sign in sign up
<<
Home , Inhalant

Review Article

Substance abuse and : mass in Khartoum

Fath Al Alim AbdulRahim, MRCPsych, FRCPsych*, Abdulghani Al Shiekh, MRCPsych**,

Department of Psychiatry, University of Medical Sciences and Technology, Khartoum, Sudan * Department of Psychiatry, El Ribat University, Khartoum, Sudan**

د. ﻓﺘﺢ اﻟﻌﻠﻴﻢ ﻣﺤﻤﺪ ﻋﺒﺪاﻟﺮﺣﻴﻢ, د.ﻋﺒﺪاﻟﻐﻨﻲ اﻟﺸﻴﺦ ﻏﺒﺪاﻟﻐﻨﻲ

اﻟﺘﺴﻤﻢ ﺑﺎﻟﻤﻴﺜﺎﻧﻮل ﻟﺪى ﻣﺠﻤﻮﻋﺔ ﻣﻦ اﻟﻤﺸﺮدﻳﻦ ﺑﻮﻻﻳﺔ اﻟﺨﺮﻃﻮم

اﻟﺨﻼﺻﺔ ﻳﻌﺘﺒﺮ اﻟﻤﻴﺜﺎﻧﻮل أو اﻟﻜﺤﻮل اﻟﻤﻴﺜﻴﻠﻲ ﻣﻦ أﺑﺴﻂ أﻧﻮاع اﻟﻜﺤﻮﻟﻴﺎت ﺗﺮآﻴﺒﺎ و ﻳﺤﻀﺮ ﺑﺎﻟﺘﻘﻄﻴﺮ اﻹﺗﻼﻓﻲ ﻟﻠﺨﺸﺐ ﻟﺬﻟﻚ ﺳﻤﻲ (آﺤﻮل اﻟﺨﺸﺐ ).اﻟﻜﺤﻮل اﻟﻤﻴﺜﻴﻠﻲ ﻳﺴﺘﻌﻤﻞ آﻤﺎدة ﻣﺬﻳﺒﻪ ﻓﻲ اﻟﻜﻠﻮﻧﻴﺎت واﻟﻌﻄﻮر وﺑﻌﺾ اﻟﻤﺮآﺒﺎت اﻟﺼﻨﺎﻋﻴﺔ آﻤﺎ ﻳﻮﺟﺪ ﻓﻲ اﻟﺨﻤﻮر اﻟﻤﺼﻨﻌﺔ ﻣﺤﻠﻴﺎ . وﻟﺮﺧﺺ ﺛﻤﻦ اﻟﻜﺤﻮل اﻟﻤﻴﺜﻴﻠﻲ ﻣﻘﺎرﻧﺔ ﺑﺄﻧﻮاع اﻟﻜﺤﻮل اﻷﺧﺮى ﻓﻬﻮ ﻳﺴﺘﻌﻤﻞ ﻹذاﺑﺔ هﺬﻩ اﻟﻤﻮاد أو ﻳﺘﻢ أﺿﺎﻓﺘﻪ ﻟﻠﻜﺤﻮل اﻷﻳﺜﻴﻠﻲ آﻤﺎ ﺣﺪث ﻣﺆﺧﺮا ﺑﻮﻻﻳﺔ اﻟﺨﺮﻃﻮم ﻋﻨﺪﻣﺎ أﻗﺪم ﻋﺪد ﻣﻦ اﻟﻤﺸﺮدﻳﻦ ﻋﻠﻰ ﺷﺮب ﻣﺎدة اﻷﺳﺒﻴﺮت ﺑﺎﻷﺻﺎﻓﺔ اﻟﻰ ﻣﻮاد ﺳﺎﻣﺔ أﺧﺮى ﻣﺜﻞ اﻟﻤﺬﻳﺒﺎت اﻟﻄﻴﺎرة ﻣﻤﺎ أدى ﻟﻮﻓﺎة ﺣﻮاﻟﻰ 71 ﺷﺎب وﺷﺎﺑﺔ ﺗﺘﺮاوح أﻋﻤﺎرهﻢ ﺑﻴﻦ 13-25 ﻋﺎﻣﺎ ﻣﻦ ﻓﺌﺔ اﻟﻤﺸﺮدﻳﻦ ﺗﻢ اﻟﻌﺜﻮر ﻋﻠﻰ ﺟﺜﺚ ﺑﻌﻀﻬﻢ ﻓﻲ أﻣﺎآﻦ ﻣﺘﻔﺮﻗﺔ ﻣﻦ اﻟﻌﺎﺻﻤﺔ اﻟﻤﺜﻠﺜﺔ وﺗﻮﻓﻲ ﺑﻌﻀﻬﻢ ﺧﻼل ﺳﺎﻋﺎت ﻣﻦ وﺻﻮﻟﻬﻢ اﻟﻤﺴﺘﺸﻔﻴﺎت, آﻤﺎ ﺗﻢ ﻋﻼج أﻋﺪاد أﺧﺮى وﺧﺮوﺟﻬﻢ ﻣﻦ اﻟﻤﺴﺘﺸﻔﻴﺎت. هﺪف اﻟﺒﺎﺣﺜﺎن ﻓﻲ هﺬﻩ اﻟﻤﺮاﺟﻌﺔ اﻟﻌﻠﻤﻴﺔ اﻟﻰ زﻳﺎدة اﻟﻤﺎم اﻷﻃﺒﺎء وﺧﺎﺻﺔ أﻃﺒﺎء أﻗﺴﺎم اﻟﻄﻮارئ ﺑﺎﻷﺿﻄﺮاﺑﺎت اﻟﻨﺎﺗﺠﺔ ﻋﻦ اﻟﺘﺴﻤﻢ ﺑﻤﺎدة اﻟﻤﻴﺜﺎﻧﻮل واﻟﻤﺬﻳﺒﺎت اﻟﻄﻴﺎرة وﻃﺮق ﻣﻌﺎﻟﺠﺘﻬﺎ ﺑﻬﺪف اﻟﺘﻘﻠﻴﻞ ﻣﻦ ﻧﺴﺒﺔ اﻷﺿﺮار واﻟﻮﻓﻴﺎت. ﺧﻠﺼﺖ اﻟﻤﺮاﺟﻌﺔ اﻟﻰ ﺿﺮورة ﻧﺸﺮ اﻟﻮﻋﻲ ﻓﻲ وﺳﺎﺋﻞ اﻷﻋﻼم ﻋﻦ ﺧﻄﻮرة أﺳﺘﻌﻤﺎل هﺬﻩ اﻟﻤﻮاد وآﺬﻟﻚ ﻟﺪى ﺟﻤﻴﻊ اﻟﻌﺎﻣﻠﻴﻦ ﻓﻲ اﻟﺤﻘﻞ اﻟﺼﺤﻲ واﻟﺘﻌﻠﻴﻢ وأوﻟﻴﺎء اﻷﻣﻮر ﺑﺎﻷﺿﺎﻓﺔ اﻟﻰ ﺗﺄﻣﻴﻦ ﺧﺪﻣﺎت اﻟﺘﺪﺧﻞ اﻟﻔﻮري ﻓﻲ ﻣﺜﻞ هﺬﻩ اﻟﺤﺎﻻت اﻟﻄﺎرﺋﺔ وذﻟﻚ ﺑﺄﻧﺸﺎء ﻣﺮاآﺰ ﻣﺘﺨﺼﺼﺔ ﻟﻬﺬا اﻟﻐﺮض ﻟﺘﻘﺪﻳﻢ اﻟﻤﺸﻮرة و اﻟﻌﻼج.

Background with no after effects. As per the director of the During the last week of last July 2011 a surge hospital morgue, 38 deaths were attributed to of volatile -related mortalities and methanol intoxication and these were found morbidities was reported in Khartoum State scattered in various locations in Omdurman by local newspapers and internet market(3). Investigations by law enforcement websites(1,2,3). An estimated 71 deaths were agencies resulted in confiscation of 84 bottles reported among 13-25 years old homeless of methanol (500ml/bottle) and it was alleged youth who consumed methanol and other that the substance was leaked for illicit use by toxic substances. Attention was drawn to the perfumers in Omdurman market(3). It is nature of the problem when a homeless female worthy to note that official statistics by adolescent presented to Omdurman teaching Khartoum state government indicated that the hospital emergency department with severe number of homeless people in the state is exhaustion and drowsiness and died within 2 estimated to be 9350;3200 were given shelter hours due to intoxication. and only about 956 were reunited with their Subsequently, a flow of similar patients families (1-3). continued to arrive. Three patients developed Public concern is legitimate as to whether this permanent blindness and 36 were released mass methanol poisoning is an isolated phenomenon or just the tip of an iceberg of an ______epidemic proportion. Obviously, the Corresponding author magnitude of this problem requires much Fath Al Alim AbdulRahim needed epidemiological studies. Email: [email protected] The purpose of this communication is to Fax: 0024983224799 increase awareness of medical practitioners

1 Sudan Med J 2012 April;48(1)

Review Article Methanol poisoning Fath AA AbdulRahim specifically those working in emergency units Volatile that are often abused by about the medical and neuropsychiatric youth include glue, paint thinner, paint, aspects of volatile solvent-related disorders. , , lighter fluid, rubber Keywords: volatile solvent abuse, methanol cement, shoe conditioner, etc...(4,5,6). mass poisoning, Sudan propellants can also be abused by spraying The terms abuse, solvent abuse and directly into the mouth or inhaled from a volatile substance misuse are used balloon or bag, and include hairspray, spray interchangeably in the literature to indicate the paint, spray , cooking spray and deliberate ingestion or of the computer cleaning dusters(5). substance for its intoxicating and mind- The substance is typically inhaled by sniffing altering effects. directly from a container or via a soaked rag Volatile solvents are a large diverse group of or inhaled directly from a plastic bag with chemical compounds contained in multiple high concentration of fumes. The solvent may household and industrial products. A solvent be ingested accidentally by children, or is a chemical in a liquid or semi-solid state intentionally as a suicidal attempt or for that dissolves other substances, the word intoxication purposes(5,6,7). The commonly “volatile” refers to the rapid evaporation of abused volatile substances are shown in Table the chemical when exposed to air. 1. Epidemiological studies have shown that nearly 90% of abusers use -containing substances(8,9).

Table1: Commonly abused volatile substances and their sources(4). Volatile substance Product source 1. , isobutane, cigarette lighter refills, fuel gas, aerosol propellants 2. chlorofluoracarbons(halons) , , fire extinguishers 3. toluene, , adhesives, paints, thinners 4. 1,1,1-trichloroethane, (trilene), typewriter correcting fluid, degreasing agents, dry tetrachloroethane cleaning fluid

Epidemiology findings indirectly indicate that there is a Solvent abuse is a popular practice worldwide problem that needs to be urgently addressed. because these substances are easily accessible, Volatile solvent abuse is frequently observed legal, inexpensive, and easily concealed(5,6). among impoverished teenagers and young There is a paucity of epidemiological studies adults in the low socioeconomic strata(5,6,9). in indexed journals about the magnitude of the According to the 2007 National Survey on problem in the Sudan let alone the Use and Health, USA, approximately biopsychosocial profile of abusers. SABAH 775,000 people were inhalant users, an Association for Children and Development in estimated 23.5 million people older than 12 association with other nongovernmental years reported trying an inhalant use at least organizations conducted a survey covering 75 once and about 3-4% of American teenagers in Khartoum state reported high engage in sniffing on a regular basis(8). In the prevalence of volatile , United Kingdom, 3.5-10% of children particularly glue, among both genders; younger than 13 years have abused volatile polysubstance abuse was reportedly substances and 0.5(1%) were reported to be prevalent(10). The recent locally reported long-term users (9). methanol mass poisoning with subsequent In low-income families in Sao Paolo, Brazil, high mortalities and morbidities among 24% of children had inhaled volatile abusers and the international literature substances at sometime(9). In Singapore, 2 Sudan Med J 2012 April;48(1)

Review Article Methanol poisoning Fath AA AbdulRahim toluene sniffing was reported to have reached literature(7,23). The content of some epidemic proportions at one time(11). In 2005, toxic may exceed that of many it was reported that a high proportion of street conventional alcoholic beverages. Financial children in were abusing toluene- constraints and ease of availability are factors containing substances, citing easy access, leading to their abuse as cheap substitutes for affordability and a regular “high” as reasons alcohol. Ethylene glycol is complex for usage(12). The 2005 World Drug Report and not fully understood, but is mainly due to found that inhalant abuse had increased in 11 severe metabolic acidosis caused by its countries in 2003 compared to previous metabolite glycolate and to calcium oxalate years(13). Youth in developed nations generally precipitation in different organs including the report using volatile solvents because of peer brain and the kidneys(23). Isopropanol is found pressure, curiosity and defiance, whereas in alcohol swabs, cleaning supplies, paint those in underdeveloped nations are more thinners and perfumes. Ingestion causes likely to use solvents as a coping mechanism central (CNS) to suppress hunger and escape which manifest with lethargy, ataxia, , impoverishment(13,14). while its irritant effect in the gastro-intestinal Mass poisoning with methanol, much like the tract results in abdominal pain, haemorrhagic recent outbreak in Khartoum, is rare, but has gastritis and vomiting(23). Unlike methanol been reported in both developed and and ethylene glycol, isopropanol does not developing countries(15-22). In an outbreak of cause metabolic acidosis. methanol mass poisoning in Estonia, 154 Methanol, known as wood alcohol, is a highly patients were poisoned resulting in the death toxic, colourless and odourless volatile liquid of 68(44%), 20(18%) patients survived with that is found commonly in household products permanent sequelae including impaired vision like antifreeze, varnish, paint remover, paint and brain damage(17). The prognosis was thinners and windshield wiper fluid. Methanol reported to be related to the degree of can be absorbed by the gastrointestinal tract, metabolic acidosis, serum methanol through the skin or by inhalation and peak concentration and coma upon admission(18). serum levels are reached in 30-90 The largest methanol mass poisoning occurred minutes(15,16,23). When metabolized by hepatic in 2006 in Nicaragua during Independence alcohol dehydrogenase into formaldehyde and celebrations; out of 801 persons afflicted 45 formic acid, it causes a severe metabolic died and 15 were left permanently blind(19). A acidosis which is directly toxic to body similar outbreak occurred in El Salvador in tissues, especially the brain and the eye (15-17). 2000 in which 93 out of 167 individuals The lethal dose is estimated to be 1-2 ml/kg died(20). The United States also experienced body weight. It takes about 24 hours before similar outbreaks of mass methanol poisoning signs and symptoms of intoxication are in 1951 and 1968 due to consumption of manifested including visual, neuropsychiatric whisky laced with methanol(21,22). and metabolic acidosis complications(17,23). Any alcohol can be toxic if ingested in large Detoxification is by administering ethanol quantities, but the term toxic alcohols usually since the affinity of alcohol dehydrogenase for refer to isopropanol, methanol and ethylene ethanol is 10-20 times more than methanol(17). glycol. Ingestion of non-beverage , Haemodialysis should be considered if the fragrants such as cologne, perfume and after- methanol serum level is high and if there are shave, and non-beverage alcohols such as visual, mental disturbance, severe acidosis or ethylene glycol and methanol for the purpose renal impairment. Intravenous sodium of intoxication has been reported in bicarbonate should also be given if the pH is

3 Sudan Med J 2012 April;48(1)

Review Article Methanol poisoning Fath AA AbdulRahim less than 7.2 to reduce the amount of formic and haematemesis(28). Hepatotoxicity may acid from entering the blood brain barrier. manifest with jaundice, hepatomegally and Folic acid has also been recommended to failure(29). Hepatic reticuloendothelial increase the rate of formate metabolism(23). failure has been reported with toluene The pattern of volatile substance abuse is exposure(30). Reported toluene renal toxicity categorized as experimental, recreational or includes renal tubular acidosis, hypokalemia, habitual and all may act as a gateway to other hypophosphatemia, sterile pyuria, haematuria substance abuse. The experimental abuser and proteinuria(31). Haemotological sequelae tries solvents intermittently out of curiosity or of exposure may include lymphocytosis, under peer pressure, while the recreational eosinophylia and in severe cases, aplastic abuser adopts a periodic pattern of use, anemia(28). Toluene can affect skeletal muscles usually in a group setting(24). directly resulting in rhabdomyolysis and Volatile solvents are used to produce altered myoglobinemia(32). Profound hypokalemia states of consciousness. Much like alcohol, due to renal tubular acidosis may produce these substances act as central nervous system severe muscle weakness mimicking Guillain- after rapid absorption through the Barre’s syndrome(32). . The effects appears within minutes and Sudden death from inhalation of toluene and last for 30 minutes to several hours. Toluene other volatile substances (sudden sniffing and other volatile substances are highly death) has been reported and is attributed to lipophilic which explains the rapid primary anoxia, respiratory depression, vagal effect on the CNS. Recent research has shown stimulation and most importantly cardiac that toluene interacts with several brain (33-36). Volatile substances neurotransmitters mainly -aminobutyric acid sensitize the myocardium to circulating (GABA) and to lesser degree glycine and catecholamines which peak up when the dopamine(25). Magnetic resonance and abuser is suddenly startled as when caught by postmortem studies have shown diffuse white parents or during police chase. matter degeneration and gliosis in habitual The lessons that can be extrapolated from this users(26). Acute intoxication with toluene and epidemic are that specific efforts should be other is presented by acute CNS adopted to prevent volatile substances abuse, symptoms which include , visual these may include: , delusions, delirium, ataxia, a. Dissemination of information about the behavourial disturbances, stupor and coma(25). hazards of these substances to healthcare Chronic CNS sequelae due to habitual abuse workers, educators, the media, parents and has been reported to include paranoid youth. psychosis, cerebral and cerebellar b. Early intervention by establishing degeneration with ataxia, seizures, outreach counseling and treatment choreoathetosis, optic and peripheral neuritis programs for such disorders. and deafness(26,27). The combination of organic c. Increasing the awareness of healthcare solvents and high concentration of heavy professionals about subtle clinical has been reported to cause brain presentations of volatile substance atrophy, temporal lobe epilepsy, decreased IQ abusers. Tell-tale signs of volatile and EEG changes(27). substance abuse include the characteristic Inhalants have also been incriminated in smell on the breath, glue on hands and causing multisystem toxicity. Gastrointestinal clothes and facial rash in addition to the symptoms from inhalation and ingestion may CNS manifestations. result in abdominal pain, nausea, vomiting

4 Sudan Med J 2012 April;48(1)

Review Article Methanol poisoning Fath AA AbdulRahim d. Drafting legislations to govern the e. A collaborative multicenter national manufacture and sale by retailers of these epidemiological survey about substance products, prohibiting trafficking by misuse disorders will help healthcare restricting their access particularly sales to authorities to plan preventive and at-risk youngsters. treatment services.

References 13. United Nations (2005). 2005 World Drug 1. http://www.sudanpolice.gov.sd/news.php? Report, United Nations: office on action=detail&id=2259 and crime. 2. http://www.sudantribune.com/Methanol- 14. Re-solve: the dociety for the prevention of poisoning-kills-at-least,39321 solvent and volatile substances abuse. Fact 3. Sudan now magazine July 2011. sheet: an international perspective. 4. www.toxlab.co.uk/volatile.htm Available at: http://www.re-solv.org 5. Kurtzman TJ, Otsuka KN, Wahl RA. 15. Hovda KE, Hunderi OH, Tafjord AB. Inhalant abuse by adolescents. J Adolesc Methanol outbreak in Norway, 2002-2004. Health 2001;28(3):170-80. Epidemiology, clinical features and 6. Lorenc JD. Inhalant abuse in the pediatric prognostic signs. J Intern Med population: a persistent challenge. Curr 2005;258:181-90. Opin Pediatr 2003;15(2):204-9. 16. Swartz RD, Millman RP, Billi JE. 7. Suzuki J, Tyson JW. Misconceptions Epidemic methanol poisoning: clinical and about the safety of ingesting methanol- biochemical analysis of a recent episode. based solid fuels: a case report. The Prim Medicine 1981;60:373-82. Care Compan CNS Disord 17. Paasma R, Hovda KE, Tikkerberi A, 2011;13(2):112-4. Jacobsen D. Methanol mass poisoning in 8. United States Department of Health and Estonia: outbreak in 154 patients. Clin Human Services. Substance Abuse and Toxicol (Phila) 2007;45:152-7. Mental Health Services Administration 18. Paasma R, Hovda KE, Tikkerberi A, Office of Applied Studies. 2007 National Jacobsen D. Methanol poisoning and Survey on Drug Use and Health: National long-term sequelae – a six years follow-up Survey. Sept 2008. after a large methanol outbreak. BMC Clin 9. Medina-Mora ME, Real T. Epidemiology Pharmacol 2009;9:5. of inhalant use. Curr Opin Psychiatry 19. “Methanol poisoning in Leon, Nicaragua”, 2008;21(3):247-51. September, 2006, Pan American Health 10. http://www.sudanvisiondaily.com/module Organization. Available online at: s.php?name=News&file=print&sid=2251 http://www.paho.org/english/dd/ped/nicar 11. Chao TC, Lo DS, Khod. Glue sniffing aguaMetanol.htm deaths in Singapore – volatile aromatic 20. “El Salvador”, Pan American Health hydrocarbons in postmortem blood by Association. Available online at headspace gas chromatography. Med Sci http://www.patho.org/English/DD/AIS/cp Law 1993;33(3):253-60. _22htm 12. Seth R, Kotwal A, Ganguly KK. Street 21. Bennett IL, Cary FH, Mitchell GL. Acute and working children of Delhi, India, methyl alcohol poisoning: review based on misusing toluene: an ethnographic experiences in an outbreak of 323 cases. exploration. Subuse Misuse Medicine 1953;32:431-63. 2005;40(11):1659-79.

5 Sudan Med J 2012 April;48(1)

Review Article Methanol poisoning Fath AA AbdulRahim

22. Kane RL, Talbert W, Harlan J. A inhaling organic solvents. West J Med methanol poisoning outbreak in Kentucky. 1988;148(4):458-60. A clinical epidemiologic study. Arch of 30. Franco G, Fonte R, Candura F. Environ Health 1968;17(1):119-29. Hepatotoxicity of organic solvents. Br J 23. Jammaladaka D, Raissi S. Ethylene Ind Med 1986;43(2):139-42. glycol, methanol and isopropyl alcohol 31. Vos JU, Roller M, Mangelsdorf I. intoxication. Am J Med Sciences Nephrotoxicity of organic solvents. 2010;339(3):276-81. Evaluation of the literature. Federal 24. Evans AC, Raistrick D. Pattern of use and Institute of Occupational Safety and related harm with toluene-based adhesives Health, 2003, Berlin, Germany. and butane gas. BJP 1987;150:773-6. 32. Frangides CY, Tzortzatys GV, Koulouras 25. Evans AC, Raistrick D. Phenomenology V. Acute massive rhabdomyolysis due to of intoxication with toluene-based prolonged inhalation of liquid gas. Eur J adhesives and butane gas. BJP Emerg Med 2003;10(1):44-6. 1987;150:769-73. 33. Bowen SE, Daniel J, Balster RL. Deaths 26. Rosenberg NL, Kleinschmidt-DeMasters associated with inhalant abuse in Virginia BK, Davis KA. Toluene abuse causes from 1987 to 1996. Drug Alcohol Depend diffuse central nervous system white 1999;53(3):239-45. matter changes. Ann Neurol 34. Wick R, Gilbert JD, Felgate P. Inhalant 1988;23(6):611-4. deaths in : a 20-year 27. Byme A, Kirby B, Zibin T. Psychiatric retrospective autopsy study. Am J and neurological effects of chronic solvent Forensic Med Pathol 2007;28(4):319-22. abuse. C and J Psychiatry 1991;36(10): 35. Maxwell JC. Deaths related to the 735-8. inhalation of volatile substances in 28. Meadows R, Verghese A. Medical :1988-1998. Am J complications of glue sniffing. South Med 2001;27(4):689-97. J 1996;89(5):455-62. 36. King GS, Smialek JE, Troutman WG. 29. Cordes DH, Brown WD, Quinn KM. Sudden death in adolescents resulting Chemically induced hepatitis after from inhalation of typewriter correction fluid. JAMA 1985;253(11):1604-6.

6 Sudan Med J 2012 April;48(1)