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(Pediatrics in Review. 2008;29:33-34.)
© 2008 American Academy of Pediatrics
In Brief |
Recognition and Prevention of Inhalant Abuse. Anderson CE, Loomis GA.
Am Fam Physician. 2003;68
:869
–874[Medline]
Adolescent Abuse of Other Drugs. Greene JP, Ahrendt D, Stafford EM.
Adolesc Med. 2006;17
:283
–318
Inhalants of Abuse. Gussow LM. In: Ford M, Delaney KA, Ling L, Erickson T, eds.
Clinical Toxicology. Philadelphia, Pa: WB Saunders Co; 2001:651
–656
Inhalant Abuse. National Institute on Drug Abuse.
Research Reports. http://www.nida.nih.gov/ResearchReports/Inhalants/Inhalants.html. Accessed January 15, 2007
Inhalant Abuse and Dependence Among Adolescents in the United States. Wu L, Pilowsky DJ, Schlenger WE.
J Am Acad Child Adolesc Psychiatry. 2004;43
:1206
–1214[CrossRef][Medline]
Inhalant Abuse. Williams JF, Storck M, and the Committee on Substance Abuse and Committee on Native American Child Health.
Pediatrics. 2007;119
:1009
–1017
Inhalants are volatile substances that, when sniffed or snorted, can induce euphoric and hallucinogenic effects. These substances are lipid-soluble and after inhalation are absorbed rapidly through the lungs, quickly entering the central nervous system (CNS). Inhalants are classified as CNS depressants, but acute intoxication can lead to a sense of euphoria and excitability. "Sniffing" involves inhaling vapors from an open can or container, "bagging" describes inhaling vapors that have been captured in a bag, and "huffing" consists of inhaling volatile substances that have been soaked in a cloth. Bagging and huffing are preferred methods because the user can inhale large concentrations of the drug.
Inhalant abuse reaches its peak between grades 7 and 9 in the United States. Surveys of illicit drug use have revealed that use of inhalants is second to marijuana use among 8th and 10th graders and that inhalants are the third most widely used agents of abuse among 12th graders. The Youth Risk Behavior Survey 2005 reported that the overall prevalence of lifetime inhalant use was about 12%. Some studies suggest that females are as likely as males to use inhalants prior to 17 years of age but that males in the 18- to 25-year age group are more likely to do so. Rates of abuse have been reported to be higher among American Indians, whites, and Hispanics compared with African Americans. Other research has shown that a history of child abuse, a history of being in foster care, poor socioeconomic status, failing grades, and dropping out of school are risk factors associated with inhalant use.
Use of inhalants has been popular for many years because these substances are inexpensive, legal, and easy to obtain. Many can be found in common household products stored in garages, basements, and kitchens. Generally, there are four classes of inhalants. Volatile solvents are liquids that vaporize at room temperature and can be found in paint thinners, gasoline, and glues. Aerosols include spray paints, deodorant, and hair sprays. Gases can be found in many commercial products. Nitrous oxide is the most common abused gas and can be found in butane lighters, propane tanks, whipped cream dispensers, and FreonTM. Nitrites, which dilate blood vessels and relax muscles, often are used as sexual enhancers. These substances are prohibited by the Consumer Product Safety Commission but can be found in small bottles under the names "video head cleaner," "room deodorizer," or "liquid aroma."
Inhalants produce a pleasurable effect by depressing the CNS in a manner similar to that of alcohol. Research has demonstrated that toluene, found in glues, activates the brain's dopamine system. Acute effects of inhalant use include excitation followed by drowsiness, disinhibition, lightheadedness, and agitation. High doses may lead to confusion and delirium. These acute effects have a rapid onset but are short-lived, and many adolescents inhale the substances repeatedly to gain longer-lasting effects. Repeated use makes the user vulnerable to the different stages of inhalant intoxication.
Stage 1 is the excitability stage, stage 2 is the depressive phase, and stage 3 is further depression of the CNS. Stage 4 is the most worrisome stage, in which CNS depression can lead to coma, in addition to accidents and trauma due to risk-taking behaviors. Up to 50% of inhalant-related deaths are due to sudden sniffing death syndrome. Inhalants sensitize myocardial cell membranes to depolarization, and if the user is startled or engaging in vigorous activity at the time, catecholamines are released, leading to ventricular fibrillation. Inhalant-associated arrhythmias can occur after a single inhalant use in otherwise healthy adolescents. Sudden sniffing death is associated most often with the use of toluene, propane, butane, and aerosols.
Diagnosing inhalant abuse is difficult and relies on a high degree of suspicion, supported by a thorough history and physical examination. Other causes of acute intoxication or altered mental status should be considered, such as hypoxia, hypoglycemia, ethanol, illicit drugs, trauma, and infection. Inhaled hydrocarbons may be detected by gas chromatography within 10 hours of use, but this test is not readily available at most medical facilities. Although not specific, laboratory evaluation may reveal hypokalemia, hypophosphatemia, hypocalcemia, metabolic acidosis, methemoglobinemia, and carbon monoxide toxicity.
Laboratory evaluation should include a complete blood count, basic metabolic panel, calcium and phosphorous measurements, hepatic panel, and urinalysis for clues to inhalant use and urine toxicology screen to detect other illicit drug use. Consideration also should be given to cardiac and muscle enzyme analysis and electrocardiography, arterial blood gas determination to rule out methemoglobinemia, and brain imaging if neurologic signs are present. Treatment of an acute overdose is supportive, with particular attention paid to airway, breathing, and circulation. Unfortunately, no medication can reverse the effects of most inhalants.
Long-term treatment of inhalant dependence involves counseling, strict abstinence, and drug treatment protocols such as 12-step programs and inpatient and outpatient therapy. However, a recent survey found that many centers are not adequately equipped to treat inhalant abuse or dependence.
Michael Crocetti, MD
Bayview Medical Center
Baltimore, Md
Comment: Dr Crocetti's In Brief on Inhalants is really thought-provoking. He emphasizes the importance of considering inhalant use when evaluating patients whose manifestations are either acute or chronic. Because inhalants are so easily available, they often are used initially by younger, elementary school-age children; 3% of patients have tried inhalants by 4th grade. Furthermore, those who reported first use by 13 to 14 years of age were six times more likely to become dependent on inhalants than were those who began using at 15 to 17 years of age.
Signs of inhalant use may be subtle. Clinicians need to be alert to odors on the breath or clothes; discovery by parents of hidden empty cans; or signs of slurred speech, nausea, and symptoms similar to those of alcohol intoxication. Chronic users may exhibit a "huffer's rash," which is a dermatitis around the mouth or nose, with cracking of the skin and, sometimes, bacterial superinfection.
Because the effects of inhalants are short in duration, it is unusual for patients to seek medical attention unless they have developed chronic morbidity from long-term effects on the brain, heart, lung, kidney, liver, or bone marrow (suppression). Mortality can occur both from the sudden sniffing syndrome and through asphyxiation or suffocation related to bagging or huffing. Education and prevention strategies for both children and their parents must begin during elementary school to minimize the morbidity and mortality from this underdiagnosed form of drug abuse.
Janet R. Serwint, MD, Consulting Editor
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