Inhalant-related psychiatric disorders are a heterogenous group of illnesses caused by the abuse of solvents, glues, paint, fuels, or other

volatile substances. Although huffing, as it is commonly referred to, has existed since ancient times, it has regained popularity in recent years. The resurgence of this newfound phenomenon is believed to be due to a number of variables (eg, low cost, availability, peer influence, rapid mood-elevating quality), which have made this potentially fatal activity popular among many young people today. A relationship may exist between inhalant use and an increased risk of frequent drinking, binge-type drinking, smoking, and the use of other drugs, making inhalant-related disorders a new public health problem deserving of more attention. Because most of the products used in huffing are legal household products, they are easily accessible and are relatively inexpensive to obtain. Most recent reports state that nearly 1000 such products are available to huffers every day. Some of the most common products used for inhaling are spray paint (containing butane, lead, or propane), permanent markers, correction fluid (eg, Liquid Paper, Wite-Out), glue (containing toluene or ethyl acetate), lighter fluid (containing butane or isopropane), hairspray (containing butane or propane), propane, gasoline (containing lead), kerosene, and nitrous oxide from a balloon. There may be different motivation for the type of inhalant used, which may be of significance during clinical treatment.[1] Because of the increase in awareness of the potential dangers caused by sniffing or inhaling, laws have been established that prohibit the sale of certain products to minors; however, enforcing these laws is difficult. In the United States, 46 states have enacted laws to minimize inhalant abuse. TheNational Conference of State Legislatures outlines each state's statutes governing the use and the sale of aerosols and inhalants.[2] Generally, adolescents practice huffing; however, younger children and young adults also engage in this potentially fatal act. Huffing involves placing the volatile substance (most commonly some type of chemical, eg, butane found in spray paint, acetone found in nail polish remover) on a rag or in a closed container (eg, soda can, plastic bag [termed bagging]), placing the rag over the nose and mouth, and breathing deeply to cause mood-altering effects. Other common methods of huffing include spraying an aerosol directly into the oral or nasal cavities; dousing clothing such as shirt sleeves, collars, and/or cuffs with a chemical and sniffing the polluted area over time; or filling balloons with nitrous oxide or other chemicals and inhaling the products. The inhalation of these substances can cause permanent organ damage and death. Huffing is a problem in the United States and abroad, and it accounts for a large portion of emergency department visits. In a 2010 article by Howard et al, the authors reported that rates of suicidal ideation are higher among those with inhalant use disorders than nonusers. Among those who use inhalants, approximately 67.4% had thought about committing suicide and 20.2% had reportedly attempted suicide.[3] In 2004, Sakai et al found that adolescents who used inhalants were more likely to have higher rates of major depression, suicidal ideation or attempts, and abuse or dependence upon alcohol, hallucinogens, nicotine, cocaine, and amphetamines than adolescents who had never used inhalants. Their study noted higher reported rates of abuse and neglect among adolescents who were diagnosed with inhalant use disorders.[4] Diagnosis of inhalant-related psychiatric disorders is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision(DSM-IV-TR)[5] or International Classification of Diseases, 10th Revisioncriteria. Although studies have shown that inhalant abuse has been difficult to diagnose, treatment efforts for inhalant-related psychiatric disorders may be promising. Treatment consists of psychotherapy (eg, 12-step programs similar to Alcoholics Anonymous, cognitive behavior therapy, rational-emotive therapy) and pharmacotherapy. Early intervention may play a key role because engagement in this activity may lead to the use of other drugs. Some synonymous terms for inhalant abuse include air blasts, aimies/ames/amys (amyl nitrite), bagging, bolt, boppers, bullet, climax, glading, gluing, hardware, hippie crack, huffing, kick, medusa, pearls, poor

mans pot, poppers, quicksilver, rush, snappers, snorting, thrust, tolly, toncho (octane booster), whippets, and whiteout.

Case study
A 14-year-old Caucasian male is brought into the emergency department by his father after being found in a confused, euphoric state. His breath has a chemical odor and his speech is slurred. The boy complains of blurred vision and sensitivity to light (photophobia). Not only does the boys shirt have stains, but so do his hands. A rag doused with turpentine was found in the boys room. The boys pulse and vital signs are elevated. An electrocardiogram shows tachycardia. Upon further examination, the treating physician observes burns to the nasal and oral passages. A urinalysis with a screening for hippuric acid is ordered. The results come back with a high level of toluene. Three days after the boy was taken to the emergency department, the boy begins to experience severe abdominal cramping, nausea, headache, irritability, and tremors in his hands. He cannot sleep. He is experiencing withdrawals. Inhalants are CNS depressants (similar to alcohol) and are thought to influence gamma-aminobutyric acid (GABA), although the exact mechanism has yet to be determined. No evidence associates inhalants with the opiate system; N -methyl-D-aspartate may play a role.

Medical effects
y Brain: Most of the damage inflicted by inhalant abuse initially affects the brain. Tremors and uncontrollable shaking are observed in those who abuse inhalants for a long period. Inhalants also affect eyesight, causing double vision and other sight disorders. Many who abuse inhalants experience seizures. Headaches are common. Damage to the brain may lead to changes in personality. Those who abuse toluene may have significantly wider cerebellar and cerebral sulci and larger ventricular systems. Memory loss, decreased cognitive functioning, and slurred speech may ensue inhalant use. Lungs: Repeated use of inhalants can cause lung damage, including hypoxia, sinus discharge, coughing, cyanosis, and upper and lower airway irritation. Heart: Heart problems can occur, including irregular heartbeat and sudden sniffing death syndrome, which is heart failure resulting from an irregular heartbeat. Gastrointestinal: Problems include abdominal pain, nausea, and vomiting. Liver: Liver function can actually shut down, either temporarily or permanently, depending on length and extent of inhalant use (ie, cirrhosis). Kidney: Kidney stones and complete loss of kidney function can develop. Muscle: Long-term inhalant abuse leads to muscle weakness, muscle wasting, and reduced muscle tone and strength. Bone marrow: Inhalants damage bone marrow. In addition, the chemical benzene, which is found in gasoline, has been shown to cause leukemia. Peripheral nervous system: Damage from inhalants can cause temporary numbness, permanent nerve damage, permanent paralysis, or generalized weakness, depending on the frequency of abuse. Hearing: Some who abuse inhalants become deaf because of the inhalation of chemicals that destroy cells that relay sound to the brain. Other medical effects: Other effects of inhalant abuse include respiratory problems, asphyxiation, aeration, and fetal damage similar to that observed in patients with fetal alcohol syndrome. Psychiatric effects The psychiatric effects of inhalant abuse include impaired judgment, confusion, fright, hyperactivity, anxiety, acute psychosis, increased violence and aggressive behavior, depression, organic brain syndrome (ie, coarse tremor, staggering gait, speech problems, thought disorder), abuse, tolerance and dependence, hallucinations, decreased intelligence quotient, intoxication, mood disorder, dementia, and withdrawal. Inhalant abuse also affects social, educational, and economic status. In addition, persons who abuse inhalants are more likely to be involved in accidents (eg, falls, burns, frostbite, motor vehicle accidents). Importantly, note that the number of planned suicides in persons with inhalant-related psychiatric disorders is equal to the number of planned suicides in persons with other psychiatric illnesses; however, the number of unplanned suicides is dramatically higher in children and adolescents who engage in huffing.

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Frequency
United States Of the population, 6% have tried huffing once and 1% are current users. According to statistics gathered by the National Inhalant Prevention Coalition, ". . . by the time a student reaches the eighth grade, 1 in 5 will have used inhalants."[6] Inhalants account for 1% of substance-induced death. Huffing is more common in rural versus inner-city adolescents, although exact numbers are difficult to determine. The National Survey on Drug Use and Health (NSDUH) report found that nearly 1 million adolescents (3.9%) used inhalants in 2007. The rates in 2003, 2004, and 2005 were higher (4.5%, 4.6%, and 4.5%, respectively). From 2002-2007, reported abuse or dependence on inhalants showed rates to be relatively stable. In 2007, approximately 99,000 (0.4%) of adolescents met the criteria for abuse or dependence on inhalants. Also in 2007, 2.1% of adolescents who had not previously used inhalants reported using these for the first time. The rate of initiation in 2007 for those who had not previously used inhalants was lower than the rate for 2002-2005, which was around 2.6%. For those surveyed who had used illicit drugs, 17.2% reported that inhalants were the first drug they used.[7] International Incidents occur worldwide, but determining exact numbers is difficult.

Mortality/Morbidity
Inhalants work quickly by passing through the nasal cavity and entering the lungs, bloodstream, and brain, all in a matter of seconds. The chemical vapors of the inhalants are dissolved into the fatty tissues of the brain. The results of inhalant abuse affect virtually every organ and function of the body, including the brain, heart, lungs, kidneys, muscle, bone marrow, and peripheral and central nervous systems, to name a few. Within just a few minutes, sudden sniffing death may occur from heart rhythm irregularities leading to cardiac arrest. In addition to causing possible cardiac disruptions, inhalant abuse may also result in death due to suffocation, asphyxiation, or aspiration. Persons who abuse inhalants long-term may become permanently disabled, losing their ability to walk, talk, and think. The possible damage depends on the chemical used, the frequency with which it is used, and the amount used.

Race
Persons who abuse inhalants predominantly are white; however, studies have found minority involvement in subcultures of American and Canadian Indians and in Hispanic persons with low-income status. Inhalant use is more common in rural and suburban areas than in urban areas.

Sex
Although long-term inhalant use is more common in males than in females, experimental use is equally common in males and females.

Age
Experimental use of inhalants normally occurs in late childhood and early adolescence (9-13 y). Longterm use appears during early and late adolescence (12-17 y). Inhalants are commonly the first substance used before the onset of substance (eg, tobacco, alcohol, marijuana, cocaine) abuse occurs. Inhalant abuse among younger children and adults is less frequent, although it does occur. In particular, nitrite abusers tend to be adults. Those who abuse nitrites tend to seek enhanced sexual experiences as nitrites can cause vasodilation, increased heart rate, and a feeling of heat and excitement.

CLINICAL PRESENTATION

Persons who abuse inhalants commonly share characteristics that may help identify them as users. While taking the patient's history, determine their diagnosis based on the DSM-IV-TR criteria for inhalant abuse, inhalant dependence, inhalant intoxication, substance intoxication delirium, substance-induced persistent dementia, substance-induced psychotic disorder, substance-induced mood disorder, substance-induced anxiety disorder, and inhalant-related disorder not otherwise specified (NOS). Pay close attention to the signs and symptoms commonly associated with persons who abuse inhalants (see below). Inquire about other drugs of abuse and a family history of drug and alcohol abuse or addiction. The diagnosis is based solely on the history and a very high index of suspicion. Signs and symptoms Chemical smell or odor on breath or body Redness, sores, or spots around the lips or mouth Redness of eyes Runny or red nose Paint stains on clothing or body Nausea or loss of appetite Drunken or dazed appearance Dizziness Irritability, excitability, or anxiety Slow verbal responses in conversation Sudden behavior change Sensitivity to light Sore or irritated throat Rashes or redness on hands y Characteristics of persons who abuse inhalants o Delinquency o Theft and burglary o Poor school attendance o Frequent suspension and expulsion from school o Social outcast o Impoverished families or middle-to-upper income status o Lack of parental control or guidance o Attention deficit o Poor academic performance o Antisocial personality o Depressive disorders o Emotional problems (specifically anxiety, depression, and anger) o Low self-esteem o Peer pressure with drug influence y Criteria for inhalant abuse, adapted from the DSM-IV-TR o A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (or more) of the following, occurring within a 12-month period:  Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home  Recurrent substance use in situations in which it is physically hazardous  Recurrent substance-related legal problems  Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance o Symptoms never meeting criteria for substance dependence for this class of substance y Criteria for inhalant dependence, adapted from the DSM-IV-TR - A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period: y o o o o o o o o o o o o o o

Tolerance A need for markedly increased amounts of the substance to achieve intoxication or desired effects Markedly diminished effects with continued use of the same amount of the substance o Withdrawal  Characteristic withdrawal syndrome for the substance  Same (or a closely related) substance taken to relieve or avoid withdrawal symptoms o Substance often taken in larger amounts or over longer periods than was intended o A persistent desire or unsuccessful effort to reduce or control substance use o Significant time spent in activities necessary to obtain the substance or recover from its effects o Important social, occupational, or recreational activities are abandoned or reduced because of the substance use o Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance y Criteria for inhalant intoxication, adapted from the DSM-IV-TR o Recent intentional use or short-term high-dose exposure to volatile inhalants o Clinically maladaptive behavioral or psychological changes that developed during or shortly after use of or exposure to volatile inhalants o Two (or more) of the following signs developing during or shortly after inhalant use or exposure:  Dizziness  Nystagmus  Incoordination  Slurred speech  Unsteady gait  Lethargy  Depressed reflexes  Psychomotor retardation  Tremor  Generalized muscle weakness  Blurred vision or diplopia  Stupor or coma  Euphoria o Symptoms not due to a general medical condition and not better accounted for by another mental disorder y Criteria for substance intoxication delirium, adapted from the DSM-IV-TR o Disturbance of consciousness with reduced ability to focus, sustain, or shift attention o A change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia o Disturbance occurs over a short period and tends to fluctuate during the course of the day o Evidence from the history, physical examination, or laboratory findings of either of the following:  Symptoms of (1) disturbance of consciousness with reduced ability to focus, sustain, or shift attention or (2) a change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia that developed during substance intoxication  Medication use etiologically related to the disturbance y Criteria for substance-induced persistent dementia, adapted from theDSM-IV-TR o Development of multiple cognitive deficits manifested by both (1) memory impairment and (2) one (or more) of the following cognitive disturbances:  Aphasia  Apraxia  Agnosia  Disturbance in executive functioning o Cognitive deficit in (1) memory impairment and (2) aphasia, apraxia, agnosia, or disturbance in executive functioning each cause significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning o Deficients do not occur exclusively during the course of a delirium and persist beyond the usual duration of substance intoxication or withdrawal o  

Evidence from history, physical examination, or laboratory findings that deficits are etiologically related to the persistent effects of substance use Criteria for substance-induced psychotic disorder, adapted from theDSM-IV-TR o Prominent hallucinations or delusion o Evidence from history, physical examination, or laboratory findings of either of the following:  Symptoms of prominent hallucinations or delusion developing during or within 1 month of substance intoxication or withdrawal  Medication use etiologically related to the disturbance o Disturbance not better accounted for by a psychotic disorder that is not substance induced o Disturbance does not occur exclusively during the course of a delirium Criteria for substance-induced mood disorder, adapted from the DSM-IV-TR o Prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:  Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities  Elevated, expansive, or irritable mood o Evidence from history, physical examination, or laboratory findings of substance intoxication or withdrawal and the symptoms of (1) depressed mood or markedly diminished interest or pleasure in activities and (2) elevated, expansive, or irritable mood developing during or within 1 month of substance intoxication or withdrawal o Disturbance not better accounted for by mood disorder that is not substance induced o Disturbance does not occur exclusively during the course of a delirium o Disturbance causes clinically significant distress or impairment in social, occupational, or other important area of functioning Criteria for substance-induced anxiety disorder, adapted from the DSM-IV-TR o Prominent anxiety, panic attacks, obsession, or compulsion predominating in the clinical picture o Evidence from history, physical examination, or laboratory findings of either of the following:  Symptoms of prominent anxiety, panic attacks, obsession, or compulsion developing during or within 1 month of substance intoxication or withdrawal  Medication use etiologically related to the disturbance o Disturbance not better accounted for by an anxiety disorder that is not substance induced o Disturbance not occurring exclusively during the course of a delirium o Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Criteria for inhalant-related disorder NOS, adapted from the DSM-IV-TR: The inhalant-related disorder NOS category is for disorders associated with the use of inhalants that are not classified as inhalant dependence, inhalant abuse, inhalant intoxication, inhalant intoxication delirium, inhalant-induced persistent dementia, inhalant-induced psychotic disorder, inhalant-induced mood disorder, or inhalantinduced anxiety disorder. y See Lab Studies; however, no specific laboratory results confirm this diagnosis. y Perform a detailed neurological evaluation to look for the following: o Apathy o Impaired judgment o Impulsiveness o Aggressive behavior o Anorexia o Nystagmus o Depressed reflexes o Altered levels of consciousness o Disinhibited behaviors y In addition, be aware of the signs and symptoms of inhalant abuse when performing the physical examination; for example, look for the following: o Amnesia o Rashes (particularly around the hand, nose, and mouth, ie, glue-sniffer's rash) o Unusual breath odors (eg, chemical smells) o Red or irritated eyes, throat, lungs, and nose o

Burns

CAUSES

Much speculation exists on the cause of inhalant abuse. Its popularity appears to be based on the fact that the substances are easily accessible to young people. The products used are fairly easy to hide, fairly inexpensive, easily attainable, and, for the most part, legal. Therefore, inhalants are readily becoming the drugs of choice. Many adolescents are becoming interested in the instant gratification huffing offers, while others engage in huffing merely because their friends are doing it. However, one subgroup of young people who abuse inhalants do so because they have seen their parents or older siblings abuse illegal drugs, and these young people have decided that huffing is the activity they choose to begin their drug use and addiction.

TREATMENT

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The medical care of patients with inhalant-related psychiatric disorders encompasses many areas. A team of medical professionals must work in unison to ensure that every aspect of the treatment plan is fulfilled. Patients likely require hospitalization. Especially if the patient is delirious, suicidal, homicidal, or gravely disabled. As inpatients, they may require the administration of medications (eg, haloperidol, risperidone, carbamazepine) to relieve any psychosis related to the chemicals inhaled. Counseling (supportive therapy) should be initiated, along with patient education to explain the dangers of huffing. Evaluate patients for psychiatric comorbidity. No controlled studies have been performed to guide the treatment of patients who abuse inhalants and who have inhalant dependence. Additionally, no specific medications indicated by the pharmaceutical industry are available for detoxification from inhalants. Programs are available that specifically treat inhalant abuse; however, they are rare and difficult to find. Therefore, treatment planning most often is tailored much like that of the treatment of patients with chemical dependence, in which the first step is to detoxify the patient. Patients who are addicted to inhalants experience withdrawal symptoms similar to those of any other patient addicted to drugs, including tremors, chills, sweats, cramps, nausea, and hallucinations. Next, a peer system is established. Once these 2 tasks are accomplished, assess the patient for physical, cognitive, and neurologic problems. If any problems are noted in these areas, they must be treated immediately. Identify any strengths the patient has and build on these strengths to increase them and to create new additional strengths for the patient. Address any other problems they may have. The goals are to return the patient to the community with a drug-free peer network and to continue or enhance self-support. Treat any conduct problems noted. Once the patient is detoxified, evaluate for other psychiatric illnesses using the DSM-IV-TR. The patient should participate in group therapy sessions, 12-step programs/chemical dependency groups, rational-emotive therapy, cognitive behavior therapy, and family therapy. Discuss safe sex with the patient, including partner precautions and birth control. In addition, the family should receive education about the disorder, secure substances that could be huffed, and become familiar with local mental health laws regarding commitment policies. No medications should be used unless a treatable DSM-IV-TR diagnosis has been identified.

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If the patient has depression independent of the inhalant abuse, treat with the antidepressant of choice. If the patient abuses alcohol in addition to inhalants, disulfiram (Antabuse) or naltrexone can be used in appropriate settings. If the patient meets DSM-IV-TR criteria for attention-deficit/hyperactivity disorder, a psychostimulant such as pemoline (Cylert) can be used for treatment. The United States Food and Drug Administration (FDA) concluded that the overall risk of liver toxicity from pemoline outweighs the benefits. In May 2005, Abbott chose to stop sales and marketing of their brand of pemoline (Cylert) in the United States. In October 2005, all companies that produced generic versions of pemoline also agreed to stop sales and marketing of pemoline. If the patient is psychotic as a result of the inhalant abuse (inhalant-induced psychosis), the physician may use an appropriate antipsychotic such as haloperidol (Haldol) or risperidone (Risperdal), with or without a benzodiazepine. This is the physician's choice. If the patient has an inhalant-induced mood disorder, detoxification is recommended, without the use of any medications unless the depression persists for longer than 2-4 weeks after withdrawal. Detoxification is also recommended for patients who are experiencing inhalant-induced anxiety; however, the use of sedatives or antianxiety medications is contraindicated because inhalant intoxication can worsen if the patient uses again. If the patient cannot maintain sobriety, the physician should consider residential treatment options, which can last anywhere from 3-12 months. Most persons who abuse inhalants receive most of their medical care in local emergency departments after they have either passed out or become psychotic from chemical inhalation. In the emergency department, they receive supportive care, social interventions, and appropriate medical care.