Inhalant Abuse

Newer Trends in Addiction

A Case Series

Abstract

Inhalant abuse is common in adolescents and young people. However, awareness about its harmful effects is low, and the potential to cause dependence remains a cause of concern. Inhalant abuse is often associated with underlying novelty-seeking traits, which can also predict propensity for other substances of abuse. Inhalants are cheap, freely available, and legal to possess and escape detection in vulnerable groups. There is a need to spread awareness about the harmful effects of inhalants and devise effective primary and relapse prevention strategies.

BACKGROUND

Inhalant abuse is alternatively called “glue sniffing,” “gasoline addiction,” “huffing,” “volatile substance abuse,” “solvent abuse,” and a series of other names. It was recognized as a growing problem in the early 1960s. Inhalants are volatile substances (including hydrocarbons), which become gases at the room temperature and can be inhaled to induce a mind-altering effect.[¹²] Inhalants have been classified into volatile solvents (glue, paint thinner, correction fluid, and nail-paint remover), aerosols (deodorants and spray paints), gases (refrigerants), and nitrites.[²] Inhalant abuse is a common problem faced by today's youth, especially in developing countries where low cost and easy availability makes it a popular choice for people of lower socioeconomic strata.[³⁴⁵] Among adolescents in the US, inhalants are one of the most commonly abused substances.[¹] In India, the overall prevalence of inhalant use is around 0.7%. It follows a global trend of being more prevalent in children and adolescents than adults.[⁶] These agents can act as gateway drugs and can predispose the user to severe substance abuse-related illnesses in the future.[³] Chronic inhalant use can result in serious cognitive and neurological impairments and personality changes.[⁴⁵] We describe the five cases of inhalant abuse in different age groups with varying levels of severity.

CASE SERIES

Case 1

A 13-year-old single girl of a working mother was brought by her parents as she had been repeatedly found to be inhaling nail polish remover fluid. The girl offered no complaints and initially denied such behavior. As rapport improved, she acknowledged being habituated to deep inhaling nail polish remover fluid as it provided her relaxation, feeling of well-being, and allayed feeling of loneliness. She believed that there was nothing wrong with it. She had initially inhaled the liquid when she was about 11 years. However, her rate of use increased over several months, eventually becoming almost 1–2 bottles daily. She felt craving before sessions of use. Her mother revealed that she had been a bright student, but her academic performance had gone down dramatically in the past 2–3 years. After the first session, the girl was lost to follow-up.

Case 2

An 18-year-old boy belonging to lower socioeconomic background was admitted to a psychiatric center at the behest of his mother for evaluation as he was found to be inhaling “Vicks vaporub” after putting it in a polythene bag. The behavior was found to be strange by his unsuspecting mother. On inquiry, the patient revealed that he had tried taking cough syrup since the age of 13 years on many occasions for achieving “high” but he quit that as the cough syrup made him sleepy. He learned the use of “Vicks Vaporub” from a bootlegger in the street and experimented with it around the age of 15 years. He found its use to be better as the high was instant and short-lasting, unlike cough syrup which induced sedation. In the last few months, his rate of use increased to daily 4–6 sessions of bagging with 3–4 containers of 50 g of “Vicks vaporub” each time. He described the experience as “My head felt light and numb” with a deep inhalation. Sessions of inhalation lasted a few seconds to about half an hour. He had often tried to stop or cut down but was unsuccessful due to intense craving. During hospitalization, the patient was managed conservatively. Specific attention focused on psychoeducation and active support for continued abstinence. However, the patient relapsed within 1 week after discharge from the hospital. He was subsequently lost to follow-up.

Case 3

A 25-year-old government employee was initially referred for counseling by his departmental colleagues through his medical authorities. As per the referral note, he was found to be in a confused state during office hours. When a search was made in his office drawer, many empty bottles of typewriter correction fluid were found. The patient recovered fully after about 20 min and acknowledged inhaling the liquid for a transient high. History revealed that he initially experimented with inhaling typewriter correction fluid around 6 years back for the experimentation on the suggestion of a colleague. He liked the experience (dizziness, mild euphoria, and sense of emotional numbing) but left it after occasional recreational use. A year before the referral, he faced multiple stressors (death of his father and son in a gap of 3 months and a property dispute). As he could not cope up with these stressors, he resumed inhalant use (correction fluid) to numb his mind. He used it by huffing. The experiences made him get away from the realities of the world. The experience lasted 5–10 min but during that period, he appeared to be in an intoxicated state. Gradually, the frequency of huffing increased and he started using it during office hours also. He developed a craving for the intoxicant and found relief after inhaling it. He denied any withdrawal symptoms. Clinical examination including ear, nose, and throat examination was essentially normal. After initial denial and minimization, he acknowledged his inhalant abuse and promised abstinence. No depression or psychosis was noted. The patient was treated with psychoeducation, cognitive behavior therapy (CBT), and relaxation techniques. The sessions were weekly and spread over 2 months. However, after 2 months, he was found to be in relapse by his departmental head and was referred again. He attributed his relapse to a quarrel with his wife over financial issues. Although he was aware of the adverse effects of inhalant abuse, he found the urge to inhale correction fluid to be beyond his coping ability. During hospitalization of about 1 month, he acknowledged the occasional craving for the inhalant. However, no withdrawal features such as tremors or tachycardia were noted. He was treated with tablet naltrexone (50 mg/day) from day 7 onward along with CBT aimed at relapse prevention and coping skills training. He was followed for 2 years and maintained on tablet naltrexone with which he maintained remission. Subsequent, follow-up for another 1 year without maintenance medications was uneventful.

Case 4

A 31-year-old security personnel was admitted at the behest of his administrative authorities as he was found to be repeatedly getting drunk during duty hours. He acknowledged drinking more than one bottle of rum (750 ml)/day in 3–4 sittings. He would drink around 120 ml of rum (without water or soda) in the morning to overcome “shakes” and “calm his nerves.” He was treated as a case of alcohol dependence syndrome with detoxification (with tapering doses chlordiazepoxide), motivational enhancement therapy (MET), and group therapy. On D10 of in-patient care, the patient was found to be inhaling shoe polish. He had hidden bottles of “Vicks vaporub” and correction fluid in his belongings and patients' bathroom. He revealed that he had been using inhalants since early adolescence for a quick high. He resorted to consuming these substances when access to alcohol was restricted during working hours. He found them cheap, easily accessible, and quick to produce intense “high” and numbing. His premorbid personality revealed novelty seeking and antisocial traits with a poor disciplinary record. The patient was treated with anti-craving medication (naltrexone 50 mg OD), MET and CBT. He was discharged after 4 weeks of therapy. However, the patient relapsed after a few days with regular alcohol and inhalant use. He was admitted and managed in for intoxication in a calm, quiet, reassuring environment with supportive care and monitoring of vital parameters, orientation, and behavior.[⁵] His symptoms resolved over 12–14 h. He was treated with supportive care including adequate hydration and nutrition, analgesics (tablet ibuprofen 200 mg SOS for headache), and re-institution of pharmacotherapy and psychotherapy. Due to poor response to treatment and adverse sociooccupational profile, he was discharged from the service. He was subsequently lost to follow-up.

Case 5

A 23-year-old truck driver was brought to psychiatry outpatient department for the treatment of his addictions. He was consuming opioids (fentanyl and tramadol), alcohol, cannabis (Charas), and MDMA. His addictions were causing significant sociooccupational impairments. History revealed that he started smoking bidi and glue sniffing at the age of 12 years in the company of his friends. They would sniff or bag the glues and keep lying for hours in the village fields. His inhalant use increased over the next 2–3 years and he would skip school to sniff/bag. He dropped out of school after class VII. He started working as an assistant to a truck driver he graduated to smoking cannabis and drinking alcohol and subsequently to opioids and amphetamines. His inhalant use stopped. His evaluation revealed irritability, tremors, tachycardia, dilated pupils, anxiety, agitation, and initial insomnia. He was hospitalized and his withdrawal managed with benzodiazepines and supportive therapy. He was started on anti-craving medications, MET and CBT. His parents ensured regular follow-up for the next 1 year during which he had 3–4 lapses of cannabis and tramadol use. However, his sociooccupational role functioning had improved significantly. Subsequently, he was lost to follow-up. In this case of poly-substance abuse, inhalants played the role of a gateway drug.

DISCUSSION

From the above cases, it is clear that inhalant abuse is not uncommon. Another glaring aspect is the loss to follow-up and frequent relapse. The problem is further compounded by the fact that the general population is ignorant about their abuse potential and inadvertently fall prey.[⁵] In our series, the cases cut across social class. Other Indian studies and case series have also reported that inhalant abuse is prevalent across all social classes.[⁷⁸] Common inhalants are typewriting correction fluid, dry cleaning fluid, petrol, and paint thinner such as turpentine oil, spray paint, hair spray, and glue.[³⁵] All inhalants are absorbed through the lungs and spread throughout the body within a few minutes.[¹³] These agents are commonly used by children and adolescents.[^{12346789101112}] because of their easy availability. Inhalants cause a fleeting sense of well-being which reinforces repetition. These effects generally last only a few minutes. The inhalant user may experience euphoria and a transient phase of relaxation. Inhalant intoxication involves clinically significant psychological and physical problems, namely impaired judgment, suspiciousness, apathy, dizziness, visual disturbances, nystagmus, in-coordination, and slurred speech, unsteady gait, and tremors. Higher doses of inhalants may lead to depressed reflexes, stupor or coma, or even deaths that result from central respiratory depression and cardiac arrhythmia.[^1291112] There may be visual loss, sensorineural deafness, or excessive crusting of the nasal epithelium leading to epistaxis. Inhalant abuse by women who are pregnant can increase the risks of spontaneous abortion or fetal solvent syndrome, which manifests as low birth weight, small head size, facial dysmorphism, and muscle tone abnormalities similar to those occurring in fetal alcohol syndrome.[¹³] Inhalants are frequently referred to as gateway agents as they depict the first mood-altering experienced by adolescents.[¹⁴] It may be that abusers have an underlying morbid trait or unmet needs and these agents merely provide transient relief.[¹⁰] The fact that the most of them discontinue their use and do not adhere to fix the pattern of use future further gives credence to this view. Almost all of the substances of this class are capable of producing abuse, dependence (including tolerance), and intoxication. However, there remains uncertainty regarding the presence of a typical withdrawal syndrome.[¹⁴⁹] Only one patient in our series (case-5) had withdrawal features, and these were due to other substances including opioids. Diagnosis of inhalant abuse is based primarily on clinical suspicion and expert history taking. Magnetic resonance imaging sometimes shows cortical atrophy, white-matter degeneration, and subcortical abnormalities, particularly in the thalamus, basal ganglia, pons, and cerebellum.[¹⁵] Cognitive impairment has been reported with deficits found in memory, attention, auditory discrimination, problem-solving abilities, visual learning, and visual-motor function.[¹²¹⁶] Specific urine drug testing is sometimes useful as part of the treatment-compliance plan when benzene, toluene, or a similar agent has been chronically abused.[¹⁷] Electrocardiogram should be done when cardiac arrhythmia is suspected. The synopsis of Indian Psychiatric Society (IPS) Clinical Practice Guidelines (CPG) on management inhalant use disorders provides a comprehensive and ready reference for the management of different phases and manifestations of inhalant use. Outreach programs involving Information, Education, and Communication activities targeted at school children and their parents about the abuse potential of inhalants may be effective preventive strategies. One of our patients was treated successfully with naltrexone (opioid antagonist). There have not been any controlled studies regarding the use of anti-craving agents in relapse prevention, but theoretically these drugs may have a role.[¹⁸] One case series reported that baclofen was effective for managing both withdrawal and craving in inhalant abuse.[¹⁹] Our case series has aptly described that inhalant abuse is rampant in society and clinical detection requires a strong suspicion in vulnerable individuals. It also highlights the challenges being faced by clinicians while handling such cases.

CONCLUSION

Inhalant abuse leads to many neurological and psychiatric complications. Since the problem is more common in younger population, educating children and parents about the dangers of inhalant use and clear parental disapproval of such acts remain the best methods for preventing huffing. Although detoxification is fairly easy, rates of relapse are high. The IPS has issued comprehensive guidelines for pharmacological and nonpharmacological treatment of inhalant abuse.[²] There is a need for specific governmental initiatives for curb this menace.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.