|Year : 2008 | Volume
| Issue : 1 | Page : 55-58
Inhalant abuse in the youth : A reason for concern
J Simlai1, C.R.J Khess2
1 M.D., Assistant Prof. of Psychiatry, RINPAS, Kanke, Ranchi, India
2 M.D., Professor of Psychiatry, C.I.P., Kanke, Ranchi, India
|Date of Web Publication||13-May-2010|
M.D., Assistant Prof. of Psychiatry, RINPAS, Kanke, Ranchi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
In recent times Inhalant or Volatile substances are emerging as a major drug of abuse in the preadolescent and adolescent age group. Most of the children are from broken homes and poor backgrounds. Inhalants have serious immediate and longterm side-effects and can also cause sudden sniffing death syndrome. It is difficult to control this ever-growing problem because Inhalants or Solvents are widely available. Management issues have been discussed in the review.
Keywords: Inhalants, Volatile Solvents
|How to cite this article:|
Simlai J, Khess C. Inhalant abuse in the youth : A reason for concern. Ind Psychiatry J 2008;17:55-8
In most reviews, Inhalant or volatile substance abuse does not emerge as a major drug abuse problem (Kurtzman et al, 2001, Kaur et al, 2008). It is a poorly recognizable risk for both morbidity and mortality in the young all over the world. Most of the young abusers are unaware of the health threats posed by inhalation of solvents. The reason inhalants are used more by the young population, is the easy availability, convenient packaging, cost effectiveness, legality of solvents, quick intoxication (instant high) and peer group influences.
Epidemiology: The practice of inhalation to produce euphoria was practiced by the ancient Greeks. Humphry Davy discovered the 'mind altering effects' of nitrous oxide and shared these experiences with friends in private parties. Subsequently ether and chloroform were discovered, which are still used by inhalant abusers. The 20th century led to the discovery of gasoline and other volatile substances. The University of Michigan's Monitoring the future study, reported lifetime prevalence of 20.5%, 18.3% and 15.2% in 8th, 9th and 10th grade students, respectively. The National Household Survey of Drug Abuse reported lower rates of lifetime prevalence, but it revealed few interesting facts like, higher rates are seen in those from lower socio economic background, chaotic broken homes and abusive families (Kurtzman et al 2001). The National Epidemiological Survey of Alcohol and related condition reported that 0.02% of 18 years or older met the criteria for Inhalant abuse for past year (Grant et al 2004). From India, studies were conducted by Das et al (1995), Pahwa et al (1998), Shah et al (1999), Duggal & Khess (2001), and Basu et al (2004). Most of the studies had addressed the issue of patterns and type of abuse and the risk factors of abuse. Though more research is required before we get an exact idea of the extent of this problem, yet certain important facts have emerged in the forefront like this and are becoming a growing menace in pre-adolescent and adolescent children. It is more prevalent in those with poorer backgrounds and broken homes. It is emerging as an important 'gateway drug' worldwide, including India. With growing industrialization and urbanization in recent times, lots of slums have sprouted all over the country giving rise to a young population at risk for inhalant abuse 'the street children'.
Classification of Inhalants : There are various ways of classifying Inhalants and also the Inhalant abusers (Sharp & Rosenberg 1997). A simple and useful pharmacological classification of Inhalants is given below:
Group I -
Group II - Nitrous Oxide (laughing gas)
- Volatile Solvents - toluene, acetone, methylene chloride, ethyl acetate, TCE etc
- Fuels - butane, propane, gasoline, octane, etc.
- Anesthetics - ether, halothane, enflurane, ethyl chloride, etc.
Group III -Volatile alkyl nitrites: Cyclohexyl nitrite, isobutyl nitrite, butyl nitrite, isopropyl nitrite, etc
The term 'inhalant' encompasses a wide range of pharmacologically diverse substances that readily vapourize. They are not classified as per a specific central nervous system action. As per DSM IV (APA, 1994) Inhalant use disorders include volatile solvents, but dependence on anesthetics or nitrites are classified elsewhere. Inhaled substances generally fall into the following families: -
Methods of Abuse: The various methods of abuse are as follows: -
- Aliphatic Hydrocarbons
- Alkyl Halides
- Aromatic Hydrocarbons
- Ethers, and
The primary objective in inhaling volatile substances is to deliver the highest concentration of the substance to the lungs and brains.
- Sniffing (Snorting) - This involves inhalation of vapours directly from an open container or a heated pan.
- Bagging - This involves inhalation of vapours from a plastic or paper bag containing the substance.
- Huffing - This involves oral inhalation of vapours by holding a piece of cloth soaked in the substance against the nose and mouth.
- Glading - Refers to inhalation of air-freshener and aerosol.
- Dusting - Refers to abuse of computer and personal electronic cleaning material by placing the canister straw to the mouth or nose.
Immediate Effects (of inhalants): The initial effect is a stimulating 'rush', then light-headedness, excitation and impulsivity. Intoxication lasts for few minutes but can be prolonged for several hours by repeated inhalation. Four stages of development of symptoms have been described.
Long Term Effects(Medical Consequences) of Inhalant Abuse : Inhalants have a long-term effect on almost every system of the body (Anderson & Loomis 2003).
- Stage One - This is the excitatory stage and includes symptoms like euphoria, excitation, dizziness, hallucinations, sneezing,coughing, excess salivation, intolerance to light, nausea, vomiting, flushed skin and bizarre behaviour.
- Stage two - This is the stage of early nervous system depression and includes confusion, disorientation, dullness, loss of control, ringing/buzzing in the head, blurred/double vision, cramps, headache, insensitivity to pain and paleness.
- Stage three - This is the stage of medium central nervous system depression and includes drowsiness, muscular in coordination, slurred speech, depressed reflexes, nystagmus/rapid involuntary oscillations of eyeballs.
- Stage Four - This is the stage of late central nervous system depression and includes unconsciousness, bizarre dreams, epileptiform seizures and E.E.G changes.
1. Pulmonary Effects: Volatile substances may displace oxygen and cause hypoxia. At critical levels can cause unconsciousness. Hydrocarbon vapours cause chemical pneumonitis, further worsening hypoxia.
2. Central Nervous System Effects : This is the most vulnerable system to the toxic effects of inhalant, which act as CNS depressants. Neurons are particularly susceptible to the solvent properties due to their high lipid content. In chronically exposed individuals two major consequences are a peripheral neuropathy and encephalopathy. The major neurologic syndromes are:
- Encephalopathy: Acute & chronic
- Central Ataxia
- Peripheral Neuropathy
- Cranial Neuropathy (mainly V & VIIth Cranial nerves)
- Parkinsonism More Details
- Visual Loss (Optic neuropathy)
3. Renal System Effects: The Toluene containing compounds are especially toxic to the kidneys because it inhibits active proton secretion in the distal tubule and collecting duct. This results in renal tubular acidosis and recurrent calculi formation (Kaneko et al, 1992). Hydrocarbon solvents are related to formation of glomerulonephritis. The major renal consequences are-:
4. Hepatic Effects : The hepatotoxic effects of tetrachloride have been known since long, but the centrilobular necrosis may be caused by metabolic effect rather than the compound itself. The free radicals produced in the kidneys and liver may cause the peroxidation and epioxidation of the hepatocyte cell membrane. Chlorinated hydrocarbon vapours and chloroform are known to cause toxic hepatitis. Hepatic destruction has been reported with trichloroethane and trichloroethylene too.
- Distal tubular acidosis
- Interstitial nephritis (leading to renal failure)
- Recurrent renal calculi formation
- Proximal tubular acidosis (less common)
5. Hematologic Effects : Methylene chloride increases carboxyhaemoglobin levels, which may become sufficiently high to cause brain damage or death. Organic nitrites produces methaemoglobinaemia and haemolytic anemia. Benzene can cause aplastic anemia and acute myelocytic leukemia, lymphomas and multiple myelomas.
6. Teratogenic Effects : Inhalants cross the placenta easily because they are highly lipophilic. Toluene is associated with fetal malformations like oral clefts, micrognathia, microcephaly, retarded growth and developmental delay. Toluene and some hydrocarbons can also cause spontaneous abortion or premature delivery (Jones & Balster,1998, Arnold et al, 1994, Khattak et al,1999).
7. Cardiac Effects : The Cardiac effects are acute and can be fatal at times. Sudden sniffing death syndrome (SSDS) is caused by arrhythmias. Hydrocarbon sensitize myocardium to epinephrine. At low doses hydrocarbons cause mild hypotension and tachycardia, but at high doses cause decreased cardiac output and bradycardia. Nitrates and Nitrites can cause vasodilatation and pooling of blood in lower limbs leading to orthostatic hypotension and syncope.
Diagnosis : The diagnosis can be made based on the clinical presentation and investigations. The clinical presentation would be characterized by signs and symptoms and behaviours described earlier in this article. Apart from that there may be a distinct odour of the substance in the breath or the clothes of the individual (AAP,1996). Severe drying of facial skin and mucous membrane can be seen in chronic abusers. Cracking of skin may lead to perioral and perinasal pyodermas (Huffer's rash) due to bacterial infection (Henretig,1996)
Investigations include complete blood count, oxygen saturation, serum electrolytes, liver function tests, serum creatinine, blood urea, nitrogen, blood glucose and urinanalysis. Urine toxicology can be done to rule out other substances in polysubstance abuse. Chest X-Ray and E.C.G and other additional tests can be done in chronic abusers with systemic complications (Dinwiddie,1994).
Management: The golden dictum of Addiction Psychiatry -' Prevention is better than cure', holds good for Inhalant Abuse too. Prevention would be easier said than done as the adolescents and preadolescent abusers often report poor family relations, disrupted living situations, academic problems and exposure to drug abusing peers. Further, the inhalants are widely and easily available substances. So, in the presence of poor family and social support and the easy availability of inhalants prevention would not be an easy job. Education is the cornerstone of prevention. Health education regarding inhalants can be incorporated in the school curriculum in the primary school levels itself. Non-Government Organizations (N.G.Os) and other social organizations should be made aware of this menace. General Physicians too could be trained and made aware of the condition, so that they participate in the endeavour to control this problem. The American Academy of Pediatrics has established recommendations regarding the role of pediatricians in the prevention, identification and management of Inhalant Abuse (Kulig, 2005). Maybe we should pick up cues from these recommendations and have something implemented in our own country on similar lines. History of current use, as well as prior abuse is helpful in the management. A careful medical examination, which includes cognitive and neurological assessment, is necessary. Often patients will be brought in intoxication or with life threatening injury (Henretig,1996), so the patient's airway breathing and circulation have to be stabilized. Cardiopulmonary monitoring is required because of the risk of Cardiac arrest and CNS depression with apnoea. Close observation and hydration with normal saline is necessary. The non-pharmacological management should focus on psychosocial issues like the patient's peer group, family and issues pertaining to the individual, like dynamics of the individual's abuse and life-skills. Workers have developed "peer patient advocate" system, where peers already on treatment have been involved. Family involvement should be sought. Aftercare planning, involving issues like availability of Inhalants, residual cognitive impairment and poor social functioning, are also important.
| Conclusion|| |
Since Inhalants are freely and legally available and are abused by preadolescent and adolescent population, this has become a cause for great concern. The Inhalants have a wide range of adverse effects on all the major systems of the body, specially the central nervous system. Inhalants may lead to polysubstance and Intravenous drug use (Dinwiddie et al,1991,1992, Schutz et al,1994, Young et al,1999) and it may lead also to suicidal behaviour and criminal behaviour (Howard & Jenson,1999). Further it may cause sudden sniffing death syndrome.
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