Recognition and Prevention of Inhalant Abuse CARRIE E. ANDERSON, M.D., and GLENN A. LOOMIS, M.D. St. Francis Hospital and Health Centers, Beech Grove, Indiana Inhalant abuse is a prevalent and often overlooked form of substance abuse in ado- lescents. Survey results consistently show that nearly 20 percent of children in middle O A patient informa- school and high school have experimented with inhaled substances. The method of tion handout on inhalant abuse, writ- delivery is inhalation of a solvent from its container, a soaked rag, or a bag. Solvents ten by the authors of include almost any household cleaning agent or propellant, paint thinner, glue, and this article, is provided lighter fluid. Inhalant abuse typically can cause a euphoric feeling and can become on page 876. addictive. Acute effects include sudden sniffing death syndrome, asphyxia, and serious injuries (e.g., falls, burns, frostbite). Chronic inhalant abuse can damage cardiac, renal, hepatic, and neurologic systems. Inhalant abuse during pregnancy can cause fetal abnormalities. Diagnosis of inhalant abuse is difficult and relies almost entirely on a thorough history and a high index of suspicion. No specific laboratory tests confirm solvent inhalation. Treatment is generally supportive, because there are no reversal agents for inhalant intoxication. Education of young persons and their parents is essential to decrease experimentation with inhalants. (Am Fam Physician 2003;68:869- 74,876. Copyright© 2003 American Academy of Family Physicians.) See page 785 for defi- lthough inhalant abuse is quite Illustrative Case 1 nitions of strength-of- prevalent, it is an often over- evidence levels. A 21-year-old man is unconscious when he looked form of substance abuse is brought to the emergency department. His in adolescents. National sur- friends report that he has been “huffing” veys1 report that nearly 20 per- (placing a rag soaked in a substance over his Acent of young persons have experimented nose and mouth and then inhaling) for sev- with inhalants at least once by the time they eral months. On examination, the thin young are in eighth grade. In the United States, the man is briefly arousable to deep pain. He mean age of first-time inhalant abuse is 13 slowly becomes more arousable. Laboratory years.2 At present, rates of abuse are higher in tests and a computed tomographic (CT) scan Hispanics and whites than in blacks. of the head are negative. At 24 hours after Because the inhalants that are abused are in presentation, the patient becomes completely common household products and are rela- coherent and demands to be released from tively inexpensive, they are accessible to chil- the hospital. He is released against medical dren who are too poor or too young to access advice. other drugs. Furthermore, inhalant abuse Three weeks later, the young man again pre- appears to be a gateway phenomenon among sents to the emergency department, this time younger adolescents: children who abuse in full cardiac arrest. After extensive resuscita- inhalants early in life are more likely later to tive efforts, the patient dies. Family and use other illicit drugs.3,4 friends confirm that he had been inhaling gun Injuries and illnesses related to inhalant cleaner daily. abuse occur with alarming frequency. Hence, family physicians should be alert to the pres- Illustrative Case 2 ence of this form of substance abuse in young A 13-year-old girl with a primary com- patients and should provide information plaint of headaches is brought to the physi- about its acute and chronic effects. Parents cian’s office by her mother. The patient See editorial on page 811. also should be educated about the warning reports headaches that have been increasing signs and dangers of inhalant abuse. in frequency over the past year and are now SEPTEMBER 1, 2003 / VOLUME 68, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 869 Signs of recent inhalant abuse include paint or oil stains on Definition clothing or skin, spots or sores around the mouth, red eyes, Inhalant abuse involves breathing in a rhinorrhea, chemical odor on the breath, and a dazed substance directly from its container (sniff- ing or snorting), placing a rag soaked in the appearance. substance over the nose and mouth and inhaling (“huffing”), or pouring the sub- stance into a plastic bag and breathing the present daily. The headaches have resulted in fumes (“bagging”).5(pp257-60) several days missed from school. The patient’s Abused substances include fuels, solvents, mother also notes that the adolescent occa- propellants, glues, adhesives, and paint thin- sionally seems confused and uncoordinated ners. The active chemicals in commonly (“clumsy”), and is “not eating much.” Her abused inhalants are listed in Table 1.6,7 Abuse grades have declined dramatically over the of amyl and butyl nitrites (called “poppers”) is past semester. not included in this review because of the dif- On physical examination, the patient is ferent mechanism of action and adverse noted to have dry, cracked perioral skin with effects of these substances.8 Inhaled solvents irritation and sores on the lips, and fingernail likely share cellular actions with ␥-aminobu- beds that appear to be stained with ink. The tyric acid–receptor drugs (e.g., benzodi- examination is otherwise normal. During pri- azepines, barbiturates, alcohol), resulting in a vate questioning, the patient admits to sniffing depressant effect.5(pp257-60) glue and spray paint “once or twice” with a Use of inhalants can produce a euphoric friend over the past few months. feeling similar to that experienced with other illicit drugs.9 When a person using inhalants becomes hypercapnic and hypoxic by TABLE 1 rebreathing from a closed bag, the effects of Chemicals in Commonly Abused Inhalants the inhalant are intensified.8 The criteria for inhalant abuse, intoxication, Chemical Commonly abused inhalants and dependence are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Toluene Paint thinner, spray paint, airplane glue, rubber cement, 4th ed. (DSM-IV). These criteria are listed in nail polish remover, shoe polish Table 2.5(p239) Butane Lighter fluid, fuel, spray paint, hair spray, room freshener, deodorants Presentation Propane Gas grill fuel, spray paint, hair spray, room freshener, In the office setting, it is seldom obvious deodorants which preadolescent or adolescent patients are Fluorocarbons Asthma sprays, analgesic sprays, Freon® gas, spray paint, abusing inhalants. Victims of child abuse tend hair spray, deodorants, room fresheners to be at greater risk for inhalant abuse,10 as are Chlorinated Dry-cleaning agents, spot removers, degreasers, correction young persons whose friends or relatives hydrocarbons fluid abuse other substances. Acetone Nail polish remover, rubber cement, permanent markers Patients who have been abusing inhalants may report dizziness, irritability, tiredness, Adapted with permission from Bowen SE, Daniel J, Balster RL. Deaths associated loss of appetite, headache, photophobia, or with inhalant abuse in Virginia from 1987 to 1996. Drug Alcohol Depend 11,12 1999;53:241, and Sharp CW, Rosenberg NL. Inhalants. In: Lowinson JH, Ruiz P, cough. Most symptoms are nonspecific Millman RB, Langrod JG, eds. Substance abuse: a comprehensive textbook. 3d and can be mistaken for those of other ill- ed. Baltimore: Williams & Wilkins, 1997:246-64. nesses or syndromes. Signs of recent inhalant abuse include paint or oil stains on clothing or 870 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 68, NUMBER 5 / SEPTEMBER 1, 2003 Inhalant Abuse skin, spots or sores around the mouth, red eyes, rhinorrhea, chemical odor on the breath, Sudden sniffing death syndrome occurs when the acutely and a dazed appearance (Table 3).13 intoxicated inhalant abuser is startled, causing the release of a Patients with long-term inhalant abuse can burst of catecholamines that can trigger ventricular fibrillation. present to the emergency department or office setting with a wide range of neuropsychiatric signs and symptoms. The most commonly recognized acute presentation is sudden unconsciousness or death during known TABLE 2 inhalation of a solvent. Other, nonspecific Diagnostic Criteria for Inhalant Intoxication complaints include the following: memory loss, especially loss of short-term memory; Recent intentional use or short-term, high-dose exposure to volatile inhalants delusions or hallucinations; slurred or changed (excluding anesthetic gases and short-acting vasodilators) speech; staggering, stumbling, or wide-based Clinically significant maladaptive behavior or psychologic changes ataxic gait; visual and optical changes, such as (e.g., belligerence, assaultiveness, apathy, impaired judgment, impaired nystagmus; and loss of hearing or sense of social or occupational functioning) that developed during, or shortly after, use of or exposure to volatile inhalants smell.8 Unfortunately, no specific syndromes or clinical presentations confirm inhalant Two (or more) of the following signs developing during, or shortly after, inhalant use or exposure: dizziness, nystagmus, incoordination, slurred abuse. speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, Because of the variety of solvents that are tremor, generalized muscle weakness, blurred vision or diplopia, stupor or inhaled, the range of adverse effects is quite coma, or euphoria broad9 (Table 4).14 Furthermore, it is difficult The symptoms are not due to a general medical condition and are not better