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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 hydrocarbonbased 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 γaminobutyric 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, highdose 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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