Acetaminophen is metabolized by cytochrome P450 to N-acetyl-p-benzoquinone imine (NABQI). This metabolite reacts with critical cellular macromolecules to give toxicity. The administration of 10% ethanol in the drinking water to 100 g male rats for 6 weeks markedly increases the toxicity of acetaminophen. This increase was associated with a 71% increase in microsomal protein binding of acetaminophen [4.8pmol/min/mg protein in control microsomes versus 8.2 pmol/min/mg protein in ethanol microsomes (P < 0.01)] and a 131% increase in aniline hydroxylase [0.52 nmol/min/ mg protein in control microsomes versus 1.20 nmol/min/mg protein in ethanol microsomes (P < 0.001)]. On the other hand, cysteine conjugation of acetaminophen showed an increase of only 12% [2.8 nmol/ min/mg protein in control microsomes versus 3.1 nmol/min/mg protein in ethanol microsomes (P < 0.05)]. Ethylmorphine- and benzphetamine N-demethylases did not increase. In microsomes from both control and ethanol animals, imidazole (1 mM) inhibited the two N-demethylases, aniline hydroxylation and acetaminophen binding by 85-95% but inhibited the cysteine conjugation by only 50%. For control and ethanol animals, both 80% CO/20% O2 and SKF-525A (1 mM) totally inhibited cysteine conjugation but only inhibited the other activities by about 36-60%. KCN (1 mM) had no effect on any of the activities except protein binding (60-67% inhibition). Scavengers of reactive oxygen [mannitol (1 mM), dimethyl sulfoxide (1 mM), Superoxide dismutase (15 μg mL) and catalase (65 μg mL)] had no effect on any of the reactions. Of all these treatments only CO/O2 decreased the protein binding and cysteine conjugation of NABQI in the presence of either NADP+ or NADPH. The data from the inhibitor studies and the effect of ethanol on acetaminophen and NABQI metabolism would suggest that protein binding and cysteine conjugation are catalyzed by different isozymes of cytochrome P450. Finally, the current results indicate that the increased toxicity of acetaminophen observed with ethanol more closely parallels the increase in protein binding activity rather than cysteine conjugation.