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 the list below:

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

Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract. 2011 Jul. 6(1):18-31. [QxMD MEDLINE Link]. [Full Text].
Baydala L. Inhalant abuse. Paediatr Child Health. 2010 Sep. 15(7):443-54. [QxMD MEDLINE Link]. [Full Text].
Ahern NR, Falsafi N. Inhalant abuse: youth at risk. J Psychosoc Nurs Ment Health Serv. 2013 Aug. 51(8):19-24. [QxMD MEDLINE Link].
Phatak DR, Walterscheid J. Huffing air conditioner fluid: a cool way to die?. Am J Forensic Med Pathol. 2012 Mar. 33(1):64-7. [QxMD MEDLINE Link].
Praharaj SK, Kongasseri S. Naphthalene addiction. Subst Abus. 2012. 33(2):189-90. [QxMD MEDLINE Link].
Takagi MJ, Yücel M, Lubman DI. The dark side of sniffing: paint colour affects intoxication experiences among adolescent inhalant users. Drug Alcohol Rev. 2010 Jul. 29(4):452-5. [QxMD MEDLINE Link].
Youth Use of Inhalants and Aerosols - State Laws 2010. National Conference of State Legislatures. Available at http://www.ncsl.org/default.aspx?tabid=16447.
Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract. 2011 Jul. 6(1):18-31. [QxMD MEDLINE Link]. [Full Text].
Howard MO, Perron BE, Sacco P, Ilgen M, Vaughn MG, Garland E. Suicide ideation and attempts among inhalant users: results from the national epidemiologic survey on alcohol and related conditions. Suicide Life Threat Behav. 2010 Jun. 40(3):276-86. [QxMD MEDLINE Link].
Sakai JT, Hall SK, Mikulich-Gilbertson SK, Crowley TJ. Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems. J Am Acad Child Adolesc Psychiatry. 2004 Sep. 43(9):1080-8. [QxMD MEDLINE Link].
Garland EL, Howard MO. Volatile substance misuse : clinical considerations, neuropsychopharmacology and potential role of pharmacotherapy in management. CNS Drugs. 2012 Nov. 26(11):927-35. [QxMD MEDLINE Link].
Whitt A, Garland EL, Howard MO. Helium inhalation in adolescents: characteristics of users and prevalence of use. J Psychoactive Drugs. 2012 Nov-Dec. 44(5):365-71. [QxMD MEDLINE Link].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). 4th ed. Washington, DC: APA Press; 2000. 257-64.
Duncan JR, Lawrence AJ. Conventional concepts and new perspectives for understanding the addictive properties of inhalants. J Pharmacol Sci. 2013. 122(4):237-43. [QxMD MEDLINE Link].
Baird CA, Furek MW. Adolescents and inhalant abuse: how huffing affects the myelin sheath. J Addict Nurs. 2012 May. 23(2):129-31. [QxMD MEDLINE Link].
Takagi M, Lubman DI, Walterfang M, Barton S, Reutens D, Wood A, et al. Corpus callosum size and shape alterations in adolescent inhalant users. Addict Biol. 2013 Sep. 18(5):851-4. [QxMD MEDLINE Link].
Tsao JH, Hu YH, How CK, Chern CH, Hung-Tsang Yen D, Huang CI. Atrioventricular conduction abnormality and hyperchloremic metabolic acidosis in toluene sniffing. J Formos Med Assoc. 2011 Oct. 110(10):652-4. [QxMD MEDLINE Link].
Bowen SE. Two serious and challenging medical complications associated with volatile substance misuse: sudden sniffing death and fetal solvent syndrome. Subst Use Misuse. 2011. 46 Suppl 1:68-72. [QxMD MEDLINE Link].
Hsu CK, Chen YQ, Lung VZ, His SC, Lo HC, Shyu HY. Myelopathy and polyneuropathy caused by nitrous oxide toxicity: a case report. Am J Emerg Med. 2012 Jul. 30(6):1016.e3-6. [QxMD MEDLINE Link].
McCabe A, McCann B, Kelly P. Pop goes the O2: a case of popper-induced methaemoglobinamia. BMJ Case Rep. 2012 Nov 21. 2012:[QxMD MEDLINE Link].
Vilar-López R, Takagi M, Lubman DI, et al. The effects of inhalant misuse on attentional networks. Dev Neuropsychol. 2013. 38(2):126-36. [QxMD MEDLINE Link].
National Inhalant Prevention Coalition. National Inhalant Prevention Coalition Web Site. Available at www.inhalants.org. Accessed: Feb 4, 2008.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH Report: Trends in Adolescent Inhalant Use: 2002 to 2007. March 16, 2009. Available at http://www.eric.ed.gov/PDFS/ED504728.pdf.
Kay J, Lieberman JA, Tasman A. Inhalant Use Disorders. Psychiatry: behavioral science and clinical essentials. 1st. Philadelphia, Penn: WB Saunders Company; 2000. 263-269.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2006. Youth Violence and Illicit Drug Use. U.S. Department of Health and Human Services. Available at http://www.oas.samhsa.gov/2k6/youthViolence/youthViolence.htm.
Balster RL. Neural basis of inhalant abuse. Drug Alcohol Depend. 1998 Jun-Jul. 51(1-2):207-14. [QxMD MEDLINE Link].
Cheong R, Wilson RK, Cortese IC, Newman-Toker DE. Mothball withdrawal encephalopathy: case report and review of paradichlorobenzene neurotoxicity. Subst Abus. 2006 Dec. 27(4):63-7. [QxMD MEDLINE Link].
Courser MW, Holder HD, Collins D, Johnson K, Ogilvie K. An evaluation of retail outlets as part of a community prevention trial to reduce sales of harmful legal products to youth. Eval Rev. 2007 Aug. 31(4):343-63. [QxMD MEDLINE Link].
Deas D, Brown ES. Adolescent substance abuse and psychiatric comorbidities. J Clin Psychiatry. 2006 Jul. 67(7):e02. [QxMD MEDLINE Link].
Dinwiddie SH. Abuse of inhalants: a review. Addiction. 1994 Aug. 89(8):925-39. [QxMD MEDLINE Link].
Doogue M, Barclay M. Death due to butane abuse--the clinical pharmacology of inhalants. N Z Med J. 2005 Nov 11. 118(1225):U1732. [QxMD MEDLINE Link].
Edwards RW, Stanley L, Plested BA, Marquart BS, Chen J, Thurman PJ. Disparities in young adolescent inhalant use by rurality, gender, and ethnicity. Subst Use Misuse. 2007. 42(4):643-70. [QxMD MEDLINE Link].
Espeland K. Identifying the manifestations of inhalant abuse. Nurse Pract. 1995 May. 20(5):49-50, 53. [QxMD MEDLINE Link].
Flanagan RJ, Ives RJ. Volatile substance abuse. Bull Narc. 1994. 46(2):49-78. [QxMD MEDLINE Link].
Giovacchini RP. Abusing the volatile organic chemicals. Regul Toxicol Pharmacol. 1985 Mar. 5(1):18-37. [QxMD MEDLINE Link].
Hernandez-Avila CA, Ortega-Soto HA, Jasso A, et al. Treatment of inhalant-induced psychotic disorder with carbamazepine versus haloperidol. Psychiatr Serv. 1998 Jun. 49(6):812-5. [QxMD MEDLINE Link].
Jones HE, Balster RL. Inhalant abuse in pregnancy. Obstet Gynecol Clin North Am. 1998 Mar. 25(1):153-67. [QxMD MEDLINE Link].
Kaplan HI, Sadhock BJ. Kaplan and Sadhock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Baltimore, Md: Williams & Wilkins; 1998. 430-32.
Korman M, Matthews RW, Lovitt R. Neuropsychological effects of abuse of inhalants. Percept Mot Skills. 1981 Oct. 53(2):547-53. [QxMD MEDLINE Link].
Kucuk NO, Kilic EO, Ibis E, et al. Brain SPECT findings in long-term inhalant abuse. Nucl Med Commun. 2000 Aug. 21(8):769-73. [QxMD MEDLINE Link].
Kurbat RS, Pollack CV Jr. Facial injury and airway threat from inhalant abuse: a case report. J Emerg Med. 1998 Mar-Apr. 16(2):167-9. [QxMD MEDLINE Link].
Kurtzman TL, Otsuka KN, Wahl RA. Inhalant abuse by adolescents(1). J Adolesc Health. 2001 Mar. 28(3):170-80. [QxMD MEDLINE Link].
Lacy BW, Ditzler TF. Inhalant abuse in the military: an unrecognized threat. Mil Med. 2007 Apr. 172(4):388-92. [QxMD MEDLINE Link].
Maxwell JC. Deaths related to the inhalation of volatile substances in Texas: 1988-1998. Am J Drug Alcohol Abuse. 2001 Nov. 27(4):689-97. [QxMD MEDLINE Link].
McDermott MJ, Drescher CF, Smitherman TA, et al. Prevalence and sociodemographic correlates of lifetime substance use among a rural and diverse sample of adolescents. Subst Abus. 2013. 34(4):371-80. [QxMD MEDLINE Link].
McGarvey EL, Clavet GJ, Mason W, Waite D. Adolescent inhalant abuse: environments of use. Am J Drug Alcohol Abuse. 1999 Nov. 25(4):731-41. [QxMD MEDLINE Link].
Meadows R, Verghese A. Medical complications of glue sniffing. South Med J. 1996 May. 89(5):455-62. [QxMD MEDLINE Link].
Misra LK, Kofoed L, Fuller W. Treatment of inhalant abuse with risperidone. J Clin Psychiatry. 1999 Sep. 60(9):620. [QxMD MEDLINE Link].
Muilenburg JL, Johnson WD. Inhalant use and risky behavior correlates in a sample of rural middle school students. Subst Abus. 2006 Dec. 27(4):21-5. [QxMD MEDLINE Link].
National Conference of State Legislatures. Unpublished Information on Inhalation Legislation through June 2000.
National Institute on Drug Abuse. Inhalant Abuse Research Report. 2005.
National Institute on Drug Abuse and University of Michigan. Monitoring the Future 2005 Data From In-School Surveys of 8th-, 10th-, and 12th-Grade Students. Dec 2005.
Office of National Drug Control Policy. Drug Policy Information Clearinghouse, Street Terms: Drugs and the Drug Trade Inhalations Section.
Oh SJ, Kim JM. Giant axonal swelling in "huffer's" neuropathy. Arch Neurol. 1976 Aug. 33(8):583-6. [QxMD MEDLINE Link].
Russe BR, McCoy CB, Barton JE. Recent findings concerning inhalant use. Chem Depend. 1980. 4(1-2):113-26. [QxMD MEDLINE Link].
Santos de Barona M, Simpson DD. Inhalant users in drug abuse prevention programs. Am J Drug Alcohol Abuse. 1984. 10(4):503-18. [QxMD MEDLINE Link].
Shen YC. Treatment of inhalant dependence with lamotrigine. Prog Neuropsychopharmacol Biol Psychiatry. 2007 Apr 13. 31(3):769-71. [QxMD MEDLINE Link].
Soderberg LS. Immunomodulation by nitrite inhalants may predispose abusers to AIDS and Kaposi's sarcoma. J Neuroimmunol. 1998 Mar 15. 83(1-2):157-61. [QxMD MEDLINE Link].
Weintraub E, Gandhi D, Robinson C. Medical complications due to mothball abuse. South Med J. 2000 Apr. 93(4):427-9. [QxMD MEDLINE Link].
Wu LT, Ringwalt CL. Inhalant use and disorders among adults in the United States. Drug Alcohol Depend. 2006 Oct 15. 85(1):1-11. [QxMD MEDLINE Link].
Young SJ, Longstaffe S, Tenenbein M. Inhalant abuse and the abuse of other drugs. Am J Drug Alcohol Abuse. 1999 May. 25(2):371-5. [QxMD MEDLINE Link].
Batis JC. Effectiveness of Inhalant Abuse Legislation. Subst Use Misuse. 2017 Jan 28. 52 (2):175-181. [QxMD MEDLINE Link].
Nguyen J, O'Brien C, Schapp S. Adolescent inhalant use prevention, assessment, and treatment: A literature synthesis. Int J Drug Policy. 2016 May. 31:15-24. [QxMD MEDLINE Link]. [Full Text].
Hasin DS, Sarvet AL, Meyers JL, Saha TD, Ruan WJ, Stohl M, et al. Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry. 2018 Apr 1. 75 (4):336-346. [QxMD MEDLINE Link]. [Full Text].