Inhalant-Related Psychiatric Disorders 

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

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.^[1]

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.^[2]

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.^[3]

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.^[4]

Diagnosis of inhalant-related psychiatric disorders is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)^[5] 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.

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

• Brain: Most of the damage inflicted by inhalant abuse initially affects the brain. Tremors and uncontrollable shaking are observed in those who abuse inhalants for a long period. Inhalants also affect eyesight, causing double vision and other sight disorders. Many who abuse inhalants experience seizures. Headaches are common. Damage to the brain may lead to changes in personality. Those who abuse toluene may have significantly wider cerebellar and cerebral sulci and larger ventricular systems. Memory loss, decreased cognitive functioning, and slurred speech may ensue inhalant use.
• Lungs: Repeated use of inhalants can cause lung damage, including hypoxia, sinus discharge, coughing, cyanosis, and upper and lower airway irritation.
• Heart: Heart problems can occur, including irregular heartbeat and sudden sniffing death syndrome, which is heart failure resulting from an irregular heartbeat.
• Gastrointestinal: Problems include abdominal pain, nausea, and vomiting.
• Liver: Liver function can actually shut down, either temporarily or permanently, depending on length and extent of inhalant use (ie, cirrhosis).
• Kidney: Kidney stones and complete loss of kidney function can develop.
• Muscle: Long-term inhalant abuse leads to muscle weakness, muscle wasting, and reduced muscle tone and strength.
• Bone marrow: Inhalants damage bone marrow. In addition, the chemical benzene, which is found in gasoline, has been shown to cause leukemia.
• Peripheral nervous system: Damage from inhalants can cause temporary numbness, permanent nerve damage, permanent paralysis, or generalized weakness, depending on the frequency of abuse.
• Hearing: Some who abuse inhalants become deaf because of the inhalation of chemicals that destroy cells that relay sound to the brain.
• Other medical effects: Other effects of inhalant abuse include respiratory problems, asphyxiation, aeration, and fetal damage similar to that observed in patients with fetal alcohol syndrome.

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.

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."^[6] 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.^[7]

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.