eMedicine Specialties > Psychiatry > Addiction

Inhalant-Related Psychiatric Disorders

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
Jeanie McGee Gary, BS, Editorial Manager, Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport

Updated: Feb 5, 2008

Introduction

Background

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. 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.

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.

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. Diagnosis of inhalant-related psychiatric disorders is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR)¹ 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.

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

• 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. Those who abuse toluene may have significantly wider cerebellar and cerebral sulci and larger ventricular systems.
• 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). 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."² 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.

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. 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 (age 9-13 y). Long-term use appears during early and late adolescence (age 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.

Clinical

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.

• Signs and symptoms
  • Chemical smell or odor on breath or body
  • Redness, sores, or spots around the lips or mouth
  • Redness of eyes
  • Runny or red nose
  • Paint stains on clothing or body
  • Nausea or loss of appetite
  • Drunken or dazed appearance
  • Dizziness
  • Irritability, excitability, or anxiety
  • Slow verbal responses in conversation
  • Sudden behavior change
  • Sensitivity to light
  • Sore or irritated throat
  • Rashes or redness on hands
• Characteristics of persons who abuse inhalants
  • Delinquency
  • Theft and burglary
  • Poor school attendance
  • Frequent suspension and expulsion from school
  • Social outcast
  • Impoverished families or middle-to-upper income status
  • Lack of parental control or guidance
  • Attention deficit
  • Poor academic performance
  • Antisocial personality
  • Depressive disorders
  • Emotional problems (specifically anxiety, depression, and anger)
  • Low self-esteem
  • Peer pressure with drug influence
• Criteria for inhalant abuse, adapted from the DSM-IV-TR
  • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (or more) of the following, occurring within a 12-month period:
    • Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
    • Recurrent substance use in situations in which it is physically hazardous
    • Recurrent substance-related legal problems
    • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
  • Symptoms never meeting criteria for substance dependence for this class of substance
• Criteria for inhalant dependence, adapted from the DSM-IV-TR - A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period:
  • Tolerance
    • A need for markedly increased amounts of the substance to achieve intoxication or desired effects
    • Markedly diminished effects with continued use of the same amount of the substance
  • Withdrawal
    • Characteristic withdrawal syndrome for the substance
    • Same (or a closely related) substance taken to relieve or avoid withdrawal symptoms
  • Substance often taken in larger amounts or over longer periods than was intended
  • A persistent desire or unsuccessful effort to reduce or control substance use
  • Significant time spent in activities necessary to obtain the substance or recover from its effects
  • Important social, occupational, or recreational activities are abandoned or reduced because of the substance use
  • Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
• Criteria for inhalant intoxication, adapted from the DSM-IV-TR
  • Recent intentional use or short-term high-dose exposure to volatile inhalants
  • Clinically maladaptive behavioral or psychological changes that developed during or shortly after use of or exposure to volatile inhalants
  • Two (or more) of the following signs developing during or shortly after inhalant use or exposure:
    • Dizziness
    • Nystagmus
    • Incoordination
    • Slurred speech
    • Unsteady gait
    • Lethargy
    • Depressed reflexes
    • Psychomotor retardation
    • Tremor
    • Generalized muscle weakness
    • Blurred vision or diplopia
    • Stupor or coma
    • Euphoria
  • Symptoms not due to a general medical condition and not better accounted for by another mental disorder
• Criteria for substance intoxication delirium, adapted from the DSM-IV-TR
  • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
  • A change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia
  • Disturbance occurs over a short period and tends to fluctuate during the course of the day
  • Evidence from the history, physical examination, or laboratory findings of either of the following:
    • Symptoms of (1) disturbance of consciousness with reduced ability to focus, sustain, or shift attention or (2) a change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia that developed during substance intoxication
    • Medication use etiologically related to the disturbance
• Criteria for substance-induced persistent dementia, adapted from the DSM-IV-TR
  • Development of multiple cognitive deficits manifested by both (1) memory impairment and (2) one (or more) of the following cognitive disturbances:
    • Aphasia
    • Apraxia
    • Agnosia
    • Disturbance in executive functioning
  • Cognitive deficit in (1) memory impairment and (2) aphasia, apraxia, agnosia, or disturbance in executive functioning each cause significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning
  • Deficients do not occur exclusively during the course of a delirium and persist beyond the usual duration of substance intoxication or withdrawal
  • Evidence from history, physical examination, or laboratory findings that deficits are etiologically related to the persistent effects of substance use
• Criteria for substance-induced psychotic disorder, adapted from the DSM-IV-TR
  • Prominent hallucinations or delusion
  • Evidence from history, physical examination, or laboratory findings of either of the following:
    • Symptoms of prominent hallucinations or delusion developing during or within 1 month of substance intoxication or withdrawal
    • Medication use etiologically related to the disturbance
  • Disturbance not better accounted for by a psychotic disorder that is not substance induced
  • Disturbance does not occur exclusively during the course of a delirium
• Criteria for substance-induced mood disorder, adapted from the DSM-IV-TR
  • Prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
    • Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
    • Elevated, expansive, or irritable mood
  • Evidence from history, physical examination, or laboratory findings of substance intoxication or withdrawal and the symptoms of (1) depressed mood or markedly diminished interest or pleasure in activities and (2) elevated, expansive, or irritable mood developing during or within 1 month of substance intoxication or withdrawal
  • Disturbance not better accounted for by mood disorder that is not substance induced
  • Disturbance does not occur exclusively during the course of a delirium
  • Disturbance causes clinically significant distress or impairment in social, occupational, or other important area of functioning
• Criteria for substance-induced anxiety disorder, adapted from the DSM-IV-TR
  • Prominent anxiety, panic attacks, obsession, or compulsion predominating in the clinical picture
  • Evidence from history, physical examination, or laboratory findings of either of the following:
    • Symptoms of prominent anxiety, panic attacks, obsession, or compulsion developing during or within 1 month of substance intoxication or withdrawal
    • Medication use etiologically related to the disturbance
  • Disturbance not better accounted for by an anxiety disorder that is not substance induced
  • Disturbance not occurring exclusively during the course of a delirium
  • Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• Criteria for inhalant-related disorder NOS, adapted from the DSM-IV-TR: The inhalant-related disorder NOS category is for disorders associated with the use of inhalants that are not classified as inhalant dependence, inhalant abuse, inhalant intoxication, inhalant intoxication delirium, inhalant-induced persistent dementia, inhalant-induced psychotic disorder, inhalant-induced mood disorder, or inhalant-induced anxiety disorder.

Physical

• See Lab Studies; however, no specific laboratory results confirm this diagnosis.
• Perform a detailed neurological evaluation to look for the following:
  • Apathy
  • Impaired judgment
  • Impulsiveness
  • Aggressive behavior
  • Anorexia
  • Nystagmus
  • Depressed reflexes
  • Altered levels of consciousness
  • Disinhibited behaviors
• In addition, be aware of the signs and symptoms of inhalant abuse when performing the physical examination; for example, look for the following:
  • Amnesia
  • Rashes (particularly around the hand, nose, and mouth, ie, glue-sniffer's rash)
  • Unusual breath odors (eg, chemical smells)
  • Red or irritated eyes, throat, lungs, and nose
  • Burns

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.

Differential Diagnoses

Anxiety Disorders
Delirium
Depression
Stimulants

Other Problems to Be Considered

Because substance-induced psychiatric disorders resemble the primary mental disorders (ie, major depression, generalized anxiety disorder), these should be considered in the differential diagnosis.

Other disorders to consider include the following:
Conduct disorder
Antisocial personality disorder
Alcohol abuse and dependence
Cannabis abuse and dependence
Temporal lobe epilepsy
Psychosis
Polysubstance dependence
Gambling
Delinquency
Physical and sexual abuse

Workup

Laboratory Studies

• Sequential multiple analysis
  • Electrolyte (eg, sodium, potassium, chloride) levels
  • Liver function tests
  • BUN determination
  • Creatinine level
  • Cholesterol level
  • Anion gap measurement
• Complete blood cell count with differential and platelets
• Urinalysis
• Urine drug screen
• Rapid plasma reagin testing
• Thyrotropin testing
• Thyroid function tests
• Urine pregnancy tests
• Creatine kinase, if not included in sequential multiple analysis
• Twenty-four–hour urine test
• Heavy metal screening test
• HIV-antigen test

Imaging Studies

• Order a CT scan and EEG if neurological symptoms are present (eg, hearing loss, headaches, cerebellar signs, paresis, motor impairment, parkinsonism, encephalopathy).
• Perform an EEG to help identify seizure activity, specifically temporal lobe epilepsy.
• If a positron emission tomography scan cannot be obtained, order a single-photon emission computed tomography scan to help identify nonhomogenous uptake of radiopharmaceuticals, which may indicate hypoperfusion and hyperperfusion foci.

Other Tests

• Electrocardiogram (may be necessary)
• Wechsler Adult Intelligence Scale
• Wide Range Achievement Test
• Trail-Making Test

Procedures

• Liver or kidney biopsy, if indicated

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.

Treatment

Medical Care

• The medical care of patients with inhalant-related psychiatric disorders encompasses many areas.
  • A team of medical professionals must work in unison to ensure that every aspect of the treatment plan is fulfilled.
  • Patients likely require hospitalization. Especially if the patient is delirious, suicidal, homicidal, or gravely disabled. As inpatients, they may require the administration of medications (eg, haloperidol, risperidone, carbamazepine) to relieve any psychosis related to the chemicals inhaled.
  • Counseling (supportive therapy) should be initiated, along with patient education to explain the dangers of huffing. Evaluate patients for psychiatric comorbidity.
• No controlled studies have been performed to guide the treatment of patients who abuse inhalants and who have inhalant dependence. Additionally, no specific medications indicated by the pharmaceutical industry are available for detoxification from inhalants.
• Programs are available that specifically treat inhalant abuse; however, they are rare and difficult to find. Therefore, treatment planning most often is tailored much like that of the treatment of patients with chemical dependence, in which the first step is to detoxify the patient.
  • Patients who are addicted to inhalants experience withdrawal symptoms similar to those of any other patient addicted to drugs, including tremors, chills, sweats, cramps, nausea, and hallucinations.
  • Next, a peer system is established.
  • Once these 2 tasks are accomplished, assess the patient for physical, cognitive, and neurologic problems. If any problems are noted in these areas, they must be treated immediately. Identify any strengths the patient has and build on these strengths to increase them and to create new additional strengths for the patient. Address any other problems they may have. The goals are to return the patient to the community with a drug-free peer network and to continue or enhance self-support.
  • Treat any conduct problems noted.
  • Once the patient is detoxified, evaluate for other psychiatric illnesses using the DSM-IV-TR.
• The patient should participate in group therapy sessions, 12-step programs/chemical dependency groups, rational-emotive therapy, cognitive behavior therapy, and family therapy.
• Discuss safe sex with the patient, including partner precautions and birth control. In addition, the family should receive education about the disorder, secure substances that could be huffed, and become familiar with local mental health laws regarding commitment policies.
• No medications should be used unless a treatable DSM-IV-TR diagnosis has been identified.
  • If the patient has depression independent of the inhalant abuse, treat with the antidepressant of choice.
  • If the patient abuses alcohol in addition to inhalants, disulfiram (Antabuse) or naltrexone can be used in appropriate settings.
  • If the patient meets DSM-IV-TR criteria for attention-deficit/hyperactivity disorder, a psychostimulant such as pemoline (Cylert) can be used for treatment. The United States Food and Drug Administration (FDA) concluded that the overall risk of liver toxicity from pemoline outweighs the benefits. In May 2005, Abbott chose to stop sales and marketing of their brand of pemoline (Cylert) in the United States. In October 2005, all companies that produced generic versions of pemoline also agreed to stop sales and marketing of pemoline.
  • If the patient is psychotic as a result of the inhalant abuse (inhalant-induced psychosis), the physician may use an appropriate antipsychotic such as haloperidol (Haldol) or risperidone (Risperdal), with or without a benzodiazepine. This is the physician's choice.
  • If the patient has an inhalant-induced mood disorder, detoxification is recommended, without the use of any medications unless the depression persists for longer than 2-4 weeks after withdrawal.
  • Detoxification is also recommended for patients who are experiencing inhalant-induced anxiety; however, the use of sedatives or antianxiety medications is contraindicated because inhalant intoxication can worsen if the patient uses again.
• If the patient cannot maintain sobriety, the physician should consider residential treatment options, which can last anywhere from 3-12 months.
• Most persons who abuse inhalants receive most of their medical care in local emergency departments after they have either passed out or become psychotic from chemical inhalation. In the emergency department, they receive supportive care, social interventions, and appropriate medical care.

Surgical Care

• Patients may need liver or kidney transplantation.

Consultations

• Chemical dependence counselor
• Attorney, if legal problems develop
• Social worker
• Family therapist
• Peer-group therapist
• Dietitian (possibly)

Diet

• Consultation with a dietitian may be helpful if patients have poor nutrition (eg, liver problems, low protein).
• If no additional medical problems are present, patients can eat a regular diet.

Activity

• Maintain sobriety.
• Patients who are not a danger to themselves or others, are not gravely disabled, and are medically stable can maintain routine activities.

Medication

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.

Antipsychotics

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.

Haloperidol (Haldol)

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

Dosing

Adult

0.5-5 mg PO bid; 2-5 mg IM q4-8h

Pediatric

<3 years: Not established
3-12 years (15-40 kg): 0.05-0.15 mg/kg/d PO
>12 years: Administer as in adults

Interactions

May increase TCA serum concentrations and hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects; coadministration with anticholinergics may increase intraocular pressure; encephalopathylike syndrome associated with concurrent administration of lithium

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics; if IV/IM, watch for hypotension; caution in diagnosed CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue if it occurs); elevates prolactin levels

Risperidone (Risperdal)

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.

Dosing

Adult

0.25-6 mg/d PO qd/bid

Pediatric

Not established

Interactions

Coadministration with carbamazepine may decrease effects; may inhibit effects of levodopa; clozapine may increase levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Orthostatic hypotension, seizures, dysphagia, hyperprolactinemia, cognitive and motor impairment, priapism, and rare thrombotic thrombocytopenic purpura may occur

Anticonvulsants

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.

Carbamazepine (Tegretol)

Used to treat epilepsy and trigeminal neuralgia.

Dosing

Adult

200-600 mg PO bid; 800-1200 mg/d maintenance

Pediatric

<6 years: 10-20 mg/kg/d PO bid; <35 mg/kg/d maintenance
6-12 years: 100 mg PO bid; 400-800 mg/d maintenance
>12 years: Administer as in adults

Interactions

Do not coadminister with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; grapefruit juice, danazol, isoniazid, cimetidine, fluoxetine, erythromycin, and phenelzine increase plasma levels; phenytoin, alprazolam, clonazepam, primidone, and phenobarbital decrease levels
Decreases levels of imipramine, phenothiazines, haloperidol, ritonavir, contraceptives, risperidone, thiothixene, corticosteroids, doxycycline, trazodone, and amitriptyline; increases plasma levels of diltiazem and verapamil; can reduce its own level by autoinduction; coadministration with clozapine further increases bone marrow toxicity and resulting agranulocytosis

Contraindications

Documented hypersensitivity; administration of MAOIs within 14 d; history of liver disease and blood dyscrasias

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Very small but significant risk of agranulocytosis or aplastic anemia; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks requiring alertness; caution in mixed seizure disorders and cardiac, renal, liver, or hematological problems; report any indications of blood dyscrasias (eg, easy bruising, sore throats, fever, rash)

Valproic acid (Depakote, Depakene)

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%.

Dosing

Adult

10-20 mg/kg/d PO divided bid; may gradually titrate upward by 5-10 mg/kg/d at weekly intervals; not to exceed 30-60 mg/kg/d

Pediatric

Administer as in adults

Interactions

Coadministration with cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may significantly reduce valproate levels; in pediatric patients, protein binding and metabolism of valproate decrease when taken concomitantly with salicylates; coadministration with carbamazepine may result in variable changes of carbamazepine concentrations with possible loss of seizure control; valproate may increase diazepam and ethosuximide toxicity (monitor closely); valproate may increase phenobarbital and phenytoin levels while either one may decrease valproate levels; valproate may displace warfarin from protein binding sites (monitor coagulation tests); may increase zidovudine levels in HIV seropositive patients

Contraindications

Documented hypersensitivity; hepatic disease/dysfunction; hyperammonemic encephalopathy and urea cycle disorders

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Thrombocytopenia and abnormal coagulation parameters have occurred; the risk of thrombocytopenia increases significantly at total trough valproate plasma concentrations > 110 mcg/mL in females and 135 mcg/mL in males; at periodic intervals and prior to surgery determine platelet counts and bleeding time before initiating therapy; reduce dose or discontinue therapy if hemorrhage, bruising or a hemostasis/coagulation disorder occur; hyperammonemia may occur, resulting in hepatotoxicity; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness

Follow-up

Further Inpatient Care

• Patients who represent a danger to themselves or to others, are gravely disabled, or are medically unstable require inpatient care, even if involuntary measures are needed.

Further Outpatient Care

• Therapy should include interventions such as a 12-step program or chemical dependency counseling, cognitive behavior therapy, or rational-emotive therapy.
• Continued pharmacotherapy may be indicated.
• Patients may need to join Alcoholics Anonymous.

Inpatient & Outpatient Medications

• Continued pharmacotherapy depends on the diagnosis and what medications were started in the hospital.

Transfer

• Transfer to a medical/surgical hospital may be necessary.
• If legal problems develop, transfer to prison, jail, or a juvenile detention center may be necessary.

Deterrence/Prevention

• Educating students, educators, parents, those who abuse inhalants, and the community in general may help prevent further abuse and decrease experimentation with inhalants.
• Early identification of the problem may help prevent continued abuse.

Complications

• Social problems
• Difficulty at work
• Psychosis
• Dementia
• Anxiety
• Mood disorders
• Delirium
• Legal problems
• Death
• Visual problems
• Decreased coordination
• Nausea or vomiting
• Arrhythmias
• Violence or aggression
• Confusion or impaired judgment

Prognosis

• The prognosis is fair if inhalants are used short-term.
• The prognosis is poor if inhalants are used long-term.

Patient Education

• Prevention
• Education about substance abuse
• Social skills training
• Drug Abuse Resistance Education (D.A.R.E.)
• For excellent patient education resources, visit eMedicine's Substance Abuse Center. Also, see eMedicine's patient education article Substance Abuse.
• Additional patient resources can be obtained from the National Inhalant Prevention Coalition, NIDA Facts About Inhalant Abuse, and NIDA Research Report on Inhalant Abuse.

• If you suspect someone is huffing, call 911 immediately. Attempt to keep the patient calm.
• Contact the poison control center for information if no emergency exists.
• Inform the physician of the source of the inhalant (eg, gasoline, glue)
• Children and adolescents need to be taught the purpose of household products, the proper use of the products, and precautions in the use of the products. Review the risk and consequences of abusing the household products.

Miscellaneous

Medicolegal Pitfalls

• Failure to know local and state laws is a potential pitfall; persons who abuse inhalants may be placed in jail.

Special Concerns

• HIV infection: Any person who engages in risky behavior that results in impaired judgment (eg, use of drugs, alcohol, inhalants) should be made aware of the risks associated with the acts, especially drug abuse that is known to occur in a subgroup of adolescents aged 12-17 years. Whether the impaired judgment leads to promiscuity, impaired cognitive functioning that can affect driving, or other activities in which accidents can be expected to occur, an awareness of the additional risk of HIV infection must be conveyed. Even tissue damage in the nose associated with huffing, which can cause nosebleeds, can put someone at risk.
• Pregnancy: The use of inhalants can cause preterm labor, fetal growth retardation, low birth weight, and abnormalities similar to those associated with fetal alcohol syndrome. Other issues involve decreased cognition, speech, and motor ability for the child exposed to inhalants in utero.
• Conduct disorder: Abuse may be more frequent and extensive, thus worsening treatment outcome.
• Antisocial personality disorder: Abuse may be more frequent and extensive, thus worsening treatment outcome.
• Chronicity and relapse: Inhalant-related psychiatric disorders may have a chronic and relapsing course, which can be difficult to treat and can be frustrating for both families and physicians. A nonjudgmental approach may decrease some of this frustration.

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Keywords

huffing, sniffing, bagging, volatile substance abuse, substance abuse, drug abuse, drug-induced psychosis, inhalant abuse, inhalant dependence, inhalant intoxication, substance intoxication delirium, substance-induced anxiety disorder, inhalant-related disorder NOS, inhalant-related disorder not otherwise specified, substance-induced psychotic disorder, depression, general anxiety disorder, sudden sniffing death syndrome

Contributor Information and Disclosures

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
Guy E Brannon, MD is a member of the following medical societies: American Medical Association, American Medical Writers Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Clinical Research Professionals, Louisiana State Medical Society, and Southern Medical Association
Disclosure: AstraZeneca Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Janssen Honoraria Speaking and teaching

Coauthor(s)

Jeanie McGee Gary, BS, Editorial Manager, Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport
Jeanie McGee Gary, BS is a member of the following medical societies: American Medical Writers Association
Disclosure: Nothing to disclose.

Medical Editor

Barry I Liskow, MD, Vice Chairman, Director Psychiatry Residency Program, Professor, Department of Psychiatry, University of Kansas Medical School
Barry I Liskow, MD is a member of the following medical societies: American Academy of Addiction Psychiatry
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Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

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
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
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