Noah Vinter
Alcohol biomarkers are used to detect alcohol consumption or harmful alcohol use, offering an objective verification of self-reported alcohol consumption. While blood alcohol testing is the most accurate method of measuring the amount of alcohol in the body, alcohol can also be measured in samples of a person's sweat, hair, urine, breath, and saliva. Blood biomarkers of alcohol use include Carbohydrate-deficient transferrin (CDT), Phosphatidylethanol (PEth), and ethyl glucuronide and ethyl sulfate (EtG/EtS). CDT is the most widely used blood biomarker for alcohol use and is regarded as one of the most reliable biomarkers for heavy alcohol consumption. PEth levels can be used to identify individuals with chronic excessive drinking behavior, as they are closely aligned with the amount of alcohol consumed. At-home alcohol testing methods include breathalyzers and wearable alcohol biosensors like BACtrack Skyn, which can provide near real-time estimates of blood alcohol concentration (BAC).
| Characteristics | Values |
|---|---|
| Blood biomarkers | Blood Alcohol Concentration (BAC), Phosphatidyl ethanol (PEth), Fatty acid ethyl ester (FAEE), Carbohydrate-deficient transferrin (CDT), Beta-Hex, MCV, AST, ALT, GGT, CETP |
| Other methods | Hydrometer, Refractometer, Gas chromatography, Breathalyzer, Urine test, Sweat test, Hair test, Saliva test |
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Serum ethanol testing
The test measures the amount of ethanol in the blood, which is absorbed rapidly from the gastrointestinal tract. Peak blood levels usually occur within 40 to 70 minutes on an empty stomach, and food in the stomach can decrease the absorption of alcohol. The level of intoxication (and peak) is influenced by age, gender, weight, the presence of food in the stomach, the number of drinks per hour, the percentage of alcohol in the drink, and the presence of other drugs that interact with the alcohol.
It is important to note that serum ethanol testing has a limited window of accuracy. It is only reliable within the first 6 to 8 hours after the last drink, and the test should be administered within a 6- to 12-hour window for the most accurate results. Additionally, test results may vary depending on the individual's age, gender, health history, and other factors, as well as the specific laboratory conducting the test.
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EtG and EtS markers
Ethyl glucuronide (EtG) and ethyl sulfate (EtS) are direct metabolites of ethanol and are considered good markers of acute, short-term alcohol ingestion. EtG and EtS are sensitive markers that can detect alcohol consumption within the last 24 hours. However, some tests may detect alcohol up to 80 hours after the last drink, but the chances of a false negative increase after the first 24 hours.
EtG and EtS tests are typically conducted on urine samples, which is the most widely used specimen type for drug testing due to its ease of collection and analysis. However, these markers can also be detected in blood tests, where they can indicate alcohol consumption up to 24 hours after the last drink.
It is important to note that EtG and EtS markers do not distinguish between alcohol exposure and consumption at low levels. Therefore, disciplinary or legal action should not be based solely on the detection of these markers. Instead, a combination of markers and clinical evaluations should be considered.
Additionally, elevated urine concentration can increase EtG and EtS levels, which may be influenced by factors such as the number of analytes present. As a result, normalizing reported values to adjust for concentration is crucial, especially for lower levels of EtG and EtS.
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CDT markers
Carbohydrate-deficient transferrin (CDT) is a biomarker that can be used to detect recent harmful levels of alcohol consumption. CDT is one of the most accurate indirect biomarkers, with a sensitivity of 77% at detecting chronic alcohol abuse. CDT tests are often used in conjunction with other biomarkers to monitor long-term abstinence.
The test works by establishing the percentage of transferrin that is carbohydrate deficient. Transferrin is produced in the liver and is responsible for "transferring" iron molecules from the intestine to organs and cells that require iron to function. Typically, transferrin has carbohydrates attached to it, but when someone consumes alcohol at a rate of five units per day, the liver is unable to produce transferrin in the same way, leading to a reduction in the number of carbohydrates attached to the transferrin.
Healthy individuals with no or low reported alcohol consumption will have a CDT level of less than 1.7%. Elevated levels of CDT suggest recent heavy alcohol consumption, especially if other liver-associated enzymes, such as GGT, are also elevated. However, it is important to note that certain rare liver disorders can also increase CDT levels.
CDT tests are useful for detecting binge drinking or daily heavy drinking, defined as consuming at least 15 drinks per week for men and eight drinks per week for women. The consumption of 50 to 80 grams of alcohol every day for a week induces a rise in CDT levels, which then decline with a half-life of 14 to 17 days.
While CDT testing is a reliable method for detecting heavy alcohol consumption, it is an indirect marker, and its accuracy can be influenced by factors such as medication, health issues, and previous consumption. Direct markers, such as PEth, are considered more accurate.
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PEth markers
Phosphatidylethanol (PEth) is a direct ethanol metabolite and a highly specific and sensitive modern alcohol testing method used to identify alcohol consumed within the previous 4 weeks. It is a reliable marker of unhealthy alcohol use.
PEth is formed in the body only when alcohol is consumed. Phosphatidylethanols are a group of phospholipids formed exclusively in the presence of ethanol. PEth 16:0/18:1 is measured as a specific alcohol biomarker. Unlike CDT and LFT markers, PEth is not influenced by any liver disease, making it useful in monitoring heavy drinkers with hepatic pathology. PEth is more sensitive than the indirect alcohol marker CDT (carbohydrate-deficient transferrin). PEth levels rise even after a single drinking episode.
The Alcohol Use Disorders Identification Test (AUDIT) and its short form, the AUDIT-C, are the main clinical instruments used to identify unhealthy drinking behaviours. However, they are influenced by memory bias and under-reporting. In contrast, PEth in blood has emerged as a marker of unhealthy alcohol use. PEth testing can determine heavy, moderate, and minimal alcohol use. It is less invasive and more specific than alcohol marker blood tests.
PEth levels are evaluated against the following three tiers for interpretation:
- <20 ng/ml – Light or No Consumption – Supports claim of abstinence or low alcohol consumption up to a month prior to specimen collection.
- 20-200 ng/ml – Significant Consumption – Indicates a moderate level of alcohol consumption up to a month prior to specimen collection.
- >200 ng/ml – Heavy Consumption – Indicates Excessive alcohol consumption up to a month prior to the specimen collection.
PEth testing can be used to monitor alcohol consumption, identify early signs of harmful alcohol consumption, and track cases of alcohol use disorder or dependence.
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Gas chromatography
The technique involves passing a sample through a stationary phase (typically a column packed with a stationary phase material) and a mobile phase (usually a gas) under specific conditions. This process separates the individual components of the sample, allowing for the accurate and reliable quantification of the alcohol component. The amount of alcohol present in the sample is determined by comparing the peak area of the ethanol component to the peak area of the internal standard, which provides the concentration of alcohol in the blood sample as a percentage.
GC is commonly used to analyse BAC, which is the amount of alcohol present in a person's bloodstream. This information is crucial for determining if an individual is driving under the influence of alcohol and enforcing drunk driving laws. The legal limit for BAC varies across the globe, but it is typically set at 0.08% or lower.
In addition to its use in forensic toxicology, GC is also employed in the beverage industry to measure the percentage of alcohol in beer, wine, and other alcoholic drinks. Manufacturers may utilise laboratories that offer advanced techniques, including gas chromatography, to analyse their beverages.
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Frequently asked questions
Ethanol, ethyl glucuronide (EtG), and ethyl sulfate (EtS) are the most specific markers for detecting acute alcohol exposure.
Carbohydrate-deficient transferrin (CDT) and phosphatidylethanol (PEth) are specific markers for detecting chronic alcohol use.
Gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) are some of the nonspecific markers used to detect alcohol consumption.
Gas chromatography is the typical test methodology used to measure toxic alcohol concentrations. Other methods include high-pressure liquid chromatography (HPLC) and multi-capillary electrophoresis.
Serum ethanol testing provides the most accurate determination of a patient’s alcohol level. However, it is not reliable beyond the first 6-8 hours. EtG and EtS are also considered good markers of acute, short-term alcohol ingestion.
