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INHALANT USE DISORDER

DANA BARTLETT, RN, BSN, MSN, MA

ABSTRACT

An inhalant use disorder is diagnosed according to criteria of the

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(DSM-5) and includes use of traditional categories of inhalants, such

as aerosols, gases, nitrites, and solvents. Inhalants are often used to

describe volatile substances that the user inhales for a psychoactive

effect. Chemicals misused as inhalants are often found in various

household products that some United States jurisdictions have started

to regulate. Identification and treatment of an inhalant use disorder

requires partnership with professionals and community support

persons. Inhalant use disorders require a unique approach by all

members of the interdisciplinary health team to raise awareness of the

risk, prevention, and available treatment of an addiction to solvents.

Statement of Learning Need

Clinicians need to be informed about how to identify and diagnose an

inhalant use disorder according the DSM-5 criteria. To diagnose

accurately, clinicians need to able to know of the physical and

psychological effects of an inhalant use disorder and the available

treatment for individuals with an acute solvent intoxication and an

inhalant use disorder.

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Course Purpose

To provide information about DSM-5 criteria to diagnose an inhalant

use disorder as well as the treatment and ongoing support for those

affected by it.

Introduction

An Inhalant use disorder is defined by the American Psychiatric

Association as the “ . . . problematic pattern of use of a hydrocarbon-

based inhalant substance leading to clinically significant impairment or

distress.”1 Still commonly known as solvent abuse or volatile

substance abuse, this substance use disorder puts users at risk for

significant acute and chronic clinical effects and long-term inhalant use

can cause irreversible physical and psychiatric damage. Because

inhalants are widely available and can be legally purchased they are

often the first choice of adolescents who are beginning to experiment

with altering consciousness and their use is associated with illicit drug

use, as well.

Intoxication from commonly used inhalants is rapid in onset, dissipates

quickly, and does not produce a marked hangover, and these qualities

make inhalants a popular “starter” drug. Fortunately, inhalants have

never been as popular as alcohol or marijuana and although

adolescents may use them for a (relatively) brief period of time, the

incidence of the disorder declines significantly after the teenage

years,1 and there is statistical evidence that in recent years inhalant

use disorder has been declining.2 However, these are dangerous

substances. As mentioned previously the commonly used inhalants can

cause significant clinical effects, including sudden death. Although

long-term, chronic use is quite uncommon, it has been estimated that

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at least 10% of American adolescents aged 13 have used an inhalant

at least once.1 Given the nature of the risk, inhalant use disorder is a

serious public health problem.

Products And Solvents Commonly Used

There are dozens of legal and commercially produced substances that

are used for inhalant use. Examples include:3-6

Table 1: Substances Used For Inhalant Use

Air fresheners

Cleaning products

Computer keyboard cleaners

Fluorinated hydrocarbons, a.k.a., Freon

Gasoline

Glue

Hair spray

Lighter fluid

Nail polish remover

Nitrous oxide

Pain stripper

Paint thinner

Simple asphyxiant gases, i.e., butane, propane

Spray paints

Typewriter correction fluid

Whipped cream dispensers

Many of the products listed in the table above differ in their ingredients

and some are quite similar or almost identical to each other.

Regardless of the differences or similarities, each one contains a

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solvent or is a compound that can be used as a solvent. The solvent is

volatile and can easily evaporate to form a vapor. In addition, many of

these solvents are hydrocarbons. The definitions of these terms are

important to remember.

Table 2: Definitions

Solvent

A solvent is defined as a substance that is capable of dissolving. Solvents are

valued for this capability and are often used as a carrier vehicle for other chemicals

or compounds. Examples include: simple petroleum distillates are often used as a

carrier vehicle in household pesticides and alcohol is used as a solvent/carrier

vehicle in products such as mouthwashes and solid deodorants. Toluene is one of

the most common solvents and is often found in the products such as glue that are

used for inhalant use.

Volatile

Volatility is defined as the ability to evaporate and form a vapor.

Vapor

A vapor is defined as the gaseous form of a liquid.

Hydrocarbon

A hydrocarbon is an organic compound that contains carbon and hydrogen only.

Hydrocarbons are derived from petroleum (oil), they can be gases or liquids, and

hydrocarbon-based products are perhaps the most common solvent used.

Hydrocarbons are in use everywhere; gasoline, lighter fluid, kerosene, and paint

thinner are hydrocarbons.

Substances that are used for solvent use rarely involve a single

compound. In addition, some of the products in Table 1 may: 1) not

contain a hydrocarbon, 2) be a mixture of many hydrocarbons, 3) be a

mixture of hydrocarbons and non-hydrocarbon compounds; and,

4) not be used as solvents. For example, gasoline and the simple

asphyxiants are hydrocarbons, they are volatile and they are often

used, but they are not solvents. Glues themselves are not solvents,

but they typically contain hydrocarbons such as hexane and toluene

that are used as solvents, and they often contain acetone, a ketone

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which is not a hydrocarbon but that forms a vapor that can cause

intoxication.

This complexity in nomenclature and in the nature of the products that

may be inhaled can make understanding solvent use difficult. But if

the definitions in Table 2 and the definition of solvent use are kept in

mind, understanding the problem of an inhalant use disorder becomes

simpler. An example is typewriter correction fluid, which contains a

hydrocarbon, petroleum naphtha. The petroleum naphtha is used as a

solvent for the other ingredients of the correction fluid, and the

chemical properties of petroleum naphtha allow it to easily form a

vapor. It is the vapor from the petroleum naphtha that is inhaled and

produces intoxication; and, an inhalant use disorder is the deliberate

inhalation of the vapors from volatile organic compounds for the

purposes of altering consciousness.

Table 3: Commonly Used Solvents/Products

Acetone: Glues, nail polish removers, paint removers

Amyl nitrite: Vasodilator, cyanide antidote

Butane: Fuels for lighters, stoves, etc.

Fluorocarbons: Propellants in many aerosol cans

Hexane: Glues

Hydrocarbons: Gasoline, lighter fluid, paint thinner

Ketones: Adhesives, paints

Methanol: Automotive products

Methylene chloride: Paint strippers

Mineral spirits: Paints, paint thinner

Naphtha: Glues, paint thinner

Nitrous oxide: Propellant in some whipped cream canisters

Toluene: Glues, lacquer thinner

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Trichloroethane: Typewriter correction fluid

Xylene: Glues, paint strippers

Pharmacology

Although Table 1 is a list of products that are very different, they all

are or contain compounds that have similar properties that make them

attractive for the purposes of inhalant use. These properties are

summarized below.4,6,7

Rapid absorption:

The substances or products used for inhalant use are volatile

compounds, or they have a high concentration of a volatile compound.

These volatile compounds are very rapidly absorbed through the lungs

and they move quickly and efficiently into the pulmonary circulation.

High lipid solubility:

The volatile compounds that are used for inhalant use are very lipid

soluble. This property (in combination with their rapid absorption

through the lungs and into the pulmonary circulation) allows them to

readily reach organs and tissues that have high lipid content, i.e., the

brain, kidneys, and the liver. In particular, the volatile inhalants easily

cross the blood-brain barrier and enter the nervous system and they

do so almost immediately.

Rapid metabolism:

The volatile inhalants are quickly metabolized and excreted. These

specifics about the volatile compounds that are used for inhalation use

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clearly illustrate why they are so attractive to people who want to get

high. No special equipment or techniques are needed to use them, and

intoxication begins within seconds of use and is relatively brief. The

inhalant use disorder offers a cheap simple high with a relatively low

commitment and an immediate and dramatic change in consciousness.

These characteristics explain why these volatile compounds produce

intoxication so quickly and easily, but it is not known exactly how they

do so. However, the similarities between the clinical effects of the used

volatile compounds closely resemble the clinical effects of barbiturates,

benzodiazepines, and ethanol, and it is possible that they work in the

same way. The barbiturates, benzodiazepines, and ethanol all have

receptors that are in close proximity to gamma-aminobutyric acid

(GABA) receptors. These drugs produce central nervous system

depressant effects by increasing the activity of GABA, and there is

evidence and a logical mechanistic explanation - but no proof - that

the intoxication of the volatile compounds is mediated by GABA, as

well.3,4,6,8

It has also been speculated that the volatile compounds identified in

solvent use may decrease the activity of N-methyl-D-aspartate, NMDA,

which is part of the glutamate excitatory neurotransmitter system.

Inhalants may also affect dopamine, glycine, nicotine, and serotonin

receptors.

Gamma-aminobutyric acid binds to

specific post-synaptic cell receptors and

hyperpolarizes cell membranes by

increasing the duration and frequency of

Knowledge Check:

Gamma-aminobutyric acid -

also called GABA, or γ-

aminobutyric acid - is one of

the two primary inhibitory

neurotransmitters.

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the opening of chloride ion channels. Because of the hyperpolarization,

the affected cells are less able to depolarize in response to a stimulus.

N-methyl-D-aspartate (NMDA) is an amino acid derivative, which is not

naturally occurring. NMDA refers to a specific glutamate receptor that

is stimulated by this compound and the term NMDA is used to identify

that type of glutamate receptor.

Another substance that is popular for inhalant use is amyl nitrite and

this compound has a well defined and understood mechanism of

action. Amyl nitrite relaxes smooth muscle and acts as a vasodilator,

and it also promotes the formation of methemoglobin (discussed later

in this learning module). Amyl nitrite is supplied in small glass

capsules covered with gauze. The capsule is crushed, held directly

underneath the nose and the vapors inhaled. Amyl nitrite was once

popular as an emergency treatment for angina, and it still has a

limited role as a cyanide antidote.

How Solvents Can Lead To A Solvent Use Disorder

Solvent use is not limited to any specific geographical area. It is

generally, but certainly not exclusively, more popular among pre-teens

and teens and in lower socio-economic groups.1,4 Males are more likely

to try solvents but whether solvents are used by males or females,

chronic, long-term inhalant use is the exception; most people who use

solvents experience this as a “phase” and stop completely by their late

‘20s. Solvent use is more common in pre-teens and younger teens and

many will go on to try illicit drugs. It may be that as the user gets

older and becomes more affluent and mobile, more expensive and

difficult to obtain drugs such as cocaine and marijuana become

popular.

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Selling or distributing to minors any products that contain commonly

used solvents, i.e., spray paint, is illegal almost everywhere in the

United States.6 The laws regarding the use of these products for the

purposes of intoxication, or being intoxicated from a solvent vary from

state to state. Driving under the influence (DUI) laws can be applied to

solvent use in certain states, as well. In many states the law prohibits

sale, transfer to, or offer to sell to a minor any vapor containing

substance that contains a toxic ingredient. In some states these laws

are quite specific and in others they are not.9

Solvents are usually used by one of three methods. Sniffing is simply

inhaling the product directly from the container. Huffing is saturating a

piece of cloth or paper with the product, placing this over the mouth

and nose, and inhaling. Bagging involves pouring or spraying the

product into a paper or plastic bag and then periodically inhaling the

vapors from the bag, closing the bag between inhalations, and then

opening again to inhale. People who use solvents often inhale very

large concentrations of vapor. Glue sniffers may inhale a concentration

of vapor that is hundreds of times higher than what would be allowed

by the Occupational Safety and Health Administration (OSHA) in a

workplace.

Diagnosis Of An Inhalant Use Disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

uses specific criteria for diagnosing an inhalant use disorder. The

individual in question has a problematic pattern of use of a

hydrocarbon-based inhalant substance that leads to clinically

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significant impairment or distress, and is accompanied by at least two

of the following in a 12-month period.

1. The inhalant is often used in larger amounts or over a longer

period than the user intended.

2. The user has a persistent desire or makes unsuccessful efforts to

cut down or control his/her use.

3. Significant time is expended obtaining the inhalant, using it, or

recovering from intoxication.

4. He/she has a craving or strong or urge to use the inhalant

substance.

5. Inhalant use is the cause of failure to meet important obligations

at home, school, or work.

6. Inhalant use continues despite persistent or recurrent social or

interpersonal problems caused or exacerbated by its effects.

7. Occupational, social, or recreational activities are stopped or

reduced because of inhalant use.

8. The inhalant is repeatedly used in physically dangerous situations.

9. Inhalant use continues despite knowing that persistent physical or

psychological problems that are likely to have been caused or

exacerbated by the substance.

10. Tolerance is present, this being defined as either:

a. Needing greater amounts to become intoxicated, or

b. A decreased level of intoxication from the same amount of

inhalant.

If possible the specific inhalant should be identified and it should be

determined if the patient is in early or sustained remission. (See the

DSM-5 for definitions).

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Acute inhalant intoxication is defined in DSM-5 as: “Inhalant

intoxication is an inhalant-related, clinically significant mental disorder

that develops during, or immediately after, intended or unintended

inhalation of a volatile hydrocarbon substance.”1 Acute intoxication

from an inhalant is diagnosed using the following criteria.1

1. The patient has recent intended or unintended short-term, high-

dose exposure to inhalant substances, including volatile

hydrocarbons such as toluene or gasoline.

2. He/she has clinically significant behavioral or psychological changes

that are maladaptive and problematic such as belligerence,

assaultive behavior, apathy, impaired judgment that developed

during, or shortly after, exposure to inhalants.

3. The patient has two or more of the following signs or symptoms

that occur during or shortly after use of an inhalant.

a. Dizziness.

b. Nystagmus.

c. Incoordination.

d. Slurred speech.

e. Unsteady gait.

f. Lethargy.

g. Depressed reflexes.

h. Psychomotor retardation.

i. Tremor.

j. Generalized muscle weakness.

k. Blurred vision or diplopia.

Other inhalant-induced disorders described in the DSM-5 are

1) inhalant-induced psychotic disorder, 2) inhalant-induced depressive

disorder, 3) inhalant-induced anxiety disorder, 4) inhalant-induced

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major or mild neurocognitive disorder, and 5) inhalant intoxication

delirium.

Primary Acute Clinical Effects

The primary acute clinical effects of inhalant intoxication are

neurological and cardiac. However, other organ systems can be

affected as well and every effort should be made to identify the

product as there are specific problems associated with some of the less

commonly used inhalants.

Neurological

The most common neurological effect of solvent inhalation is central

nervous system depression. This can range from mild drowsiness to

coma, and it is usually preceded by a mild level of excitation and

euphoria.3 Patients can also develop ataxia, confusion, diplopia,

dizziness, hallucinations, headache, euphoria, seizures, slurred speech,

tremor, and weakness.3-6 The intensity of the central nervous system

effects can be mild and they can be profound. The duration of the

neurological effects - the high - is typically an hour or two, but

depending on the pattern of use it may be more or less.

Cardiovascular

Tachycardia is common. Conversely, reflex bradycardia caused by

vagal stimulation is possible,10,11 and atrioventricular block and other

conduction abnormalities, cardiomyopathy, and myocardial infarction

have been reported.6,11-14 Deadly ventricular arrhythmias and sudden

death caused by solvent use are well described in the medical

literature3,4,6 but given the enormous number of incidents of huffing,

sniffing, and bagging these are very, very uncommon.15

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The mechanism by which sudden death from inhalant use occurs is not

completely understood, but it may involve sensitization of the

myocardium to catecholamines, QT prolongation, increased level of

catecholamines, or inhibition of the potassium and/or sodium in

channels of the myocardium.4,6,15,16 If the solvent user experiences a

catecholamine surge, for example, in a situation of running to avoid

police custody or arrest, the sudden and intense increase in circulating

levels of epinephrine and norepinephrine will stimulate the vulnerable

myocardium and produce an arrhythmia. On the other hand, vagal

stimulation and bradycardia that has been reported in solvent use may

be due to cold stimulation of the larynx and throat. These situations

have been well documented and are called “sudden sniffing

death.”3,6,17,18 Sudden sniffing death can happen to a first-time solvent

user or to someone who chronically inhales solvents, and although it

most often happens very soon after inhalation of a solvent, ventricular

fibrillation can occur hours after an exposure.16

Pulmonary

Many of the inhaled solvents act as irritants so cough, dyspnea, and

wheezing are common pulmonary effects. Because the volatile

solvents are simple asphyxiants and centrally acting respiratory

depressants, hypoxia is one of the primary acute effects of solvent

use.3,6 Freezing injuries from inhalation of fluorinated hydrocarbon

propellants and acute upper airway obstruction after volatile substance

inhalation have been reported.19,20 Airway obstruction caused by

angioedema has been reported, as well.21,22 Aspiration of a liquid

hydrocarbon can cause chemical pneumonitis, and people who indulge

in long sessions of bagging may develop hypercapnia.6

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Metabolic and Hematologic

Except for toluene exposure metabolic effects are not common after

use of the common inhalants, but there are some products that can

produce metabolic derangements or have the capability of doing so.

Paint strippers can contain methylene chloride. Methylene chloride is

converted in vivo to carbon monoxide and carbon monoxide poisoning

has been reported after accidental exposure to or improper use of

paint strippers.23 Some automotive products contain ethylene glycol

and/or methanol, toxic alcohols that can cause metabolic acidosis.24,25

The nitrites, amyl nitrite, butyl nitrite, and isobutyl nitrite, act as

oxidative stressors and convert hemoglobin to methemoglobin.

Methemoglobin is hemoglobin that has lost an electron from its iron

atom. Methemoglobin is normally produced as the body encounters

oxidative stressors, but reducing mechanisms normally maintain the

methemoglobin level at 1-3%. The iron molecule in methemoglobin is

in the ferrous Fe2+ state instead of its normal ferric Fe3+ state and

ferrous iron cannot combine with oxygen. Symptomatic

methemoglobinemia has been reported after nitrite use.26 Acute

toluene intoxication can cause hypokalemic paralysis and a normal

anion gap metabolic acidosis.27-29

Gastrointestinal

Abdominal pain, diarrhea, nausea and vomiting are possible as a result

of inhalant use. Hydrocarbons are well known to be very irritating to

the gut.

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Dermal

The gases that are in aerosol cans are compressed and under high

pressure. When they are released and they rapidly expand, the gases

are cooled and can cause cold thermal injuries to the skin and the

respiratory tract, in some cases significant enough to require

endotracheal intubation.30 Many of the solvents and hydrocarbons act

as de-fatting agents (they “dissolve” the normal surface oils on the

skin) and if there is dermal contact the skin can become dry and

cracked. Prolonged skin contact can cause first degree and more

serious burns.3

Fatalities

It is not possible to form an accurate estimate of the number of

fatalities caused by an inhalant use disorder, but deaths caused by use

of these substances appear to be very unusual. The American

Association of Poison Control Centers (AAPCC) publishes a yearly

reporting of overdose and accidental poisonings called into poison

control centers, and the number of deaths attributed to or caused by

inhalants is very small.31 The mechanisms by which inhalants can kill

are listed in Table 4.5,6, 32-34

Table 4: Causes of Death from Solvent Use

Aspiration,

Asphyxia

Allergic reaction

Central nervous system depression

Ventricular arrhythmias

Hypoxia

Respiratory depression

Trauma

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Vagal inhibition

Methemoglobinemia

Intoxication from a volatile solvent may last for 15-30 minutes or for

several hours, and the recovery is rapid. Chronic users develop a

tolerance and a withdrawal syndrome has been described.35-37

Assessment For Inhalant Intoxication

Unless use of an inhalant is witnessed, obvious signs of use (i.e., paint

residue around the mouth or nose), chemical odor on the patient’s

breath, or the patient admits to using, determining the presence of an

acute inhalant intoxication depends on non-specific signs or

symptoms. Table 5 lists some common physical and behavioral signs

of inhalant use.5 Some of the commonly used substances can be

detected in blood or urine by laboratory testing but not in a timely

manner. Primary care providers or other healthcare professionals that

screen patients for the presence of inhalant use can utilize the Volatile

Solvent Screening Inventory (VSSI) or the Comprehensive Solvent

Assessment Interview (CSAI).38

Table 5: Signs of Inhalant Use

Behavior changes

(i.e., apathy, depression, hostility, paranoia, social withdrawal)

Conjunctivitis

Chronic fatigue

Confusion

Decreased appetite

Drowsiness

Epistaxis

Frostbite or burns in/around the mouth or nose

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Poor hygiene and grooming

Weight loss

Wheezing

Chronic Clinical Effects

If solvent use is sporadic and the duration of use is brief, there are no

sequelae. However, long-term use of a solvent can cause multi-organ

system damage. Some of the organ damage can be reversible, but the

cardiac and neurological changes may become permanent. The

nervous system is especially at risk. As mentioned previously, inhaled

solvents are highly lipophilic and because of that they accumulate in

myelin (75% lipid) and in neuronal membranes (up to 45% lipids).

Cardiovascular

Myocardial infarction,10 cardiomyopathy with depressed ejection

fraction,6,12 congestive heart failure,10 and chronic myocardial

inflammation and fibrosis6 have been reported after chronic inhalant

use.

Neurological

Chronic solvent inhalation can cause serious, significant and

irreversible neurological damage, cognitive, motor, and visual

impairment.5,6,38-41 Cerebellar damage, cortical atrophy, dementia,

peripheral neuropathy, and optic nerve damage have all been reported

as consequences of chronic solvent use, and there is a wide range of

clinical effects that these injuries produce, i.e., ataxia, depression,

headache, intellectual impairment, memory loss, mood changes,

sensory disorders, spasticity, tremor - the list is long.10 It is not clear

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how long solvent use must continue before neurological damage

becomes permanent, and there is no clear dose-response relationship.

Chronic solvent use is also associated with increased risk for suicide

and suicidal ideation, psychosis, attention deficit hyperactivity

disorder, concurrent use of alcohol, tobacco, and illicit drugs, anxiety,

depression, and other mental health disorders.5,42

Pulmonary

Long-term solvent use has been associated with Goodpasture’s

syndrome, panacinar emphysema, decreased vital capacity, decreased

exercise tolerance, cough, recurrent epistaxis, chronic rhinitis, and

other pulmonary abnormalities.6,43-45

Renal

Toluene is often used as a solvent in glue. Chronic toluene inhalation is

a well-known cause of renal tubular acidosis.6,46-48.

Hepatic

Exposure to carbon tetrachloride, toluene, and trichloroethylene has

been associated with liver damage.6 Fortunately, the risk of liver

damage from exposure to these substances - carbon tetrachloride in

particular - is well recognized and their availability in over-the-counter

products is much less than previously. Exposure to toluene has been

reported to cause hepatorenal syndrome.48

Caring For An Individual With An Inhalant Use Disorder

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Individuals with an inhalant use disorder may seek help for acute

medical problems or chronic problems. The care will differ somewhat

for each situation, but in either case a careful history should be taken.

The clinician should be sure to ask the individual the following during a

history and physical.

1. When he/she was last inhaling.

2. If he/she was experimenting or solvent use is a chronic behavior.

3. How he/she is using the inhalant; if solvent use is being done by

bagging, huffing, or inhaling.

4. What is being inhaled, for example, whether it is a liquid (i.e.,

paint thinner) or an aerosol (i.e., an aerosolized computer

keyboard cleaner). Also the patient should be asked if he/she has

been using any illicit drugs or drinking alcohol.

Most importantly, it should be determined what the patient has been

using and what it contains. It is not enough to simply know what the

patient has been inhaling, for example, an automotive brake cleaner; a

list of the ingredients that the patient has been inhaling must be

obtained. Although many of the clinical effects produced by solvent

inhalation are common to all of the typically used products, the patient

may be inhaling something that can cause a distinct pathology; for

example, carbon monoxide poisoning from paint strippers that contain

methylene chloride, glues that contain toluene can cause renal

damage, etc.

If the patient cannot inform the clinician what he/she was inhaling

(doesn’t remember, is incapacitated, etc.), someone not directly

involved in patient care should try to obtain this information. There are

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four ways to get a list of ingredients for a commercially manufactured

product. These are listed here from the simplest to the most difficult:

1. Call the local poison control center. Poison control centers all have

a data base that contains detailed information about millions of

commercial products, and a local center may be able to quickly

provide information of what is in the product that a person has

been using. Many poison control centers still maintain a local

number, but all poison control centers use the national number,

and this number will connect callers to the closest poison control

center: 1-800-222-1222.

2. Look for the material safety data sheet (MSDS) on line. This can

be done by going to the manufacturer’s website (if the

manufacturer of the product is known) and checking to see if they

have the MSDS, or by doing a simple on line search using any

search engine; i.e., type in “Amazing Automotive Heavy Duty

Brake Cleaner, MSDS”.

3. Check with Chemtrec. Chemtrec is a free service that provides

emergency assistance to HAZMAT teams, first responders, etc.,

who are dealing with a hazardous materials incident such as a

chemical spill. In addition, Chemtrec also has a database of

manufacturers and access to the MSDS of their products.

Chemtrec is available 24 hours at 1-800-424-9300.

4. Call the manufacturer and have the MSDS emailed or faxed. This

last option is by far the slowest and least reliable. The company

may be closed (if the call is placed on the weekend or at night) or

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it may take someone in the company a long time to find the

information. Locating current contact information can be

challenging, as well.

The Basics of Acute Care

When an individual arrives to an acute care setting due to a serious

outcome related to inhaling a substance, care begins with an

assessment of the patient’s airway, breathing, and circulation, and the

individual should be checked for any signs of a traumatic injury. As

this assessment is being done, any contaminated clothing should be

removed and health team responders should decontaminate the skin if

needed. A close examination of the oral cavity and the surrounding

area should be done for evidence of obstruction or thermal injury (due

to edema or cold thermal injury), and the lungs carefully auscultated

and the oxygen saturation checked using pulse oximetry; the clinician

should be looking for signs of aspiration and/or hypoxia and

hypercapnia.

If there are abnormalities in the assessment of the airway and

breathing, or if the patient is complaining of dyspnea, the following

should be obtained: a chest x-ray, an arterial blood gas, and

measurement of serum carbon monoxide and methemoglobin levels. A

12-lead ECG should be obtained and the patient placed on continuous

cardiac monitoring. Serum electrolytes, a complete blood count, liver

transaminases, blood urea nitrogen (BUN) level and a creatinine level

should be obtained. The volatile solvents and their metabolites are not

detected in urine drug screens and although they can be detected in

the blood by using chromatography, this type of testing cannot be

done stat or immediately; the results would take several days to be

available.

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There are no specific treatments for acute solvent intoxication.

Treatment is essentially symptomatic and supportive. If the patient is

having respiratory distress, the following approach should be followed.

Respiratory Distress

If there is evidence of airway constriction, it should be determined

where the problem is; it could be in the upper airway structures (i.e.,

thermal damage from an inhalant) or it could be in the lower airway

structures (i.e., response to the irritating nature of a solvent or from

an aspiration). Supplemental oxygen should be administered and if the

airway constriction is in the lower airway structures, carefully consider

the benefits and risks of an inhaled bronchodilator such as albuterol

(discussed later in this learning module).

If the patient is having respiratory distress and has an abnormal chest

X-ray, aspiration and chemical pneumonitis are likely. The treatment

includes supplemental oxygen and consultation with a poison control

center or a pulmonologist about the use of antibiotics and systemic

corticosteroids; these are not typically needed or useful but may be in

certain circumstances.

In a situation of a high carbon monoxide level, supplemental oxygen

and time should be sufficient treatment.

If the patient has been inhaling a product that causes

methemoglobinemia and he/she is having respiratory distress or has a

methemoglobin level that is >30%, supplemental oxygen should be

administered and consideration given to the use of methylene blue.

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Methylene blue is the antidotal therapy for an elevated methemoglobin

level. It is given intravenously (IV) at a dose of 1-2 mg/kg of a 1%

solution slowly over 5 minutes. The dose can be repeated as in 30-60

minutes as needed.

If the arterial blood gas reveals a metabolic acidosis, the patient may

have been inhaling a product that contains ethylene glycol or methanol

(it should be noted that toluene exposure is also possible). Blood

samples should be sent for measurement of ethylene glycol and

methanol, and for close monitoring of acid-base status and renal

function. The patient should also be assessed for visual deficits.

Intravenous hydration should be started and if exposure to ethylene

glycol or methanol is confirmed or strongly suspected, the use of

fomepizole or hemodialysis should be considered. There should be

consultation with the local poison control center for advice.

Cardiovascular Abnormalities

A 12-lead ECG should be done for every patient who is using inhalants

and measurement of serum calcium, magnesium, and potassium

should be done, as well. If the patient is having an arrhythmia, it

should be treated with established protocols; consultation with a

poison control center toxicologist should be obtained, as well.

Sympathomimetic drugs such as epinephrine, isoproterenol, or

norepinephrine should not be used to treat ventricular fibrillation (VF),

and catecholamines and drugs that are adrenergic stimulants should

only be used after a careful risk-benefit analysis6,15 and after

consultation with a toxicologist or a cardiologist. Hypotension can be

treated with fluids.

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Chronic Solvent User

Chronic solvent users should be evaluated for neurological,

cardiovascular, renal, hepatic, and hematologic problems, so the

appropriate testing should be ordered and consultation made. There is

no specific treatment for health problems caused by chronic solvent

use; patients should be treated with symptomatic and supportive care

and the appropriate consultations. Neurological and cardiac damage is

likely to be permanent whereas damage to other organs will usually

resolve and repair over time.

Patients who have an inhalant use disorder will need psychological

support and counseling. Unfortunately there is a dearth of good

research on the medical, pharmacological, and psychological

interventions for this problem6,42 and no clear conclusions as to which

approach is best.49 The interested clinician is advised to read two

relatively recent literature reviews by Howard, et al. (2011) and

MacLean, et al. (2012) for more information.35,49

Summary

Inhalant use disorder is defined as the problematic pattern of use of a

hydrocarbon-based inhalant substance leading to clinically significant

impairment or distress. Also known as solvent abuse or volatile

substance abuse, the use of solvent-based inhalants can cause serious

and irreversible complications and death. Inhalant use disorder is a

(relatively) common phenomenon in pre-teen and adolescent

populations, and its popularity can be explained in part because the

inhalants are cheap and legal and the high is relatively brief.

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The effects of inhalant intoxication typically last for one to two hours

and central nervous system depression and tachycardia are the most

commonly seen clinical signs. More serious effects such as airway

compromise or damage, hypoxia, respiratory depression, metabolic

acidosis, methemoglobinemia, carbon monoxide poisoning, renal

tubular acidosis, and deadly cardiac arrhythmias are possible, as well.

Chronic use of inhalants can cause irreversible cognitive effects and

neurological damage, cardiomyopathy, hepatic and renal damage, and

myocardial damage. The treatment of acute inhalant intoxication and

inhalant use disorder is essentially symptomatic and supportive.

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