Addiction Treatment Blog

Dr. Snow gave that blessed chloroform and the effect was soothing, quieting and delightful beyond measure.

Queen Victoria describing the administration anaesthetic chloroform in her Journal.

Volatile Substance Abuse

History of Volatile Substance Abuse

Volatile substance abuse (VSA) can be defined as ‘deliberate inhalation of a volatile substance to achieve a change in mental state‘. Compulsive abusive of ether and chloroform was known in Victorian England and in Ireland but this was a relatively minor problem compared to the wider abuse of other substances such as opium. It was not until the 1970s that UK mortality data for VSA became available and the problem then began to attract medical and media attention. The number of deaths attributed to VSA gradually increased until 1990 but there has been a decline since then. In 1990, the number of deaths peaked at 151. In 1991 thus fell to 122, then 84 in 1992, 71 in 1993 and by 1994 – the latest year for which figures are available – the number of fatalities was 57. This decline is most welcome but the reasons for it are unknown. It may represent a genuine decrease in use due to recognition of the potential adverse consequences. Alternatively, and more likely, other abusable substances have become more popular. Tobacco and alcohol are readily available. There is evidence for increased use of tobacco amongst teenage girls in particular and certain alcoholic products seem to be marketed with teenagers in mind. Ecstasy, but also cannabis, has become cheaper and more fashionable.

The volatile substances or ‘inhalants‘ are perhaps unique amongst substances of abuse in that the main abusers are children and teenagers: most are between 10 and 18 years old. The majority start when aged between 10 and 14, and although estimates vary, up to one in 10 secondary school pupils are believed to abuse volatile substances to some degree. However, local statistics show that this figure varies considerably across the country. A survey of 7722 schoolchildren aged 15 or 16 from around the UK was reported in 1996. Self-reported abuse of volatile substances on at least one occasion was described by 21 per cent of girls and 19.7 per cent of boys. In 1992, the Department of Health considered about 70 per cent of users ‘experimented‘ with the method a school children became long-term users’. This latter population abuse inhalants regularly for more than three months. In the USA, two large studies estimated the extent of VSA amongst school-age teenagers at 7 to 8 per cent and 16.6 per cent, respectively. It is unclear whether VSA encourages abuse of other substances subsequently.

Effects Sought

The first ‘rush‘ or ‘buzz‘ occurs when a relatively high concentration of inhaled substance reaches the brain quickly. This often produces a rapid ‘high’ or feeling of intense exhilaration. The subsequent effects can appear similar to drunkenness: feeling merry, playful and uninhibited, and sociability is often increased. The emotions prevalent at the time can be heightened. Unlike alcohol, inhalants commonly cause euphoria, hallucinations and perceptual disturbances. The hallucinations can, to some extent, be controlled and sometimes become a group activity.

All these effects appear very quickly – within minutes – but do not last long. However, the experienced (usually chronic) abuser can sustain the desirable effects for several hours by repeating inhalations when the effects of previous exposures to wear off.

There may be a subsequent hangover feeling in some users even after a single exposure. This usually takes the form of drowsiness, headache and inability to concentrate.

It is not always easy to understand why a particular child has taken to volatile substance abuse. Undoubtedly the ‘naughtiness‘ and potential danger associated with a behaviour that would shock or anger parents is an attraction for some. Loneliness, boredom, domestic strife or feelings of inadequacy may sometimes be important causes. For others, solvents are simply an easily-obtainable, affordable alternative to the alcohol consumed by older friends and relatives. Inhalants are still more accessible to many teenagers than tobacco. The hallucinations and loss of control experienced can be pleasurable or frightening, but either way can represent an appealing escape from reality.

There is some evidence that abusers are more likely to come from families at the lower end of the socioeconomic scale and that the incidence is greater in inner city areas. Inhalant abusers are also more likely to play truant from school than other children.

Administration

The terms ‘glue sniffing‘ and ‘solvent misuse‘ only cover part of the problem. Numerous products are involved as volatile substances have a wide variety of uses in the domestic, school and workplace setting. Some of these preparations are identified in the table below. It is difficult to be certain which ones are used most commonly. The 1994 data for abuse-related deaths showed that gas fuels accounted for nearly two-thirds of all deaths. In previous years, the mortality statistics have shown a greater preponderance of aerosols and glues, which seem to be implicated in progressively fewer deaths. It is not clear whether certain volatile substance-based products, and the methods of using them, are intrinsically more likely to cause harm than others of whether greater awareness of the problem by suppliers and more controls on the sales of glues, in particular, have limited availability.

Note that nitrites are also abused by inhalation but these will be discussed in detail later.

As with many forms of drug abuse, VSA can be either a group or an individual activity. The practice can take place in quiet public areas (such as car parks, recreation grounds and woodland) or in the home. The administration methods adopted depend on the inhalant being abused. The abuser needs to obtain higher concentration of volatile substance in the lungs quickly in order to experience the sudden ‘rush’ of intoxication which is the initial desired effect. To accomplish this, chlorofluorocarbons (CFCs) and butane are sometimes sprayed directly down the throat. This is known to be a very hazardous practice which can cause sudden death (see below).

A far more common procedure is to inhale concentrated fumes from a limited space and to rebreathe this air repeatedly until a ‘high‘ is achieved. Usually this is facilitated by holding a plastic bag containing the inhalant firmly over the mouth and nose and then breathing in and out rapidly several times. This is known as ‘huffing‘; supermarket carrier bags and crisp packets are commonly used. Other methods have involved placing plastic bags completely over the head or inhaling from underneath bedclothes or similar whole-body covering. Clearly some of these activities carry a risk of death from suffocation.

Many techniques also produce varying degrees of hypoxia, which is known to exacerbate the pro-arrhythmic potential of these agents.

Sometimes abusers breathe fumes directly from the original container; others inhale from hands cupped over the mouth or nose. The inhalant may be applied to clothes (e.g. cuffs and sleeves of jumpers, scarves) or a handkerchief or rag soaked in the solvent can be carried.

Substances which may be abused by inhalation

Pharmacokinetics

Following inhalation, vapours are readily absorbed into the bloodstream and a rapid access to the brain is afforded by the high lipophilicity of the substances involved. The lungs are an important route of excretion subsequent to inhalation. Consequently, being volatile, most solvents and related substances do not cause long-lasting central nerveous system (CNS) effects following a single ’sniff’ because pulmonary excretion is usually rapid. The actions of butane and CFCs disappear after a few minutes but the effect of toluene can last 30 to 45 minutes following a single ‘sniffing‘ episode.

Adverse Effects

The irritant properties of certain solvents such as toluene can produce erythema around the mouth and nose and inflammation of perioral abrasions or spots. Coughing, lacrimation and salivation can also occur as a result of this irritancy. Other undesirable effects from the user’s point of view include vomiting, confusion, dizziness and drowsiness. Some abusers become very depressed, aggressive, agitated or frightened. In 1990, over 4 per cent of all UK deaths in boys aged 10 to 14 years old were caused by inhalant abuse. Deaths are basically the result of one of three consequences: CNS depression, accidents arising as a result of intoxication or sudden death.

All of the inhaled products can cause a CNS derangement which appears superficially similar to drunkenness. Historically, trichloroethane, trichloroethylene and chloroform have all been used as general anaesthetistics, so the ability of commonly abused inhalants to produce CNS depression should not be underestimated. As with all similar drugs, the effects produced in an individual are dose-dependent; greater levels of exposure may result, progressively, in disorientation, ataxia, sedation, unconsciousness and even respiratory depression or coma. In one study of 335 abusers, 3 per cent had been admitted to hospital in a coma and a further 14 per cent had experienced ‘blackouts‘ without hospital admission. There is no evidence that short-term volatile substance abuse causes residual CNS damage or neuropsychological problems but this can occur with chronic exposure.

Although the direct CNS effects in isolation are rarely serious, significant repercussions may arise indirectly. Accidental deaths and serious injuries can be sustained by the semiconscious or disorientated abuser, sometimes as a result of hallucinations or illusions; some believe that they are able to fly or swim and falls from heights and drownings do occur. Aspiration of vomit while sedated and suffocation in the large plastic bags used by some teenagers have also been described. In addition, there is a fire risk associated with solvents, fuels and butane propellants because there are highly flammable and many abusers or their associates smoke.

Apart from the direct or indirect CNS effects, the other major cause of mortality is sudden death. Tragically, some these deaths are in first-time users and, as has already been stated, most of these are young teenagers who would probably only have abused once or twice as an ‘experiment‘. There are also many fatal cases documented amongst long-term abusers. Most of these deaths are thought to have been due to ventricular fibrillation but this has been difficult to confirm because the majority of sufferers are either found dead or die shortly afterwards. Even when the cause and/or diagnosis has been confirmed at an early stage, resuscitation is often unsuccessful.

Many sudden deaths occur shortly after a bout of ‘sniffing‘ when the abuser is stressed emotionally or physically (particularly by running). It is therefore probable that sympathetic nervous system activity or circulating adrenaline play a role in the aetiology. It seems likely that volatile substances sensitise the myocardium to catecholamines. Animal studies show that both adrenaline and asphyxia increase the arrhythmogenic actions of solvents and that ethanol may further potentiate some of these effects.

Animal work also confirms that myocardial sensitivity may persist for hours after inhalant exposure. This may explain why certain documented cases of sudden death seem to occur some time after a sniffing event. The inhalational anaesthetic halothane, itself a CFC, can rarely cause arrhythmias and has been precipitated or exacerbated cardiac problems in those known to have been chronically exposed to solvents, providing further evidence that cardiac sensitisation is not always an acute short-lived effect. Interestingly, trichloroethane was used briefly as a general anaesthetic in the 1960s but this practice was discontinued because of a high incidence of ventricular arrhythmias. It is structurally related to halothane.

Another form of sudden death with a cardiac origin is believed to result from vagal inhibition as a reflex response to inhalants being sprayed directly against the back of the throat. Very rapid cooling of the larynx can stimulate the vagus nerve to the extent that the pulse rapidly slows and then the heart stops. This is particularly associated with the butane and CFC propellants.

Although a range of different arrhythmias has been observed in animals exposed to inhalants, ventricular arrhythmias are reported most consistently in humans. Other rare human cardiac effects have included dilated cardiomyopathy and myocardial infarction.

Given the many serious risks that the abuser may encounter following inhalation, sniffing by oneself is potentially more hazardous than group activity. Occasionally those presenting with severe arrhythmia are successfully resuscitated but this does spend on help being near at hand.

Long-term Use

Generally, chronic abuse may be associated with a decreased ability to concentrate, insomnia and nightmares. Chronic abusers are also more likely to have resorted to theft to keep the habit going. Various medical problems may occur as a result of long-term misuse but there is no consistent pattern to these problems and it is not clear why some abusers suffer and others do not. Adverse effects that have been reported include peripheral and central neurological damage (e.g. peripheral neuropathy, cerebellar damage, encephalopathy), renal failure, hepatoxicity, severe gastrointestinal upset and muscle damage. Some inhalants are more toxic than others; chronic exposure to toluene seems to cause a particularly wide array of adverse effects. Benzene toxicity and lead poisoning have been described in persons regularly exposed to petrol.

Tolerance seems to develop in the chronic user such that much larger amounts of inhalant are required to achieve a ‘high’. This tolerance quickly reserves if inhalants are withheld. Dependence of the psychological type can occur after long-term use but physical dependence is less well-known. However, a withdrawal syndrome of irritability, headaches, and delirium tremens-like features has been described in humans. This appears to be rare but usually takes one or two days to develop following abstinence and lasts a further two to five days. Animal work suggests that withdrawal may occur only with certain solvents. On the whole, VSA has a low dependence potential and usually is not associated with chronic daily usage or a compulsion to continue administration.

Reducing The Problem

Given the range of potentially abusable substances available, it is virtually impossible to restrict supplies via legislation. The Intoxicating Substances Supply Act of 1985 makes it illegal for any shopkeeper to sell volatile substances with the knowledge that they are likely to be abused but a breach of the law can be difficult to prove. The then Department of Health and Social Security issued guidelines to shop owners in 1984, suggesting how abusers might be identified and that some products (e.g. adhesives) could be kept behind the counter. It is not illegal to abuse inhalants in public unless the law is broken in other respects (e.g. breach of the peace, criminal damage, trespass).

The retailer needs to appreciate which substances on his/her premises are open to abuse and ensure that all staff understand the nature of the problem. Some products are clearly a greater attraction to abusers than others. For example, of the aerosol products, hairsprays and air fresheners contain a proportionally larger amount of available propellant for abuse than, say, shaving foam or spray paint. These latter products are thus much less likely to be abused. Some products contain virtually pure volatile substances and are particularly open to abuse, e.g. camping stove gas refills, cigarette lighter fuel refills, dry cleaning fluid, PR Spray and correction fluid or paint thinners. Many of these are unusual products for a young teenager to buy and so arouse suspicion. A recent national report in the UK recommended that all potentially abusable household products should be labelled to alert retailers and parents to the potential danger. It is of course difficult to identify a potential abuser; the table below summarises the key points.

Pointers to inhalant abuse

• The smell of volatile substances persists on the breath for several hours after inhalation; the smell may also arise from clothes or a cloth about the person
• Frequent purchase of potentially abusable substances by the same individual; groups of teenagers buying inhalants together or suspected shop-lifting of these products.
• Sings of intoxication (see text)
• Obvious truancy
• Facial erythema and spots, inflammation or abrasions around the mouth and nose.

Additionally for parents

• Finding empty containers of abusable substances or used plastic bags where the teenager has been; signs of glues etc., on skin, clothes, or bedclothes
• Regular signs of ‘hangover’ (e.g. headaches, drowsiness) or of repeated sore throats, coughing or colds
• Sudden changes in the mood, lifestyle and appetite, or secrecy concerning absences from home; inability to concentrate.

Clearly some of these indicators could be confused with the normal process of teenage development.

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