Substance Abuse: Inhalants This course has been awarded one (1) contact hour. This course expires on September 30, 2016. Copyright © 2013 by RN.com. All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com.
First Published: June 17, 2013
Acknowledgements RN.com acknowledges the valuable contributions of… ...Kim Maryniak, RNC-NIC, BN, MSN has over 23 years staff nurse and charge nurse experience with medical/surgical, psychiatry, pediatrics, and neonatal intensive care. She has been an educator, instructor, and nursing director. Her instructor experience includes med/surg nursing, mental health, and physical assessment. Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta in 1989. She achieved her Bachelor in Nursing through Athabasca University, Alberta in 2000, and her Master of Science in Nursing through University of Phoenix in 2005. Kim is certified in Neonatal Intensive Care Nursing and is currently pursuing her PhD in Nursing. She is active in the National Association of Neonatal Nurses and American Nurses Association. Kim’s current and previous roles in professional development include nursing peer review and advancement, education, use of simulation, quality, and process improvement. Her current role includes oversight of professional development, infection control, patient throughput, and nursing operations.
Conflict of Interest and Commercial Support RN.com strives to present content in a fair and unbiased manner at all times, and has a full and fair disclosure policy that requires course faculty to declare any real or apparent commercial affiliation related to the content of this presentation. Note: Conflict of Interest is defined by ANCC as a situation in which an individual has an opportunity to affect educational content about products or services of a commercial interest with which he/she has a financial relationship. The author of this course does not have any conflict of interest to declare.
Purpose and Objectives The purpose of this course is to educate healthcare professionals about a type of drug abuse that can result in sudden death: inhaling substances to induce mind-altering effects. Material protected by copyright
After successful completion of this course, the participant will be able to: 1. Identify types of inhalants and associated mind-altering effects 2. Identify signs and symptoms associated with inhalant abuse 3. Describe physiological effects of inhalants 4. Identify clinical management of illicit drug use 5. Describe substance abuse prevention strategies
Introduction A plethora of solvents, gases, aerosol propellants, nitrates and other substances can be inhaled by individuals seeking a psychoactive experience. These substances are volatile, can emit chemical vapors, and can be inhaled to produce a variety of pharmacological effects. Unfortunately, some of these effects may result in death. According to NIDA (National Institute on Drug Abuse), the term inhalants encompasses a wide range of chemicals found in hundreds of different products (NIDA, 2012a). Because many healthcare professionals may be unfamiliar with the effects or the use of inhalants, it is beneficial to learn about the types of products that might be inhaled, the signs and symptoms of inhalant intoxication and the treatment for this type of abuse.
Street Names Street names for inhalants will vary according to region and demographic. These may include: Aroma of men Bolt Boppers Bullet Bullet bolt Buzz bomb
Discorama Hardware Laughing gas Moon gas Oz Pearls
Poor man’s pot Poppers Quicksilver Rush Snappers Satan’s secret Shoot the breeze
Snappers Snotballs Whippets (NIDA, 2011)
How Inhalants are Used Inhalants are taken into the body using a few different methods. They can be inhaled through the nose or mouth by:
Inhaling from a balloon. “Huffing” (inhaling) from an inhalant soaked cloth stuffed into the mouth. Snorting or sniffing fumes directly from a container. Spraying directly into the mouth or nose. Inhaling fumes that have been put into or sprayed into a paper or plastic bag (bagging).
Solvents may be inhaled by stuffing a solvent soaked rag into the mouth and breathing rapidly ("huffing"), by placing a solvent soaked rag into a bag and inhaling repeatedly ("bagging") or by directly inhaling the fumes from the container (NIDA, 2012b). Chemicals that are inhaled become absorbed rapidly into the bloodstream. Within seconds the user experiences effects similar to those produced by alcohol. Material protected by copyright
The user might also experience euphoria, hallucinations, delusions, dizziness, slurred speech, lightheadedness, or the inability to coordinate movements. Individuals may inhale these chemicals repeatedly for hours since the effects from the inhalants don’t last more than a few minutes (NIDA, 2012a). With repeated inhalant use and each successive inhalation, users subject themselves to an increasing risk for a loss of consciousness and death. With heavy use of inhalants, abusers may become very sleepy for several hours and complain of a lingering headache (NIDA, 2012b).
Test Yourself Chemicals that are inhaled become absorbed rapidly into the bloodstream.
Categories of Inhalants There are hundreds if not thousands of chemical inhalants that an individual might use to experience a mind altering event (to get high). NIDA (2012a) organizes inhalants into four categories based on the form in which they are found in industrial, household and medical products. The categories include:
Gases such as propane, butane, aerosol propellants and nitrous oxide Volatile solvents such as glues, paint thinners and gasoline Nitrites such ascyclohexyl, isoamyl and isobutyl Aerosols Common household products such as hairspray, nail polish remover and cleaning products can become deadly when inhaled.
Types of Inhalants: Gases and Volatile Substances Gases Commercial and household products that contain gases that can be inhaled include whipped cream dispensers (readily available for purchase on the internet), refrigerants, propane tanks and butane lighters. Nitrous oxide is generally the most abused of these gases and is found in whipped cream dispensers and products that are sold to increase octane levels in racing cars. Medical anesthetic gases include nitrous oxide, halothane, ether and chloroform (NIDA, 2012a). Volatile solvents Liquids that vaporize at room temperatures are classified as volatile solvents. They can be found in many easily available and inexpensive products used for common household and industrial purposes. Types of volatile solvents include glues, gasoline, correction fluids, felt-tip markers, paint thinners and removers, degreases and dry-cleaning fluids (NIDA, 2012a). Material protected by copyright
Fumes from markers can be readily inhaled when the markers are placed in a small plastic bag. Abusers sometimes crush the markers to increase the amount of fumes available to inhale.
Types of Inhalants: Nitrites and Aerosols Nitrites Nitrites, also known as “poppers” or “snappers” are different than most other inhalants which act directly on the central nervous system (CNS). Nitrites act primarily to relax muscles and dilate blood vessels. Nitrites are often used as sexual enhances while other inhalants are used to alter mood. Nitrites include isoamyl (amyl) nitrite, isobutyl (butyl) nitrite and cyclohexyl nitrite. Amyl nitrite can also be used in certain medical diagnostic procedures and in the past was sometimes used to treat patients with angina. The Consumer Product Safety Commission now prohibits selling nitrites but they can still be found sold in small bottles labeled “leather cleaner,” "liquid aroma," "video head cleaner," or "room odorizer" (NIDA, 2012a). Aerosols Sprays that contain propellants and solvents are known as aerosols. Spray deodorants, hair sprays, spray paints, vegetable oil sprays for cooking, and fabric protector sprays are all examples of aerosols (NIDA, 2012a).
Test Yourself True or False? Nitrates are similar to most other inhalants which act directly on the central nervous system (CNS). ~ False! Nitrates act primarily to relax muscles and dilate blood vessels.
Pattern of Abuse Inhalant abuse occurs in urban and rural settings; however, factors associated with inhalant abuse include a history of child abuse, unstable socioeconomic conditions, poor grades and dropping out of school. Inhalants are often one of the first drugs that young children use (NIDA, 2012a). According to one national survey, approximately three percent of children in the United States (U.S.) have tried inhalants by the time they reach fourth grade. Although inhalant abusers will abuse any available substance, abusers often have a preference for one product over another. National surveys indicate that inhalant abuse is particularly prevalent among young people. Data suggest that abuse reaches its peak at some point during the seventh through ninth grades (NIDA, 2011). Some young people may abuse inhalants as a substitute for alcohol because they can be obtained easily. Eighth-graders regularly report the highest rates of abuse. In fact, data shows a significant increase in lifetime inhalant use among eighth-graders (NIDA, 2012b). According to the Substance Abuse and Mental Health Services Administration (SAMHSA) the uses of inhalants has been reported across the country, with rates initially decreasing since 2004, but are back on the rise. Material protected by copyright
The Drug Abuse Warning Network (DAWN) is a public health surveillance network that monitors drug-related incidents, including emergency room visits and deaths. The 2010 DAWN Emergency Department statistics for visits to emergency departments related to inhalants were 3.3/100,000 in 2004, dropped to 1.7/100,000 in 2005, and increased to 3.7/100,000 in 2010. Approximately three percent of children in the United States have tried inhalants by the time they reach fourth grade.
Recognizing Inhalant Abuse Inhalant abuse can cause serious health consequences. Nurses and other healthcare professionals should be aware of associated signs and symptoms of inhalant use such as:
Slurred speech Altered level of consciousness Appearing intoxicated by alcohol Irritability
Term Air Blast Buzz Bomb Glading Huffer
Depression Inattentiveness Chemical odor on breath or clothes Paint or stains on clothes, hands, or face
Chemical soaked rags Hidden empty aerosol or spray paint cans solvent containers (NIDA, 2012b)
Common Terms Associated with Inhalants Definition Term Definition Inhalants Bagging Using Inhalants Nitrous Oxide Climax Isobutyl Nitrate Using Inhalants Gluey Sniffing or inhaling glue Inhalants abuser Poor Man’s Pot Inhalants
Effects on the Brain Almost all inhalants except for nitrites produce pleasurable effects by depressing the central nervous system. Toluene, a solvent found in many abused inhalants such as nail polish removers, model airplane glue, paint and spray paint activates the brain's dopamine system. The release of the neurotransmitter dopamine produces feelings of pleasure. Most inhalants produce initial excitation and then rapid effects that resemble alcohol intoxication. Most solvents that are inhaled produce different levels of anesthesia with the possibility of confusion and a loss of consciousness (NIDA, 2012b). Effects may also include: work or social situations Depressed reflexes Lack of coordination Apathy (NIDA, 2012b) Nausea and vomiting, or lack of appetite Belligerence Impaired functioning in Impaired judgment Long term use of inhalants can result in a mild withdrawal syndrome that includes muscle weakness, lack of coordination, weight loss and depression (NIDA, 2012b).
Effects on the Brain: Nitrites In contrast to other inhalants, the inhalation of nitrites causes blood vessels to dilate and usually results in an increased heart rate. Material protected by copyright
In addition, nitrites might cause:
Dizziness Sensation of heat and warmth
Headache Flushed skin
The National Institute on Drug Abuse (NIDA, 2012b) reports that animal research indicates the possibility that there may be a link between nitrite inhalant abuse and the development of tumors and infectious diseases. Inhaling nitrites appears to impair and deplete cells that are responsible for fighting off infection. Nitrites are sometimes abused to enhance sexual pleasure and performance, and can be associated with unsafe sexual practices. This increases the risk of contracting infectious diseases such as HIV, AIDS, and hepatitis (NIDA, 2012a).
Test Yourself True or False? Long term use of inhalants can result in a mild withdrawal syndrome that includes muscle weakness, lack of coordination, weight loss and depression. ~ True!
Medical Consequences In addition to the potential symptoms of inhalant use, inhalant sniffing carries the possibility of devastating medical consequences. Inhaling chemicals can cause rapid and irregular heart rhythms that might result in cardiac failure and death. A syndrome known as “sudden sniffing death” may occur within minutes of inhaling highly concentrated chemicals in otherwise healthy individuals as a result of suffocation (NIDA,2012b). Abusing inhalants may also result in death from:
Accidents incurred while intoxicated Choking
Suffocation Asphyxiation Seizures
Toxic Effects of Inhaling Chemicals The toxic effects of inhaling chemicals can result in significant damage to the nervous system and brain. Chronic abuse of volatile solvents such as toluene has now been shown to damage the protective sheath around certain nerve fibers in the brain and peripheral nervous system. Cognition, vision, hearing and movement may all be affected by using inhalants. Nerve damage has been found that is comparable to that seen with neurological diseases such as Parkinson’s disease and multiple sclerosis. Inhalants are extremely toxic not only to the brain but other organs as well. Significant damage to the liver, lungs, kidneys and heart can also occur. Using inhalants during pregnancy can result in low birth weights, delayed neurobehavioral development and skeletal abnormalities (NIDA, 2012b).
Test Yourself Inhaling chemicals cab result in a syndrome known as sudden sniffing death.
Long Term Effects Serious health problems have been associated with the chronic use of inhalants. Inhaling solvents such as toluene and trichloroethylene can cause liver damage while paint thinner and glue tends to cause kidney Material protected by copyright
abnormalities. The chronic use of inhalants has been associated with a number of serious health problems. Decreased non-verbal intelligence, memory impairment and attention deficits have all been related to the abuse of inhalants (NIDA, 2012b). Hazardous Chemicals in Inhalants Amyl nitrite, butyl nitrite Methylene chloride (found in paint thinners and (“poppers”, “video head cleaner”): removers, degreasers): Sudden sniffing death syndrome, suppressed Reduction of oxygen-carrying capacity of blood, changes to immunologic function, injury to red blood cells the heart muscle and heartbeat (interfering with oxygen supply to vital tissues Benzene (found in gasoline): Bone marrow injury, impaired immunologic function, increased risk of leukemia, reproductive system toxicity
Nitrous oxide (“laughing gas”), hexane: Death from lack of oxygen to the brain, altered perception and motor coordination, loss of sensation, limb spasms, blackouts caused by blood pressure changes, depression of heart muscle functioning Butane, propane (found in lighter fluid, hair Toluene (found in gasoline, paint thinners and removers, and paint sprays): sudden sniffing death correction fluid): brain damage (loss of brain tissue mass, syndrome via cardiac effects, serious burn impaired cognition, gait disturbances, loss of coordination, injuries (because of flammability loss of equilibrium, limb spasms, hearing and vision loss), liver and kidney damage Freon (used as a refrigerant and aerosol Trichloroethylene (found in spot removers, degreasers): propellant): sudden sniffing death syndrome, sudden sniffing death syndrome, cirrhosis of the liver, respiratory obstruction and death (from sudden reproductive complications, hearing and vision damage. cooling/cold injury to airways), liver damage
Drug Addiction and Treatment Addiction to drugs is usually characterized by compulsive seeking, using and craving of drugs no matter what the consequences may be. Drug addiction often results in chronic use with many relapses that require multiple attempts at treatment. Goals for drug addiction programs address the short and long term needs of the addict. In the initial phases of treatment it is necessary to decrease medical complications related to drug use and improve an individuals’ ability to function without drugs. Changing the behavior related to drug addiction is especially challenging. In the long term, the goal for drug treatment is to help an individual remain drug free for life. Counseling and other behavioral therapies are critical components of virtually all effective treatments for addiction. About 22.5 million Americans over age 12 reported current use of drugs in 2011 (within the past month), representing approximately 8.7 percent of the population, according to the National Household Survey on Drug Use and Health (NSDUH) conducted by the Substance Abuse and Mental Health Services Administration (2011). Illegal drugs exact an enormous toll on society, taking tens of thousands of lives annually and draining the economy of billions each year. The cost in suffering related to violence and crime stemming from drug abuse is immeasurable. Material protected by copyright
Drug treatment programs can help decrease and change destructive behavior. For treatment to be successful, it must be individualized toward each person's needs (NIDA, 2012c). The recovery process takes time and effective treatment should include:
An individual’s treatment and services plan must be assessed often and modified to meet the person’s changing needs. Treatment does not need to be voluntary to be effective. No single treatment is appropriate for all individuals. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, and should provide counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Treatment needs to be readily available. Possible drug use during treatment must be monitored continuously. Effective treatment attends to multiple needs of the individual, not just his or her drug addiction. Counseling and other behavioral therapies are critical components of virtually all effective treatments for addiction. For certain types of disorders, medications are an important element of treatment, especially when combined with counseling and other behavioral therapies. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Medical management of withdrawal syndrome is only the first stage of addiction treatment and by itself does little to change long-term drug use. As is the case with other chronic, relapsing diseases, recovery from drug addiction can be a long-term process and typically requires multiple episodes of treatment, including "booster" sessions and other forms of continuing care (NIDA, 2006c).
Management Principles Thirteen treatment principles have been developed by the National Institute on Drug Abuse: 1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each patient's problems and needs is critical. 2. Treatment needs to be readily available. Treatment applicants can be lost if treatment is not immediately available or readily accessible. 3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Treatment must address the individual's drug use and associated medical, psychological, social, vocational, and legal problems. 4. At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation and social and legal services. 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The time depends on an individual's needs. For most patients, the threshold of significant improvement is reached at about 3 months in treatment. Additional treatment can produce further progress. Programs should include strategies to prevent patients from leaving treatment prematurely. 6. Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address motivation, build skills to resist drug use, replace Material protected by copyright
drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethodol (LAAM) help persons addicted to opiates stabilize their lives and reduce their drug use. Naltrexone is effective for some opiate addicts and some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an oral medication, such as buproprion, can help persons addicted to nicotine. 8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. 9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification manages the acute physical symptoms of withdrawal. For some individuals it is a precursor to effective drug addiction treatment. 10. Treatment does not need to be voluntary to be effective. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase treatment entry, retention, and success. 11. Possible drug use during treatment must be monitored continuously. Monitoring a patient's drug and alcohol use during treatment, such as through urinalysis, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that treatment can be adjusted. 12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases. Counseling to help patients modify or change behaviors that place them or others at risk of infection should also be made available. Counseling can help patients avoid high-risk behavior and help people who are already infected manage their illness. 13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment often helps maintain abstinence. (NIDA, 2012c)
Legislation Although inhalants are not regulated under the Controlled Substances Act (CSA), many state legislatures have placed restrictions on the sale of products to minors that can be used in an attempt to deter youth from buying legal products to get high. Thirty-eight states in the U.S. have restrictions on the sale and distribution to minors with certain products commonly abused as inhalants. Some states have introduced fines, incarceration, or mandatory treatment for the sale, distribution, use and/or possession of inhalant chemicals. Laws also exist in some states prohibiting the recreational inhalation of nitrous oxide (Foundation for a Drug-Free World, 2013).
Conclusion The use of volatile and concentrated chemical inhalants to achieve a mind altering experience can be extremely dangerous with devastating medical consequences. Children and adolescents have a high usage of inhalants. Nurses and other healthcare professionals who have familiarized themselves with the products used for inhalation as well as the associated signs and symptoms of inhalation abuse will be better prepared to provide care for these individuals. Material protected by copyright
Resources NIDA Web Sites drugabuse.gov steroidabuse.gov clubdrugs.gov backtoschool.drugabuse.gov teens.drugabuse.gov Other Web Sites Centers for Disease Control and Prevention: www.cdc.gov National Inhalant Prevention Coalition: www.inhalants.org Substance Abuse and Mental Health Services Administration Health Information Network: www.samhsa.gov/shin
References Center for Behavioral Health Statistics and Quality (CBHSQ), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS), and by RTI International (a trade name of Research Triangle Institute). (2011). Results from the 2011 Foundation for a Drug-Free World. (2013). The truth about inhalants. Retrieved March, 2013 from http://www.drugfreeworld.org/drugfacts/inhalants/are-they-legal.html National Survey on Drug Use and Health: Summary of national findings. Retrieved March, 2013 from http://www.samhsa.gov/data/nsduh/2k11results/nsduhresults2011.htm National Institute on Drug Abuse. (2011). Commonly abused drugs. Retrieved March, 2013 from http://www.drugabuse.gov/sites/default/files/cadchart_2.pdf National Institute on Drug Abuse. (2012a). Drug facts: Inhalants. Retrieved March, 2013 from http://www.drugabuse.gov/ National Institute on Drug Abuse. (2012b). Research report series: Inhalant Abuse. Retrieved March, 2013 from http://www.drugabuse.gov/ National Institute on Drug Abuse. (2012c). Principles of drug addiction treatment: A research based guide. Retrieved March, 2013 from http://www.drugabuse.gov/sites/default/files/podat_1.pdf Substance Abuse Mental Health Services Administration (SAMHSA). (2010). Past Month Drug Use among Persons Aged 12 and Older. Retrieved March, 2013 from: http://www.drugabusestatistics.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#2.4 Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). DAWN 2010 emergency department Excel files: National trends. Retrieved March, 2013 from http://www.samhsa.gov/data/DAWN.aspx At the time this course was constructed all URL's in the reference list were current and accessible. rn.com is committed to providing healthcare professionals with the most up to date information available.
Disclaimer This publication is intended solely for the educational use of healthcare professionals taking this course, for credit, from RN.com, in accordance with RN.com. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated Material protected by copyright
with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. As always, in assessing and responding to specific patient care situations, healthcare professionals must use their judgment, as well as follow the policies of their organization and any applicable law. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Healthcare organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Healthcare providers, hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any products/therapeutics mentioned in this course. The information in the course is for educational purposes only. There is no “off label” usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.
© Copyright 2013, AMN Healthcare, Inc.
Material protected by copyright