|Year : 2011 | Volume
| Issue : 1 | Page : 61-63
Inhalant abuse: A cause for concern
Suravi Patra1, Ajaya Mishra2, Rajnikant Shukla2
1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry, Mental Health Institute, SCB Medical College, Cuttack, Orissa, India
|Date of Web Publication||12-Jul-2012|
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Inhalant abuse is of growing concern in adolescent and young adult population in the underdeveloped regions of the world. In the absence of availability of definitive tests in routine clinical settings, diagnosis is often difficult. Equally difficult is management and ensuring adherence to therapy. We report two successive cases of inhalant abuse seen at the outpatient department of the Department of Psychiatry, Mental Health Institute, SCB Medical College, Cuttack, Orissa, India. We report here two cases of inhalant abuse: one with an unusual mode of abuse and another with atypical clinical presentation.
Keywords: Dependence, India, inhalant abuse
|How to cite this article:|
Patra S, Mishra A, Shukla R. Inhalant abuse: A cause for concern. Ind Psychiatry J 2011;20:61-3
Traditionally, inhalant-related disorders have been classified as inhalant-use disorders and inhalant-induced disorders. Diagnostic and statistical manual-IV (DSM-IV) identifies inhalant-use disorders with the maladaptive pattern of use and inhalant-induced disorders with the toxic effects of the inhaled substances.  Although inhalants include glue, gasoline, anesthetic gases, and nitrites, epidemiological and pharmacological differences prompt only the former to be grouped as inhalants. Commonly used inhalants include gasoline, glue, spray paints, solvents, cleaning fluids, and the other assorted aerosols. The pattern of use include sniffing or snorting, huffing, and bagging. The use of inhalants is associated with a feeling of euphoria which is intensified by the hypercapnia and hypoxia caused by rebreathing from a closed bag. Adolescents who meet the criteria for dependence or abuse report coexisting delinquent behaviors, multiple drug abuse and dependence, and utilize mental health services for other emotional problems. Thus, inhalant abuse and dependence may be a marker of global vulnerability rather than an isolated problem. 
| Case Reports|| |
A 14-year-old boy was brought to the psychiatry outpatient department for having problems due to inhalation and ingestion of kerosene and petrol since 2 years. The boy was using kerosene by inhalation when sufficient quantity was not available for ingestion. He liked the smell of kerosene, which had prompted him to experiment by inhaling through the mouth of a kerosene container. He felt "nice" after inhaling. A pattern of use started that landed him into the habit of ingesting kerosene or petrol. He reported a consumption of approximately 250 ml of kerosene, which he managed to buy for Rs 10-15 in his village. He would ingest or inhale only when alone; he would feel "nice" and "happy" and would continue to do so until he felt drowsy, only to lock himself into a room for a good 2 h sleep. He admitted of not being able to remain without inhaling for more than a week. His scholastic performance had deteriorated. The cessation of fuel storage at home prompted him to steal money as well as to tell lies to procure money. No other features of conduct disorder were present. In spite of rigorous efforts by his parents and family members, he could not outgrow this habit.
He admitted to his problems with inhalant abuse but did not show any eagerness to get rid of the habit; instead, it appeared that he did not want to miss the high he experienced from the use of kerosene. A detailed workup by a psychiatrist and a clinical psychologist was done. He fulfilled the criteria for inhalant dependence syndrome by international classification of diseases-10 as well as by DSM-IV. No other mental disorder could be diagnosed. General physical examination was normal. Computerized tomogram and electroencephalogram were also within normal limits.
Education about harmful effects of inhalants, counseling, and behavioral therapy were started; unfortunately, the patient did not report for a follow-up and we are unable to report his present state.
A 21-year-old male presented to the emergency department with complains of fatigue and feelings of apprehension. After routine physical examination, his cardiological examination revealed a widely split second heart sound. This prompted the physicians to investigate for possible atrial septal defect. After detailed cardiological evaluations, which included an electrocardiogram and an echocardiogram, sinus tachycardia was diagnosed. Further history taking revealed that the patient had inhaled half a tube of dendrite (glue) preceding the incidence. A psychiatry consultation was sought by the Department of Cardiology. The patient admitted of using glue twice before with friends. He also reported of feeling a certain 'high' after inhalation. This created a sense of curiosity in him and he started inhaling glues episodically. He was occasionally consuming cigarettes and alcohol. Detailed psychiatric evaluation was done and he was diagnosed as having inhalant intoxication at the time of presentation. No other psychiatric comorbid conditions could be made out.
Supportive therapy in the form of counseling and education about harmful effects of inhalants were started. Behavioral therapy was administered and the patient is under regular follow-up.
| Discussion|| |
The onset of inhalant use disorder commonly starts in adolescence.  Existing Indian case reports affirm this fact, with the mean age of gasoline inhalers from Baroda being 13.6 years and that from Chandigarh being 11.4 years. , Routine enquiry about substance abuse/inhalant abuse is usually not made. Most epidemiological studies do not include questions for eliciting solvent abuse, causing poor recognition of magnitude of the problem.  Inhalant abuse is becoming a public health problem in India due to lack of awareness of general population as well as health professionals. 
Risk factors for inhalant use disorder include low socioeconomic status, severe family dysfunction, and history of physical or sexual abuse, mental health disorder, emotional problems, peer influence, and parental substance abuse.  Inhalants are cheap, easily available, and legal to procure. They are capable of producing a rapid euphoria. Their use cannot be detected after a few hours due to their volatile nature, making it easier for the user to conceal. There is a strong relationship between juvenile delinquency and inhalant abuse. Inhalant abuse may well be a gateway to other illicit substance abuse. Inhalant problems often herald serious alcohol and polysubstance use in adulthood and few of these adolescents become chronic, deteriorated inhalant-dependent adults. Among those with conduct disorders, half develop antisocial personality disorder. A majority of the users stop using inhalants after a brief period of experimentation, and only 4% develop dependence. 
Ingestion of kerosene has been reported in earlier case reports, the amount being only half a teaspoon, once in 15 days.  Our first case illustrates ingestion of kerosene of a much larger quantity and that too in a dependent manner. Fatal dose of kerosene ingestion for poisoning is 15-50 ml.  Probably, the stated amount of intake in this case consisted of both inhalation and ingestion extended over a period of several days.
The second case illustrates intoxication due to specific glue (dendrite). The patient had presented with generalized muscle weakness and euphoria. The cardiological adverse effect of inhalant noted was in the form of dysrhythmia, i.e., sinus tachycardia. The case detection by means of cross-referral from the Department of Cardiology shows growing awareness and decreased hesitation in seeking psychiatric help.
Diagnosis of inhalant abuse depends on the high index of suspicion and a thorough history taking by the clinician. The volatile nature of these substances evades detection in urine after a few hours. The various laboratory tests available include gas chromatography or mass spectroscopic procedures. The high costs involved in these tests virtually eliminate their use in routine clinical practice and resource constrained setup.
Treatment is generally supportive. Acute effects of intoxication such as coma, bronchospasm, arrhythmia, trauma, and burns may need emergency medical management. There are no standardized medication regimens or psychotherapeutic recommendations till date for the treatment of abuse or dependence. Medications may be needed for coexisting depression or alcohol abuse.
Residential care in a drug-free environment and improving the family support system along with building on the existing personal, social, and environmental strengths may help.
| References|| |
|1.||American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Washington DC: American Psychiatric Association; 2000. |
|2.||Wu LT, Pilowsky DJ, Schlenger WE. Inhalant abuse and dependence among adolescents in the United States. J Am Acad Child Adolesc Psychiatry 2004;43:1206-14. |
|3.||Basu D, Jhirwal OP, Singh J, Kumar S, Mattoo SK. Inhalant abuse by adolescents: A new challenge for Indian physicians. Indian J Med Sci 2004;58:245-9. |
|4.||Shah R, Vankar GK, Upadhyaya HP. Phenomenology of gasoline intoxication and withdrawal symptoms among adolescents in India: A case series. Am J Addict 1999;8:254-7. |
|5.||Das PS, Sharan P, Saxena S. Kerosene abuse by inhalation and ingestion. Am J Psychiatry 1992;149:710. |
|6.||Lubman DI, Hides L, Yucel M. Inhalant misuse in youth: Time for a coordinated response. Med J Aust 2006;185:327-30. |
|7.||Crowley TJ, Sakai J. Inhalant related disorders: In: Sadock BJ, Sadock VA, editors. Kaplan and Sadock"s Comprehensive textbook of psychiatry. 8 th ed. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 1247-57. |
|8.||Narayan Reddy KS. CNS Depressants. The essentials of forensic medicine and toxicology. 28 th ed. Publisher: K Suguna Devi, Hyderabad. 2009. p. 522. |