INHALANT USE DISORDER DANA BARTLETT, RN, BSN, MSN, MA, CSPI Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely about toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Rocky Mountain Poison Control Center. ABSTRACT An inhalant use disorder is diagnosed according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and includes the use of traditional categories of inhalants, such as aerosols, gases, nitrites, and solvents. Inhalants are often used to describe volatile substances that the user inhales for a psychoactive effect. Chemicals misused as inhalants are often found in various household products that some United States jurisdictions have started to regulate. Identification and treatment of inhalant use disorder requires partnership with interdisciplinary health professionals in acute care and community settings. Inhalant use disorders require a unique approach by all members of the interdisciplinary health team to raise awareness of the risk, prevention, and available treatment when the misuse of solvents is identified. 1 NurseCe4Less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 2.5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Clinicians need to be informed about how to identify and diagnose an inhalant use disorder according to the DSM-5 criteria. To diagnose accurately, clinicians need to be able to know of the physical and psychological effects of inhalant use disorder and the available treatment for individuals when an acute solvent intoxication condition exists. Course Purpose To provide health professionals with information about DSM-5 criteria to diagnose an inhalant use disorder as well as the treatment and ongoing support for those affected by it. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures Dana Bartlett, RN, BSN, MSN, MA, CSPI, Kellie Wilson, Pharm D, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support. 2 NurseCe4Less.com Self-Assessment of Knowledge Pre-Test: 1. Which of the following is the definition of volatility? a. The ability to evaporate and form a vapor b. Resistance to flow c. Decrease in temperature when compressed d. The ability to change from a gas to a liquid 2. Which of the following substances is commonly used as an inhalant? a. Cocaine b. Typewriter correction fluid c. Methamphetamine d. Water-based paint 3. Volatile solvent compounds are a. slowly absorbed through the gut. b. rapidly absorbed through the skin. c. usually injected. d. rapidly absorbed through the lungs. 4. The effects of commonly used inhalants may be mediated by their effect on a. epinephrine. b. acetylcholine. c. GABA receptors. d. adenosine. 5. Which of these terms describe how inhalants are used? a. Bagging, huffing, and sniffing b. Snorting, smoking, and gumming c. Shooting, injecting, and rocking d. Ingesting, amping, and freebasing 3 NurseCe4Less.com Introduction Individuals who intentionally inhale chemical agents may develop an inhalant use disorder. There are many legal and commercially produced substances that can be inhaled and used as an intoxicant. These substances are highly volatile or contain high concentrations of a volatile compound. As a result, these substances or products are fast-acting and they may cause rapid, sudden harm. Fortunately, the use of inhalants appears to be declining but for those who do use them, commonly used inhalants can cause significant clinical effects. Long-term inhalant use can cause irreversible physical and psychiatric damage and inhalant use may cause sudden death. Because of these serious outcomes, it remains important to understand inhalant use disorder and the current trends in treatment. Overview of Inhalant Use Disorder An inhalant use disorder is defined by the American Psychiatric Association as a “... problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress.”1 Still commonly referred to as solvent use or volatile substance use, inhalant use disorder is the deliberate inhalation of the vapors from volatile organic compounds for the purpose of altering consciousness. This substance use disorder carries a risk for significant acute and chronic clinical symptoms in affected individuals, including sudden death. Long-term inhalant use can cause irreversible physical and psychiatric damage. Inhalants are widely available and they can be legally purchased. Intoxication from commonly used inhalants has a rapid onset, dissipates quickly, and does not produce a marked hangover. These attributes make inhalants an accessible option for adolescents who want to experiment with an intoxicant and they make inhalants a popular “starter” drug. Inhalant use is also associated with illicit drug use. Adolescents typically use inhalants for a relatively brief period of time, with the incidence of use declining significantly as the child grows older.1 4 NurseCe4Less.com Although long-term, chronic use is quite uncommon, it has been estimated that at least 10% of American adolescents aged 13 have used an inhalant at least once.1 There is additional statistical evidence that in recent years the number of adolescents using inhalants has been declining.2 Inhalants have regularly fallen behind in popularity when compared to alcohol or marijuana. However, inhalants are dangerous substances and given the risk of commonly used inhalants to cause harmful clinical effects, including sudden death, inhalant use disorder is considered a serious public health problem. Products and Solvents Commonly Used Many legal and commercially produced substances can be used as inhalants, however before discussing these substances, it is important to define important terminology relative to inhalant use. TABLE 1: DEFINITIONS OF INHALANT USE Solvent A solvent is defined as a substance that is capable of dissolving. Solvents are valued for this capability and are often used as a carrier vehicle for other chemicals or compounds. Examples include: simple petroleum distillates are often used as a carrier vehicle in household pesticides and alcohol is used as a solvent/carrier vehicle in products such as mouthwashes and solid deodorants. Toluene is one of the most common solvents and is often found in products such as glue that are used for inhalant use. Volatile Volatility is defined as the ability to evaporate and form a vapor. Vapor A vapor is defined as the gaseous form of a liquid. Hydrocarbon A hydrocarbon is an organic compound that contains carbon and hydrogen only. Hydrocarbons are derived from petroleum (oil), they can be gases or liquids, and hydrocarbon-based products are perhaps the most common solvent used. Hydrocarbons are in use everywhere; gasoline, lighter fluid, kerosene, and paint thinner are hydrocarbons. 5 NurseCe4Less.com Some examples of the more common products used as inhalants are listed below in Table 2.3-6 Many of the products listed in Table 2 differ in their ingredients and some are quite similar or almost identical to each other. Regardless of the differences or similarities, each one contains a solvent or is a compound that can be used as a solvent. TABLE 2: PRODUCTS USED AS INHALANTS Air fresheners Cleaning products Computer keyboard cleaners Fluorinated hydrocarbons, i.e., Freon Gasoline Glue Hair spray Lighter fluid Nail polish remover Nitrous oxide Pain stripper Paint thinner Simple asphyxiant gases, i.e., butane, propane Spray paints Typewriter correction fluid Whipped cream dispensers Solvents are volatile and they can easily evaporate to form a vapor. In addition, many solvents are hydrocarbons. Substances that are used as solvents rarely involve a single compound. In addition, some of the products in Table 2 may not contain a hydrocarbon, may be a mixture of many hydrocarbons, may be a mixture of hydrocarbons and non-hydrocarbon compounds, and may not be used as solvents.3-6 For example, gasoline and the simple asphyxiants are hydrocarbons; they are volatile and are often used, but they are not solvents. Glues themselves are not solvents, but typically contain hydrocarbons such as hexane and toluene that are used as solvents. They often contain acetone, a ketone which is not a hydrocarbon but that forms a vapor that can cause intoxication.3-6 6 NurseCe4Less.com This complexity in nomenclature and in the nature of the products that may be inhaled can make understanding solvent use difficult but if the definitions in Table 1 and the definition of solvent use are kept in mind, understanding the problem of inhalant use disorder becomes more clear. An example is typewriter correction fluid, which contains a hydrocarbon, such