a salad, and vodka on eggs in the morning to start your day off right. Experiment.»

“If it were up to me, I'd ban it,” said Leon Gussow, MD, a medical toxicologist, a lecturer at the University of Illinois Medical Center, and an instructor at John H. Stroger Jr. Hospital of Cook County, both in Chicago. “I'm certainly not in favor of making more alcohol available in any form, and certainly there is a potential that this will be easier for underage people to use.”

Dr. Gussow, author of The Poison Review website and EMN's Toxicology Rounds column, said he expects that problems are likely to surface quickly in states that do not ban Palcohol before it goes on the market. “We'll soon find out how bad the potential adverse effects will be. If I had to predict, I think it will be quickly taken off the market, but at this point it's unclear.”

Some hazards that were causing concern about Palcohol, such as snorting it for a quicker intoxicating effect, seem unlikely, said Dr. Gussow. “People have tried that, and it looks like it's pretty unpleasant, burning and causing headaches. An injection would be caustic and painful. If somebody were seeking a high, I'm not sure that there would be much that would offset the unpleasant effects of doing it this way.”

Palcohol creator Mark Phillips argued in a Baltimore Sun op-ed that the bans are irresponsible and hypocritical given the abuses of liquid alcohol. “While the intentions by legislators to ban powdered alcohol are good, a ban will actually cause more harm than good,” he wrote. “A ban heightens demand for the product, and the government has no control over distribution. It can be readily bought on the street.” (April 8, 2015; http://bsun.md/1E9LLsG.)

Mr. Phillips also debunked various concerns about the powdered product in videos on his website, www.Palcohol.com and on YouTube. (http://bit.ly/PalcoholVideo.) “[A]ll the hysteria about the dangers of Palcohol are unfounded. Anyone who makes those claims is either ignorant or just being untruthful to promote their agenda,” he said in the videos. He noted that surreptitiously adding a packet of Palcohol to a person's drink adds the equivalent of one shot of alcohol, which would be unlikely to incapacitate an unsuspecting victim.

If Palcohol comes to market, emergency physicians in states where it is not banned should be on the lookout for an increase in alcohol-related visits. Dr. Wen said she would like to see emergency medicine come together as a specialty to advocate for a nationwide ban.

“We emergency physicians are on the front lines,” she said. “We have to have a loud and active voice in the response. I would love it if the national emergency physician organizations could come together on this.”

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