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How can abuse be recognized? See page 4.

Research Report Series from the director:

Although many parents are appropri- ately concerned about illicit such as marijuana, , and LSD, they often ignore the dangers posed to their children from common household products that contain volatile or . Products such as glues, nail polish remover, lighter fluid, spray paints, and hair sprays, whipped cream canisters, and clean- ing fluids are widely available yet far from innocuous. Many young people inhale the vapors from these sources in search of quick intoxication with- out being aware that using inhalants, even once, can have serious health consequences.

National surveys indicate that nearly 21.7 million Americans aged 12 and older have used inhalants at least once in their lives. NIDA’s 2011 Monitoring the Future (MTF) survey reveals that 13.1 percent of 8th-graders have used inhalants. Parents and children need to know that even sporadic or single episodes of inhalant abuse can be extremely dangerous. Inhalants can disrupt heart rhythms and cause death from , or lower oxygen What Are levels enough to cause suffocation. Regular abuse of these substances can result in serious harm to vital organs, Inhalants? including the brain, heart, kidneys, and . nhalants are volatile substances that produce chemical vapors Through scientific research, we have that can be inhaled to induce a psychoactive, or mind-altering, learned much about the nature and effect. Although other abused substances can be inhaled, the extent of inhalant abuse, its pharma- I cology, and its consequences. This term “inhalants” is used to describe a variety of substances whose research has brought the picture of inhalant abuse in the Nation into focus main common characteristic is that they are rarely, if ever, taken and pointed to the dangers and the by any route other than . This definition encompasses a warning signs for parents, educators, and clinicians. We hope this compila- broad range of chemicals that may have different pharmacological tion of the latest scientific information effects and are found in hundreds of different products. As a result, will help alert readers to inhalant abuse and its harmful effects and aid efforts to precise categorization of inhalants is difficult. One classification deal with this problem effectively. system lists four general categories of inhalants—volatile solvents,

Nora D. Volkow, M.D. aerosols, gases, and —based on the forms in which they are Director often found in household, industrial, and medical products. National Institute on Abuse continued inside

U.S. Department of Health and Human Services | National Institutes of Health Research Report Series Inhalants

Volatile solvents are liquids Nitrites often are considered In fact, inhalants—particularly that vaporize at room temperature. a special class of inhalants. Un- volatile solvents, gases, and They are found in a multitude of like most other inhalants, which aerosols—are often the easiest and inexpensive, easily available prod- act directly on the central nervous first options for abuse among young ucts used for common household system (CNS), nitrites act primar- children who use drugs. NIDA’s and industrial purposes. These ily to dilate blood vessels and relax annual MTF survey of 8th-, 10th-, include paint thinners and remov- the muscles. While other inhalants and 12th-graders consistently ers, dry-cleaning fluids, degreasers, are used to alter mood, nitrites are reports the highest rates of current, , glues, correction fluids, used primarily as sexual enhancers. past-year, and lifetime inhalant use and felt-tip markers. Nitrites include cyclohexyl , among 8th-graders. Aerosols are sprays that isoamyl (amyl) nitrite, and isobutyl Inhalant use has decreased contain propellants and solvents. (butyl) nitrite and are commonly significantly among 8th-, 10th-, and They include spray paints, deodor- known as “” or “snap- 12th-graders compared to its peak ant and hair sprays, vegetable oil pers.” is used in certain years in the mid-1990s (see figure, sprays for cooking, and fabric diagnostic procedures and was page 3). According to the 2011 protector sprays. prescribed in the past to treat some MTF survey, past-year use was Gases include medical an- patients for heart pain. Nitrites now reported as 7.0, 4.5, and 3.2 percent, esthetics as well as gases used in are prohibited by the Consumer for 8th-, 10th-, and 12th-graders, household or commercial products. Product Safety Commission but can respectively. Data compiled by the Medical anesthetics include , still be found, sold in small bottles National Capital Poison Center also , halothane, and nitrous labeled as “video head cleaner,” show a decrease in the prevalence oxide (commonly called “laughing “room odorizer,” “leather cleaner,” of inhalant cases reported to U.S. gas”). is the most or “liquid aroma.” poison control centers—down 33 abused of these gases and can be Generally, inhalant abusers will percent from 1993 to 2008. The found in whipped cream dispensers abuse any available substance. How- prevalence was highest among chil- and products that boost octane lev- ever, effects produced by individual dren aged 12 to 17, peaking among els in racing cars. Other household inhalants vary, and some users will 14-year-olds. or commercial products contain- go out of their way to obtain their Demographic differences in ing gases include lighters, favorite inhalant. For example, in inhalant use have been identified tanks, and . certain parts of the country, “ at different ages. The MTF survey shoeshine,” a shoe-shining spray indicates that in 2011, 8.6 percent containing the chemical , is a of 8th-grade females reported using local favorite. inhalants in the past year, compared with 5.5 percent of 8th-grade males. In terms of ethnicity, Hispanics What Is the have the highest rates of past-year Scope of Inhalant use among 8th- and 10th-graders, compared to both Blacks and Abuse? Whites. According to the 2010 National People from both urban and ru- Survey on Drug Use and Health ral settings abuse inhalants. Further, (NSDUH), there were 793,000 research on factors contributing to persons aged 12 or older who had inhalant abuse suggests that adverse used inhalants for the first time socioeconomic conditions, a history within the past 12 months; 68.4 of childhood abuse, poor grades, percent were under the age of 18. and school dropout are associated with inhalant abuse.

2 NIDA Research Report Series How Are Inhalants Used? Inhalants can be breathed in through the nose or the mouth in a Past-Year Inhalant Use Among 8th-, variety of ways, such as— 10th-, and 12th-Graders, 1991–2011 • “sniffing” or “snorting” fumes from containers; • spraying aerosols directly into the nose or mouth; • “bagging”—sniffing or inhaling

fumes from substances sprayed Percent or deposited inside a plastic or paper bag; • “huffing” from an inhalant- soaked rag stuffed in the mouth; and • inhaling from balloons filled with nitrous oxide. Source: University of Michigan, 2011 Monitoring the Future Survey. Inhaled chemicals are absorbed rapidly into the bloodstream through the and are quickly distributed to Gender and Race/Ethnicity the brain and other organs. Differences in Past-Year Inhalant Within seconds of inhalation, Use Among 8th-Graders, 2011 the user experiences intoxication along with other effects similar to those produced by . Alcohol-like effects may include slurred speech; the inability to coordinate movements; ; and . In addition, users may experience lightheadedness, Percent , and delusions. Because intoxication lasts only a few minutes, abusers frequently seek to prolong the high by inhaling repeatedly over the course of several hours, which is a very dangerous practice. With *Level of significance of difference between Male and Female = .05 successive , abusers can ** Level of significance of difference between Whites and Hispanics and Blacks and suffer loss of consciousness and Hispanics = .001 possibly even death. At the least, Source: University of Michigan, 2011 Monitoring the Future Survey. they will feel less inhibited and

NIDA Research Report Series 3 Most inhalants produce a rapid high that resembles , with initial excitation then drowsiness, disinhibition, lightheadedness, and agitation.

less in control. After heavy use of Evidence from animal inhalants, abusers may feel drowsy studies suggests that a number What Are the for several hours and experience a of commonly abused volatile Short- and Long- lingering headache. solvents and anesthetic gases Term Effects of have neurobehavioral effects and mechanisms of action similar Inhalant Use? How Do Inhalants to those produced by CNS Although the chemical sub- Produce Their , which include alcohol stances found in inhalants may Effects? and such as produce various pharmacological and anesthetics. effects, most inhalants produce a Many brain systems may be A 2007 animal study indicates rapid high that resembles alcohol involved in the anesthetic, that toluene, a found in intoxication, with initial excita- intoxicating, and reinforcing effects many commonly abused inhal- tion followed by drowsiness, dis- of different inhalants. Nearly ants—including model airplane inhibition, lightheadedness, and all abused inhalants (other than glue, paint sprays, and paint and agitation. If sufficient amounts are nitrites) produce a pleasurable nail polish removers—activates inhaled, nearly all solvents and effect by depressing the CNS. the brain’s dopamine system. The gases produce anesthesia—a loss Nitrites, in contrast, dilate and dopamine system has been shown of sensation—and can lead to relax blood vessels rather than act to play a role in the rewarding . as anesthetic agents. effects of nearly all drugs of abuse.

How Can Inhalant Abuse Be Recognized?

Early identification and intervention are the best ways to stop inhal- ant abuse before it causes serious health consequences. Parents, educators, family physicians, and other health care practitioners should be alert to the following signs:

• Chemical odors on breath or • Drunk or disoriented clothing appearance • Paint or other stains on face, • Slurred speech hands, or clothes • Nausea or loss of appetite • Hidden empty spray paint or • Inattentiveness, lack of solvent containers, and chemi- coordination, irritability, and cal-soaked rags or clothing

4 NIDA Research Report Series A. B. The chemicals found in sol- vents, sprays, and gases can produce a variety of addi- tional effects during or shortly after use. These effects are related to inhalant intoxication and may include belligerence, apathy, impaired judgment, and impaired functioning in work or social Compared with the brain of an individual with no history of inhalant abuse situations; nausea and vomiting (A), that of a chronic toluene abuser (B) is smaller and fills less of the are other common side effects. space inside the skull (the white outer circle in each image). Courtesy of Exposure to high doses can Neil Rosenberg, M.D., NIDA Research Report (NIH 05-3818). cause confusion and delirium. In addition, inhalant abusers may experience dizziness, drowsiness, slurred speech, lethargy, depressed What Are the • convulsions or seizures— from abnormal electrical discharges in reflexes, general muscle weakness, Other Medical and stupor. For example, research the brain; Consequences of shows that toluene can produce • — from the brain shut- headache, euphoria, giddy feel- Inhalant Abuse? ting down all but the most vital ings, and the inability to coordi- Inhalant abusers risk an array of functions; nate movements. other devastating medical conse- Inhaled nitrites dilate blood • choking — from inhalation of quences. The highly concentrated vessels, increase heart rate, and vomit after inhalant use; or chemicals in solvents or aerosol produce a sensation of heat and sprays can induce irregular and • fatal injury — from accidents, excitement that can last for several rapid heart rhythms and lead to including motor vehicle fatalities, minutes. Other effects can include fatal within minutes suffered while intoxicated. flush, dizziness, and headache. of a session of prolonged sniffing. A strong need to continue Based on independent studies This syndrome, known as “sudden using inhalants has been reported performed over a 10-year period sniffing death,” can result from a by many individuals, particularly in three different states, the num- single session of inhalant use by those who have abused inhalants ber of inhalant-related fatalities an otherwise healthy young per- for prolonged periods over many in the United States is approxi- son. Sudden sniffing death is asso- days. Compulsive use and a mild mately 100–200 per year. ciated particularly with the abuse withdrawal syndrome can occur Animal and human research of butane, propane, and chemicals with long-term inhalant abuse. A shows that most inhalants are in aerosols. Inhalant abuse also recent survey of 43,000 Ameri- extremely toxic. Perhaps the can cause death by— can adults suggests that inhalant most significant toxic effect of users, on average, initiate use of • asphyxiation—from repeated chronic exposure to inhalants cigarettes, alcohol, and almost all inhalations that lead to high is widespread and long-lasting other drugs at younger ages and concentrations of inhaled fumes, damage to the brain and other display a higher lifetime preva- which displace available oxygen parts of the (see lence of substance use disorders, in the lungs; figure). For example, chronic including abuse of prescription abuse of volatile solvents, such • suffocation—from blocking air drugs, when compared with sub- as toluene or naphthalene (the from entering the lungs when stance abusers without a history volatile ingredient in mothballs), inhaling fumes from a plastic of inhalant use. damages the protective sheath bag placed over the head;

NIDA Research Report Series 5

Hazards of Chemicals Found in Commonly Abused Inhalants amyl nitrite, methylene chloride (“poppers,” “video head cleaner”) (found in paint thinners and removers, degreasers) sudden sniffing death syndrome, suppressed immuno- reduction of oxygen-carrying capacity of blood, changes logic function, injury to red blood cells (interfering with to the heart muscle and heartbeat oxygen supply to vital tissues) nitrous oxide (“laughing gas”), death from lack of oxygen to the brain, altered percep- (found in gasoline) tion and motor coordination, loss of sensation, limb injury, impaired immunologic function, spasms, blackouts caused by blood pressure changes, increased risk of leukemia, reproductive system depression of heart muscle functioning butane, propane toluene (found in lighter fluid, hair and paint sprays) (found in gasoline, paint thinners and removers, sudden sniffing death syndrome via cardiac effects, ) serious injuries (because of flammability) brain damage (loss of brain tissue mass, impaired freon cognition, gait disturbance, loss of coordination, loss of (used as a and aerosol propellant) equilibrium, limb spasms, hearing and vision loss), liver sudden sniffing death syndrome, respiratory obstruc- and kidney damage tion and death (from sudden cooling/cold injury to airways), liver damage (found in spot removers, degreasers) sudden sniffing death syndrome, cirrhosis of the liver, reproductive complications, hearing and vision damage

around certain nerve fibers in reversible when inhalant abuse is chronically abuse solvents, and the brain and peripheral nervous stopped, many syndromes caused there is evidence of subsequent system. This extensive destruction by repeated or prolonged abuse developmental impairment in of nerve fibers is clinically similar are irreversible. some of these children. However, to that seen with neurological Abuse of inhalants during no well-controlled prospective diseases such as multiple sclerosis. pregnancy also may place study of the effects of prenatal The neurotoxic effects of infants and children at increased exposure to inhalants in humans prolonged inhalant abuse include risk of developmental harm. has been conducted, and it is neurological syndromes that Animal studies designed to not possible to link prenatal reflect damage to parts of the simulate human patterns of exposure to a particular chemical brain involved in controlling inhalant abuse suggest that to a specific birth defect or cognition, movement, vision, and prenatal exposure to toluene can developmental problem. hearing. Cognitive abnormalities result in reduced birth weights, Finally, a 2008 survey of over can range from mild impairment occasional skeletal abnormalities, 13,000 high school students has to severe dementia. delayed neurobehavioral identified an association between Inhalants also are highly development, and altered disordered eating (defined as a toxic to other organs. Chronic regulation of metabolism and positive response to one or more exposure can produce significant body composition in males, as of three questions about engag- damage to the heart, lungs, well as food intake and weight ing in inappropriate behaviors for liver, and kidneys. Although gain in both sexes. A number of weight control during the past some inhalant-induced damage case reports note abnormalities 30 days) and inhalant use among to the nervous and other organ in newborns of mothers who both male and female students. systems may be at least partially

6 NIDA Research Report Series and pleasure. Research shows that of infectious diseases and tumors. What Are the abuse of these drugs in this context The research indicates that inhal- Unique Risks is associated with unsafe sexual ing nitrites depletes many cells in practices that greatly increase the the immune system and impairs Associated With risk of contracting and spreading mechanisms that fight infectious Nitrite Abuse? infectious diseases such as HIV/ diseases. A study found that even AIDS and hepatitis. a relatively small number of expo- Nitrites are abused mainly by older Animal research raises the sures to butyl nitrite can produce adolescents and adults. Typically, possibility that there may also be a dramatic increases in tumor inci- individuals who abuse nitrites are link between abuse of nitrites and dence and growth rate in animals. seeking to enhance sexual function the development and progression

Glossary

Anesthetic: An agent that causes insensitivity to Naphthalene: Volatile, active ingredient in mothballs. pain and is used for surgeries and other medical procedures. Toxic: Causing temporary or permanent effects detrimental to the functioning of a body organ or group Central nervous system: The brain and spinal cord. of organs. Dementia: A condition of deteriorated mental Withdrawal: Symptoms that occur after chronic use of function. a drug is reduced abruptly or stopped. Dopamine: A brain chemical, classified as a neurotransmitter, found in regions of the brain that regulate movement, emotion, motivation, and pleasure.

References Fung, H.L., and Tran, D.C. feeding and body Mimiaga, M.J.; Reisner, S.L.; Bowen, S.E.; Batis, J.C.; Paez- Effects of inhalant nitrites on composition. Physiol Behav Vanderwarker, R.; Gaucher, Martinez, N.; and Cruz, S.L. VEGF expression: A feasible 93(4–5):984–993, 2008. M.J.; O’Connor, C.A.; The last decade of solvent link to Kaposi’s sarcoma? J Jones, H.E., and Balster, R.L. Medeiros, M.S.; and Safren, research in animal models Neuroimmune Pharmacol Inhalant abuse in pregnancy. S.A. Polysubstance use of abuse: Mechanistic 1(3):317–322, 2006. Obstet Gynecol Clin North and HIV/STD risk behavior and behavioral studies. Hall, M.T.; Edwards, J.D.; and Am 25(1):153–167, 1998. among Massachusetts men Neurotoxicol Teratol Howard, M.O. Accidental Lubman, D.I.; Yücel, M.; who have sex with men deaths due to inhalant and Lawrence, A.J. 28(6):636–647, 2006. accessing Department of misuse in North Carolina: Inhalant abuse among Bowen, S.E.; Daniel, J.; and Public Health mobile van 2000–2008. Subst Use adolescents: Neurobiological Balster, R.L. Deaths services: Implications for Misuse 45(9):1330–1339, considerations. Br J associated with inhalant intervention development. 2010. Pharmacol 154(2):316–326, abuse in Virginia from AIDS Patient Care STDS Institute for Social Research. 2008. 1987 to 1996. Drug Alcohol 22(9):745–751, 2008. Monitoring the Future, 2011 Marsolek, M.R.; White, N.C.; Depend 53(3):239–245, Pisetsky, E.M.; Chao, Y.M.; (Study Results). Ann Arbor, and Litovitz, T.L. Inhalant 1999. Dierker, L.C.; May, A.M.; MI: University of Michigan, abuse: Monitoring trends Bowen, S.E.; Wiley, J.L.; Evans, 2012. Data retrieved by using poison control and Striegel-Moore, R.H. E.B.; Tokarz, M.E.; and 7/9/2012 from http://www. data, 1993–2008. Pediatrics Disordered eating and Balster, R.L. Functional monitoringthefuture.org. 125(5):906–913, 2010. substance use in high school observational battery Jarosz, P.A.; Fata, E.; Bowen, Maxwell, J.C. Deaths related students: Results from comparing effects of , S.E.; Jen, K.L.; and Coscina, to the inhalation of volatile the Youth Risk Behavior 1,1,1-trichloroethane, ether, D.V. Effects of abuse pattern substances in Texas: 1988– Surveillance System. Int J and flurothyl. Neurotoxicol of gestational toluene 1998. Am J Drug Alcohol Eat Disord 41(5):464–470, Teratol 18(5):577–585, 1996. exposure on metabolism, Abuse 27(4):689–697, 2001. 2008.

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NIDA Research Report Series 7 References Schepis, T.S., and Krishnan- Williams & Wilkins, 1996. mothball abuse. South Med continued from page 7 Sarin, S. Characterizing pp. 246–264. J 93(4):427–429, 2000. adolescent prescription Soderberg, L.S. Increased tumor Woody, G.E.; Donnell, D.; Riegel, A.C.; Zapata, A.; misusers: A population- growth in mice exposed Seage, G.R.; Metzgera, D.; Shippenberg, T.S.; and based study. J Am Acad to inhaled . Michael, M.; Kobling, B.A.; French, E.D. The abused Child Adolesc Psychiatry Toxicol Lett 104(1–2):35–41, Buchbinderh, S.; Grossd, inhalant toluene increases 47(7):745–754, 2008. 1999. M.; Stoneh, B.; and Judsoni, dopamine release in the Sharp, C.W., and Rosenberg, and F.N. Noninjection substance nucleus accumbens by N. Inhalant-related Mental Health Services use correlates with risky directly stimulating ventral disorders. In: Tasman, A., Administration, Office of sex among men having sex tegmental area . Kay, J., and Lieberman, Applied Studies. Results with men: Data from HIV/ Neuropsychopharmacology J.A., eds. Psychiatry, from the 2010 National NET. Drug Alcohol Depend 32(7):1558–1569, 2007. Vol. 1. Philadelphia, PA: Survey on Drug Use 53(3):197–205, 1999. Sakai, J.T.; Hall, S.K.; Mikulich- W.B. Saunders, 1997. pp. and Health: Summary of Wu, L.T.; Howard, M.O.; and Gilbertson, S.K.; and 835–852. National Findings. HHS Pilowsky, D.J. Substance Crowley, T.J. Inhalant use, Sharp, C.W., and Rosenberg, Pub. No. (SMA) 11–4658, use disorders among abuse, and dependence N.L. Inhalants. In: Lowinson, Rockville, MD: SAMHSA, inhalant users: Results from among adolescent patients: J.H., Ruiz, P., Millman, 2011. the national epidemiologic Commonly comorbid R.B., and Langrod, J.G., Weintraub, E.; Gandhi, D.; survey on alcohol and problems. J Am Acad eds. Substance Abuse: A and Robinson, C. Medical related conditions. Addict Child Adolesc Psychiatry Comprehensive Textbook complications due to Behav 33(7):968–973, 2008. 43(9):1080–1088, 2004. (3d ed.). Baltimore, MD:

Where can I get further information about inhalants?

To learn more about inhalants What’s New on the NIDA Web Site NIDA Web Sites and other drugs of abuse, www.drugabuse.gov visit the NIDA Web site at • Information on drugs of abuse and related health consequences www.inhalants.drugabuse.gov www.drugabuse.gov or contact the www.steroidabuse.gov DrugPubs Research Dissemination • NIDA publications, news, and www.clubdrugs.gov Center at 877-NIDA-NIH (877-643- events www.backtoschool.drugabuse.gov 2644; TTY/TDD: 240-645-0228). • Resources for health care professionals www.teens.drugabuse.gov • Funding information (including Other Web Sites program announcements and deadlines) Information on inhalant abuse is also available through these other • International activities Web sites: • Links to related Web sites (access • Centers for Disease Control to Web sites of many other and Prevention: www.cdc.gov organizations in the field) • National Inhalant Prevention Coalition: www.inhalants.org • Substance Abuse and Mental Health Services Administration Health Information Network: www.samhsa.gov/shin

NIH Publication Number 12-3818 Printed May 1999, Revised November 2004, Revised November 2009, Revised July 2010, Revised July 2012. Feel free to reprint this publication.