Inhalant-Related Psychiatric Disorders

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Background

Inhalant-related psychiatric disorders are a heterogenous group of illnesses caused by the abuse of solvents, glues, paint, fuels, or other volatile substances.[1]

Although huffing, as it is commonly referred to, has existed since ancient times, it has regained popularity in recent years. The resurgence of this newfound phenomenon is believed to be due to a number of variables (eg, low cost, availability, peer influence, rapid mood-elevating quality), which have made this potentially fatal activity popular among many young people today. A relationship may exist between inhalant use and an increased risk of frequent drinking, binge-type drinking, smoking, and the use of other drugs, making inhalant-related disorders a new public health problem deserving of more attention.

Because most of the products used in huffing are legal household products, they are easily accessible and are relatively inexpensive to obtain. Most recent reports state that nearly 1000 such products are available to huffers every day. Some of the most common products used for inhaling are spray paint (containing butane, lead, or propane), permanent markers, correction fluid (eg, Liquid Paper, Wite-Out), glue (containing toluene or ethyl acetate), lighter fluid (containing butane or isopropane), hairspray (containing butane or propane), propane, gasoline (containing lead), kerosene, and nitrous oxide from a balloon. There may be different motivation for the type of inhalant used, which may be of significance during clinical treatment.[2]

Because of the increase in awareness of the potential dangers caused by sniffing or inhaling, laws have been established that prohibit the sale of certain products to minors; however, enforcing these laws is difficult. In the United States, 46 states have enacted laws to minimize inhalant abuse. The National Conference of State Legislatures outlines each state's statutes governing the use and the sale of aerosols and inhalants.[3]

Generally, adolescents practice huffing; however, younger children and young adults also engage in this potentially fatal act. Huffing involves placing the volatile substance (most commonly some type of chemical, eg, butane found in spray paint, acetone found in nail polish remover) on a rag or in a closed container (eg, soda can, plastic bag [termed bagging]), placing the rag over the nose and mouth, and breathing deeply to cause mood-altering effects. Other common methods of huffing include spraying an aerosol directly into the oral or nasal cavities; dousing clothing such as shirt sleeves, collars, and/or cuffs with a chemical and sniffing the polluted area over time; or filling balloons with nitrous oxide or other chemicals and inhaling the products.

The inhalation of these substances can cause permanent organ damage and death. Huffing is a problem in the United States and abroad, and it accounts for a large portion of emergency department visits. In a 2010 article by Howard et al, the authors reported that rates of suicidal ideation are higher among those with inhalant use disorders than nonusers. Among those who use inhalants, approximately 67.4% had thought about committing suicide and 20.2% had reportedly attempted suicide.[4]

In 2004, Sakai et al found that adolescents who used inhalants were more likely to have higher rates of major depression, suicidal ideation or attempts, and abuse or dependence upon alcohol, hallucinogens, nicotine, cocaine, and amphetamines than adolescents who had never used inhalants. Their study noted higher reported rates of abuse and neglect among adolescents who were diagnosed with inhalant use disorders.[5]

Diagnosis of inhalant-related psychiatric disorders is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)[6] or International Classification of Diseases, 10th Revision criteria. Although studies have shown that inhalant abuse has been difficult to diagnose, treatment efforts for inhalant-related psychiatric disorders may be promising. Treatment consists of psychotherapy (eg, 12-step programs similar to Alcoholics Anonymous, cognitive behavior therapy, rational-emotive therapy) and pharmacotherapy. Early intervention may play a key role because engagement in this activity may lead to the use of other drugs.

Some synonymous terms for inhalant abuse include air blasts, aimies/ames/amys (amyl nitrite), bagging, bolt, boppers, bullet, climax, glading, gluing, hardware, hippie crack, huffing, kick, medusa, pearls, poor man’s pot, poppers, quicksilver, rush, snappers, snorting, thrust, tolly, toncho (octane booster), whippets, and whiteout.

Case study

A 14-year-old Caucasian male is brought into the emergency department by his father after being found in a confused, euphoric state. His breath has a chemical odor and his speech is slurred. The boy complains of blurred vision and sensitivity to light (photophobia). Not only does the boy’s shirt have stains, but so do his hands. A rag doused with turpentine was found in the boy’s room. The boy’s pulse and vital signs are elevated. An electrocardiogram shows tachycardia. Upon further examination, the treating physician observes burns to the nasal and oral passages. A urinalysis with a screening for hippuric acid is ordered. The results come back with a high level of toluene. Three days after the boy was taken to the emergency department, the boy begins to experience severe abdominal cramping, nausea, headache, irritability, and tremors in his hands. He cannot sleep. He is experiencing withdrawals.

Pathophysiology

Inhalants are CNS depressants (similar to alcohol) and are thought to influence gamma-aminobutyric acid (GABA), although the exact mechanism has yet to be determined. No evidence associates inhalants with the opiate system; N -methyl-D-aspartate may play a role.

Medical effects

Psychiatric effects

The psychiatric effects of inhalant abuse include impaired judgment, confusion, fright, hyperactivity, anxiety, acute psychosis, increased violence and aggressive behavior, depression, organic brain syndrome (ie, coarse tremor, staggering gait, speech problems, thought disorder), abuse, tolerance and dependence, hallucinations, decreased intelligence quotient, intoxication, mood disorder, dementia, and withdrawal. Inhalant abuse also affects social, educational, and economic status. In addition, persons who abuse inhalants are more likely to be involved in accidents (eg, falls, burns, frostbite, motor vehicle accidents). Importantly, note that the number of planned suicides in persons with inhalant-related psychiatric disorders is equal to the number of planned suicides in persons with other psychiatric illnesses; however, the number of unplanned suicides is dramatically higher in children and adolescents who engage in huffing.

Epidemiology

Frequency

United States

Of the population, 6% have tried huffing once and 1% are current users. According to statistics gathered by the National Inhalant Prevention Coalition, ". . . by the time a student reaches the eighth grade, 1 in 5 will have used inhalants."[8] Inhalants account for 1% of substance-induced death. Huffing is more common in rural versus inner-city adolescents, although exact numbers are difficult to determine.

The National Survey on Drug Use and Health (NSDUH) report found that nearly 1 million adolescents (3.9%) used inhalants in 2007. The rates in 2003, 2004, and 2005 were higher (4.5%, 4.6%, and 4.5%, respectively). From 2002-2007, reported abuse or dependence on inhalants showed rates to be relatively stable. In 2007, approximately 99,000 (0.4%) of adolescents met the criteria for abuse or dependence on inhalants. Also in 2007, 2.1% of adolescents who had not previously used inhalants reported using these for the first time. The rate of initiation in 2007 for those who had not previously used inhalants was lower than the rate for 2002-2005, which was around 2.6%. For those surveyed who had used illicit drugs, 17.2% reported that inhalants were the first drug they used.[9]

International

Incidents occur worldwide, but determining exact numbers is difficult.

Mortality/Morbidity

Inhalants work quickly by passing through the nasal cavity and entering the lungs, bloodstream, and brain, all in a matter of seconds. The chemical vapors of the inhalants are dissolved into the fatty tissues of the brain. The results of inhalant abuse affect virtually every organ and function of the body, including the brain, heart, lungs, kidneys, muscle, bone marrow, and peripheral and central nervous systems, to name a few. Within just a few minutes, sudden sniffing death may occur from heart rhythm irregularities leading to cardiac arrest. In addition to causing possible cardiac disruptions, inhalant abuse may also result in death due to suffocation, asphyxiation, or aspiration. Persons who abuse inhalants long-term may become permanently disabled, losing their ability to walk, talk, and think. The possible damage depends on the chemical used, the frequency with which it is used, and the amount used.

Race

Persons who abuse inhalants predominantly are white; however, studies have found minority involvement in subcultures of American and Canadian Indians and in Hispanic persons with low-income status. Inhalant use is more common in rural and suburban areas than in urban areas.

Sex

Although long-term inhalant use is more common in males than in females, experimental use is equally common in males and females.

Age

Experimental use of inhalants normally occurs in late childhood and early adolescence (9-13 y). Long-term use appears during early and late adolescence (12-17 y). Inhalants are commonly the first substance used before the onset of substance (eg, tobacco, alcohol, marijuana, cocaine) abuse occurs. Inhalant abuse among younger children and adults is less frequent, although it does occur. In particular, nitrite abusers tend to be adults. Those who abuse nitrites tend to seek enhanced sexual experiences as nitrites can cause vasodilation, increased heart rate, and a feeling of heat and excitement.

History

Persons who abuse inhalants commonly share characteristics that may help identify them as users. While taking the patient's history, determine their diagnosis based on the DSM-IV-TR criteria for inhalant abuse, inhalant dependence, inhalant intoxication, substance intoxication delirium, substance-induced persistent dementia, substance-induced psychotic disorder, substance-induced mood disorder, substance-induced anxiety disorder, and inhalant-related disorder not otherwise specified (NOS). Pay close attention to the signs and symptoms commonly associated with persons who abuse inhalants (see below). Inquire about other drugs of abuse and a family history of drug and alcohol abuse or addiction. The diagnosis is based solely on the history and a very high index of suspicion.

Physical

Causes

Much speculation exists on the cause of inhalant abuse. Its popularity appears to be based on the fact that the substances are easily accessible to young people. The products used are fairly easy to hide, fairly inexpensive, easily attainable, and, for the most part, legal. Therefore, inhalants are readily becoming the drugs of choice. Many adolescents are becoming interested in the instant gratification huffing offers, while others engage in huffing merely because their friends are doing it. However, one subgroup of young people who abuse inhalants do so because they have seen their parents or older siblings abuse illegal drugs, and these young people have decided that huffing is the activity they choose to begin their drug use and addiction.

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Histologic Findings

Findings may include evidence of heavy metal damage to specific organs, such as that caused by lead in gasoline and paint, and inflammation, rhabdomyolysis, brain atrophy, and renal tubular acidosis.

Medical Care

Surgical Care

Consultations

Diet

Activity

Medication Summary

If psychosis or delirium is present, use an antipsychotic such as risperidone or haloperidol and/or an anticonvulsant such as carbamazepine. Avoid benzodiazepines because they may worsen respiratory depression.

Haloperidol (Haldol)

Clinical Context:  Indicated for psychosis, also to treat motor and vocal tics in children and adults.

Risperidone (Risperdal)

Clinical Context:  Binds to dopamine D2 receptor with 20-times lower affinity than 5-HT2–receptor affinity. Improves negative symptoms of psychoses and reduces incidence of adverse extrapyramidal effects.

Class Summary

Reduce psychosis and aggressive behavior. All antipsychotics may be equally efficacious, but their adverse effect profiles are different. The atypical antipsychotics such as risperidone, olanzapine, quetiapine, and ziprasidone have an advantage in the adverse effect profile, especially with their lower risk to cause adverse extrapyramidal effects and tardive dyskinesia.

Carbamazepine (Tegretol)

Clinical Context:  Used to treat epilepsy and trigeminal neuralgia.

Valproic acid (Depakote, Depakene)

Clinical Context:  Although mechanism of action is not established, activity may be related to increased brain levels of GABA or enhanced GABA action. Valproate also may potentiate postsynaptic GABA responses, affect potassium channel, or have a direct membrane-stabilizing effect.

Has proven effectiveness in treating and preventing mania. Classified as a mood stabilizer and can be used alone or in combination with lithium. Useful in treating patients with rapid-cycling bipolar disorders and has been used to treat aggressive or behavioral disorders. A combination of valproic acid and valproate (ie, divalproex [Depakote]) has been effective in treating persons in manic phase, with a success rate of 49%.

Class Summary

Usually used to treat seizures but have been used for treatment of manic-depressive symptoms and behavioral agitation. Other anticonvulsants such as valproic acid (Depakene) or divalproex sodium (Depakote) may also be as effective as carbamazepine.

Further Inpatient Care

Further Outpatient Care

Inpatient & Outpatient Medications

Transfer

Deterrence/Prevention

Complications

Prognosis

Author

Guy E Brannon, MD, Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Disclosure: AstraZeneca Grant/research funds Other; Janssen Grant/research funds Other; Pfizer Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Eli Lilly Grant/research funds Other; Forrest Grant/research funds Other; Merck None; Novartis None None

Coauthor(s)

Jennifer M Thomas, MS, MA, Clinical Research Coordinator, Louisiana Clinical Research, LLC

Disclosure: Nothing to disclose.

Specialty Editors

Barry I Liskow, MD, Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Disclosure: lilly Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Otsuke Grant/research funds reseach; Merck Honoraria Speaking and teaching

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK), Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Disclosure: Nothing to disclose.

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