Quick viewing(Text Mode)

Drug-Induced Psychosis and Neurological Effects Following Nitrous Oxide Misuse: a Case Report

Drug-Induced Psychosis and Neurological Effects Following Nitrous Oxide Misuse: a Case Report

Clinical

Matthew Mo Kin Kwok, MD, CCFP(EM), FCFP, Jane de Lemos, PharmD, MSc Epid, Mazen Sharaf, BSc Pharm, ACPR -induced psychosis and neurological effects following nitrous misuse: A case report

The case of a 20-year-old female who experienced auditory and visual after inhaling she obtained legally in “whippits”—canisters used in whipped cream dispensers—highlights the need to report such adverse events to appropriate authorities so that data can be collected about the dangers associated with commercially available products and the number of misuse cases in Canada.

ABSTRACT: Nitrous oxide (N O) is an increasingly of N O as a consumer good contributes to misuse, 2 2 An increasing number of publications and popular recreational drug globally. Users com- as seen in the case of a 20-year-old female who the Global Drug Survey (GDS), a self-report monly inhale the gas from punctured canisters presented to the emergency department com- survey of , suggest N2O is known as “whippits” that are designed for use in plaining of visual and auditory hallucinations. The being misused by those seeking the whipped cream dispensers. A surge in N O use patient had no history of psychiatric or medical 2 state produced by puncturing whippits and in- has been reported in the UK, with a self-report illness before experiencing symptoms, and results haling the gas or “nanging.” The GDS found recreational drug survey finding an increase in from laboratory investigations and physical exami- that when , , and were use from 20% in 2014 to 31% in 2017. The survey nations revealed no abnormalities. The patient excluded, N2O was the seventh most common found that when nicotine, alcohol, and caffeine reported inhaling nitrous oxide on a daily basis, drug used by 130 000 respondents.3 were excluded, N O was the seventh most com- however, and had recently increased her use of 2 Whippits are readily available through mon drug used by respondents. The accessibility legally obtained whippits. A psychiatrist, a neu- storefront and online suppliers with no re- rologist, and an medicine specialist striction on age of purchaser, medical history, assessed the patient in consultation and agreed quantity desired, or intended use. As long as that her psychosis was the result of N O misuse. Dr Kwok is an emergency physician 2 the purchaser can pay for the product there is This case illustrates the need to increase at Richmond Hospital and a clinical no barrier to obtaining whippits. regarding the possible sequalae of nitrous oxide assistant professor in the Department Each whippit contains 8 g of 100% N2O, on misuse and address current reporting limitations of Emergency Medicine at the University average. The duration of action is short-lived and the ease of access consumers have to nitrous 4 of BC. Dr de Lemos is a clinical (1 to 2 minutes) after the canister is punctured oxide products. pharmacist at Richmond Hospital and and the gas is released into an inflatable or an 1 a clinical professor in the Department enclosed object for . of Pharmaceutical Sciences at UBC. At itrous oxide (N2O), commonly known N2O that is chemically identical to the N2O 1 the time of writing, Mr Sharaf was a as “laughing gas,” has historically in whippits is also sold with a drug identifica- pharmacy practice resident at Lower been used for medicinal purposes tion number (DIN) for medicinal purposes. such as , analgesia, and .2 It is Mainland Pharmacy Services. Currently, N When used as an inhalational anesthetic, N2O he is a clinical pharmacist at Children’s also available as a consumer product in canisters has and sedative effects. In accor- and Women’s Health Centre of BC. known as “whippits” that are used in whipped dance with federal legislation, N2O is classified cream dispensers. by Health Canada as an “ethical” product that This article has been peer reviewed. BC Medical Journal vol. 61 no. 10 | december 2019 385 Clinical Drug-induced psychosis and neurological effects following nitrous oxide misuse

“does not require a prescription, but that is gen- Discussion determine which authority should receive the 5 erally prescribed by a medical practitioner. Ethi- This case illustrates the need to consider the report. When N2O with a DIN is used for a cal products are unscheduled non-prescription possible sequalae of nitrous oxide misuse medicinal purpose, the appropriate authority is professional use products.”5 (whether acute or chronic), the current report- the Canada Vigilance Program, which operates

ing limitations, and N2O accessibility issues. the adverse reaction online database. When

Case data the N2O comes from a product marketed for A 20-year-old female presented to the emer- Possible sequalae making whipped cream, the appropriate author- gency department with visual and auditory hal- Beyond symptoms of psychosis, N2O misuse ity is Health Canada Consumer Products and lucinations, agitation, and gait disturbance. She has been associated with myeloneuropathy and Cosmetics. A member of our health care team voiced concerns about a “transmitting” device neurological effects, which are mentioned in submitted a report to both authorities to ensure in her throat. She believed that this device was a growing number of reports.1,2,6-8 These ad- appropriate actions could be taken. making her legs weak and affecting her walking. verse effects can result from both acute and In response to our report, a Health Canada She also heard voices from the device telling chronic exposure. A systematic review from representative explained that Consumer Prod- her to kill herself. She had come to the emer- 2016 that focused exclusively on N2O misuse ucts and Cosmetics would document the misuse gency department because she was worried for revealed that the users in 72 of 91 cases experi- but only take further action if the N2O canister her safety. enced some sort of neurological adverse effect, had faults or hazards regarding its intended use, The patient had no history of psychiatric or which is making whipped cream. medical illness. She reported inhaling nitrous To our surprise, no cases of N2O misuse oxide on a daily basis. She had increased her Nitrous oxide can be have been reported to Health Canada Consum- use recently and was inhaling gas from approxi- readily obtained as a er Products and Cosmetics, and only one case mately 100 whippits per day. The patient stated of of N O had been reported commercial product 2 that she bought the canisters legally with a shop- to the Canada Vigilance Program. ping app and showed the physician the website without any restrictions. We also contacted the BC Drug and Poi- she used to make her purchases. She reported son Information Centre (DPIC) and learned no other recreational or use. that the provincial toxicology call centre re-

The patient was a slim and slightly built predominantly myelopathy, myeloneuropathy, ceived 14 calls regarding N2O toxicity from Asian female. She appeared anxious but not and subacute combined degeneration.2 Less misuse of whippits or similar commercial distressed. She was cooperative and her vital common presentations included psychiatric products between 2015 and 2019. Since our signs at triage were stable. On examination symptoms as seen in our case. Additionally, investigation determined that Health Canada she showed no sign of head trauma. Her pupils 29 cases of nitrous-oxide-related death were received only one report of N2O misuse in were equal and reactive to light. Her speech and reported.2 Although the systematic review was this period, many incidents appear to have her gait were normal. Her neck was supple and unable to establish a dose-related toxicity be- gone unreported. her thyroid examination revealed no abnor- cause of unreliable data, the majority of cases The number of 2N O cases described in the malities. Respiratory, cardiac, and abdominal involved the daily use of whippits. literature, the calls made to BC DPIC, and findings were unremarkable. Her neurologi- The mechanism of these adverse effects is news stories of misuse9 all suggest that current cal examination results were normal with no not well understood. N2O is to be as- reporting does not reflect the magnitude of the lateralizing sign, and her mental status exam sociated with low vitamin B12 levels. N2O- toxicity problem. revealed normal affect. induced oxidation converts vitamin B12 from

Laboratory investigations included an ECG a reduced to an oxidized form, which inhibits N2O accessibility issues that revealed normal sinus rhythm and a QTC the activity of methionine synthase, leading to Nitrous oxide can be readily obtained as a of 399. CBC, electrolyte, urea nitrogen, impairment of methylation reactions and DNA commercial product without any restrictions. and creatinine levels were all within normal synthesis. This in turn leads to the accumula- In the case described here, the patient pur- limits. ASA, acetaminophen, and lev- tion of homocysteine.2,6 Clinical syndromes chased canisters from a reputable online shop- els were normal. Her vitamin B12 level was have been reported with both acute and chronic ping website and had them shipped directly also normal. nitrous oxide use. to her. A psychiatrist, a neurologist, and an addic- Whippits come in different sizes and can tion medicine physician assessed the patient in Reporting limitations be purchased in bulk. At the time of writing, consultation and agreed that she was psychotic Health care providers play an important role a package of 100 canisters could be purchased as a result of N2O misuse. The patient was kept in reporting adverse events from nitrous oxide online for less than $100.00 ($1.00 per can- in hospital until her symptoms resolved and she misuse to the appropriate authorities. In the ister).10 Because the canisters are not sold for was discharged without incident. case described here it was initially difficult to inhalation, there is no regulation that mandates

386 BC Medical Journal vol. 61 no. 10 | december 2019 Kwok M, de Lemos J, Sharaf M Clinical

providing information on the risks or possible being collected about the dangers associated References sequelae of N2O misuse, nor are sellers qualified with commercially available products or the 1. Cousaert C, Heylens G, Audenaert K. Laughing to provide this information. number of misuse cases in Canada. gas abuse is no joke. An overview of the implica- tions for psychiatric practice. Clin Neurol Neurosurg Medicinal products with a drug identifica- Increased awareness is needed regarding 2013;115:859 -862. tion number are classified by Health Canada N2O toxicity and the more serious adverse drug 2. Garakani A, Jaffe RJ, Savla D, et al. Neurologic, psychi- according to different schedules that determine effects that are possible. Solutions to misuse atric, and other medical manifestations of nitrous ox- how accessible the product is to the public and might include restricting access, adding safe- ide abuse: A systematic review of the case literature. the circumstances that require a health care Am J Addict 2016;25:358-369. 3. Global Drug Survey. The Global Drug Survey 2016 find- provider (e.g., physician or pharmacist) to be ings. Accessed 7 April 2019. www.globaldrugsurvey 11 Health Canada considers involved in acquiring the product. The safety .com/past-findingsthe-global-drug-survey-2016 and the complexity of the product and the harm nitrous oxide to be -findings. the product may cause patients when used are an “unscheduled 4. Zacny JP, Lichtor JL, Coalson DW, et al. Time course of effects of brief of nitrous oxide in normal all considered. Health Canada will reassess ac- non-prescription volunteers. 1994;89:831-839. cess to a medicinal product if new information professional use” 5. Government of Canada. Drug product database (DPD). arises, such as reports of adverse reactions, and Accessed 7 April 2019. www.canada.ca/en/health-can may choose to further restrict or to ease access product. This raises an ada/services/-health-products/drug-products/ important question: drug-product-database/terminology.html. to the public. 6. Hathout L, El-Saden S. Nitrous oxide-induced B12 de- Health Canada considers nitrous oxide to ficiency myelopathy: Perspectives on the clinical bio- if N2O used medicinally be an “unscheduled non-prescription profes- is deemed to require chemistry of vitamin B12. J Neurol Sci 2011;301:1-8. sional use” product.5 This raises an important 7. Weimann J. Toxicity of nitrous oxide. Best Pract Res health care provider Clin Anaesthesiol 2003;17:47-61. question: if N2O used medicinally is deemed to 8. Pema PJ, Horak HA, Wyatt RH. Myelopathy caused by require health care provider involvement, why involvement, why is nitrous oxide toxicity. AJNR Am J Neuroradiol 1998; is the purchase of N O used commercially not 19:894-896. 2 the purchase of N2O restricted in any way given the potential impact 9. Xiong D. Richmond man almost paralyzed after “laugh- used commercially not ing gas” abuse. Richmond News. 14 December 2017. on consumers? restricted in any way Accessed 9 April 2019. www.richmond-news.com/ news/richmond-man-almost-paralyzed-after-laughing Summary given the potential -gas-abuse-1.23123235. A case of nitrous oxide misuse by a 20-year-old impact on consumers? 10. Amazon.ca. Whipped cream canisters/chargers. Ac- female that resulted in drug-induced psychosis cessed 18 October 2019. www.amazon.ca/Whip -Brand-Original-Whipped-Chargers/dp/B0747XWTNT/ and neurological effects illustrates the need ref=sr_1_7?keywords=whip+it&qid=1571417184 for clinicians to recognize N2O as a potential &sr=8-7. substance of abuse and a possible cause of un- guards to minimize harm, and encouraging 11. National Association of Pharmacy Regulatory Authori- explained psychiatric or neurological symptoms. intervention from authorities to prevent product ties (NAPRA). Drug scheduling in Canada. Accessed 28 June 2019. https://napra.ca/drug-scheduling-canada. In addition, this case highlights the need to misuse. n report N2O-related adverse events to appropri- Competing interests ate authorities. The lack of N2O misuse reports going to Health Canada means data are not None declared.

BC Medical Journal vol. 61 no. 10 | december 2019 387