Inhalant Abuse: Nursing Implications



Inhalant Abuse

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Compiled by Tamara Espejo, RN, MS

4.0 Contact Hours

California Board of Registered Nursing CEP#15122

Key Medical Resources, Inc.

6896 Song Sparrow Rd, Eastvale, CA 92880

951 520-3116 FAX: 951 739-0378

Disclaimer: This packet is intended to provide information and is not a substitute for any facility policies or procedures or in-class training. Legal information provided here is for information only and is not intended to provide legal advice. Each state or facility may have different training requirements or regulations. Participants who practice the techniques do so voluntarily. Information has been compiled from various internet sources as indicated at the end of the packet.

Title: INHALATION ABUSE

4.0 C0NTACT HOURS CEP #15122 70% is Passing Score

Please note that C.N.A.s cannot receive continuing education hours for home study.

Key Medical Resources, Inc. 6896 Song Sparrow Rd., Corona, CA 92880

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Title: INHALATION ABUSE

Self Study Module 4.0 C0NTACT HOURS

Choose the Single Best Answer for the Following Questions and Place Answers on Form:

1. Products commonly abused by inhaling include all of the following except: A. Lighter fluid, gas, butane B. Paint, air fresheners, laughing gas C. Asthma inhalers, nail polish, hair spray D. Oxygen, ipecac, epinephrine

2. The appeal of using inhalants includes: A. Longer onset of effect B. More challenging to obtain C. Status because of rising cost D. Quality and pattern of the high

3. Characteristics of youths likely to start using are: A. Emotionally stable B. Resistant to peer pressure C. Supportive family D. Risk taker

4. The process of inhaling vapors from an open container is called: A. Huffing B. Sniffing C. Spraying D. Bagging

5. The term for groups of inhalant abusers, most likely to be involved in serious legal offenses, is: A. Transient social B. Transient isolate C. Chronic isolate D. Chronic social

6. Inhalants are absorbed into the blood from the alveoli. A. True B. False

7. Signs of inhalant abuse include all of the following except: A. Constantly smelling B. Clothing—sleeves C. Increased appetite D. Red or runny eyes and nose E. Sores around the mouth

8. Inhalant intoxication can develop within: A. 5 minutes B. 10 minutes C. 15 minutes D. 20 minutes

9. "Tolerance" means that inhalers can use less frequently and in lesser amounts to get the same effect. A. True B. False

10. Cardiovascular effects from inhalant usage include: A. Vasoconstriction B. Bradycardia C. Cardiomyopathy D. Pharyngitis

11. A diagnostic evaluation of an inhalant abuser should include all of the following except: A. ECG B. Neuropsychologic testing C. Bone scan D. MRI

12. A routine drug screen can detect inhalant usage. A. True B. False

13. Asphyxiation from inhaling is caused from displacement of available oxygen in the lungs. A. True B. False

14. "Sudden Sniffing Death" can occur the first time someone uses inhalants. A. True B. False

15. Long term consequences of inhaling include: A. Suicide B. Choking C. Suffocation D. Dementia

16. Guidelines for parents trying to prevent their children from using inhalants include having children do as they are told rather than making their own judgments and fostering independence. A. True B. False

17. According to the American Academy of Pediatrics website, the following steps can help prevent your child from turning to inhalants, EXCEPT: A. Set a good example at home B. Help your child develop different interests C. Help your child resist peer pressure D. Do not talk about drugs with your child E. Build self-esteem and confidence.

18. Inhalant abuse is the 4th most common form of drug abuse by adolescents. A. True B. False

19. Sudden sniffing death occurs when sniffing household products stops oxygen from reaching the brain and other organs. A. True B. False

20. Inhalants are substances whose vapors can be inhaled to produce a mind-altering effect. A. True B. False

21. Death from inhalant abuse can occur after a single use or after prolonged use. A. True B. False

22. Users may also inhale from balloons filled with nitrous oxide or other devices such as snappers and poppers in which inhalants are sold. A. True B. False

23. Inhalants combined with alcohol, sleeping pills, or other illicit drugs decrease the risk of death. A. True B. False

24. Inhalant abusers may spray chemicals into plastic bags or onto rags and hold them over their mouth and nose, causing skin breakdown. A. True B. False

25. Detoxification can take up to 40 days after which the patient will be completely cured. A. True B. False

Title: Inhalant Abuse

Self Study Module 4.0 C0NTACT HOURS

Please note that C.N.A.s in California cannot receive continuing education hours for home study.

Objectives

At the completion of this program, the learners will:

1. Define inhalants

2. Identify classes and examples of inhalants

3. Recognize reasons why youths are using inhalants

4. Acknowledge inhalant practices by gender and ethnicity

5. State methods of inhalation and the most frequent site of usage

6. Explain the effects of inhalants on the body

7. Define inhalant intoxication, withdrawal, tolerance and addiction

8. Identify emergency treatment

9. Recognize fatal and long-term consequences of inhaling

10. Correlate the relationship of inhalant abuse and delinquent behavior

11. List three clinical/nursing interventions to assist the patient who abuses inhalants

12. Complete exam components at a 70% competency

Introduction

Inhalant abuse is a growing trend and it can be challenging to recognize the early warning signs, which makes it more difficult to treat. Recognizing the signs and symptoms of inhalant abuse is an important assessment tool of any health care provider. As an important aspect of health promotion in the pediatric and adolescent population, screening efforts should address conditions that cause significant morbidity and mortality before it becomes life threatening.

According to the American Family Physician (AFP) about one-quarter of school aged children 'huff'. In addition, the AFP revealed that the average age of children is 12 years of age when they first see or hear about a classmate who huffs.

There are an alarming number of youths inhaling chemicals for euphoric purposes. Previously considered a drug of adolescents, inhalants are being used increasingly by preteen aged children, some as young as 5 and 6years old. Cheap and abundant, inhalants are an easy way for youths to "get high". These substances are physically and psychologically addicting and can cause death.

Nurses need to be able to recognize the signs of inhalant abuse. This is especially important, because most abusers seek help for medical or psychological problems, without mentioning the source of the problems—Inhalants.

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Statistics

Inhalants have been used throughout history to alter consciousness. Statistics from 2008 show a decline in the use of inhalants by youths. In the past decade there has been a concerted effort to educate healthcare professionals, educators, law enforcement, retailers, youths and parents about inhalants. Although there is a decline in overall usage, inhalants are being used by a significant number of school children. For example, more than 15% of eighth graders have used inhalants. Another statistical "red flag" is that there is a decline in the number of youths who do not perceive using inhalants are detrimental.

Monitoring the Future (MTF) is an ongoing study for the National Institute of Drug Abuse (NIDA) of the behaviors, attitudes, and values of American secondary school students, college students, and young adults. The following is from the 2008 data:

• Drug usage--Each year, a total of 50,000 8th, 10th and 12th grade students are surveyed. The 2008 MTF marks the sixth year in a row that illicit drug use among 8th, 10th, and 12th graders remained stable or decreased. In particular, the proportion of 8th and 10th graders reporting the use of any illicit drug in the prior 12 months declined significantly from 2007 to 2008. The decrease in illicit drug use among 8th graders continues a decline begun in 1997, but this is the first significant decline among 10th graders since 1998.

• Inhalant usage--In 2008, inhalant use among 8th and 10th graders was the lowest seen in these grades since their addition to the survey in 2001. Among 8th graders, lifetime* use decreased from 17.1% in 2007 to 15.2% in 2008, and from 15.2% to 13.5% among 10th graders. Use rates among 12th graders were at their lowest in about 20 years.

• Perceived risk of inhalants--However, the 2002 survey reported a decline among 8th graders in the perceived risk of trying inhalants once or twice, and the perceived risk of regular use of inhalants also decreased among 10th graders. Historically, changes in "perceived risk" tends to predict increases or declines in use rates for following years.

*"lifetime" refers to using the drug at least once during a respondent’s lifetime.

Prevalence of Inhalant Abuse

Most children and adolescents say they are aware of people who breathe in fumes of household products such as glue, paint, or cleaners, and nearly 25% say their friends 'huff' according to the American Academy of Pediatrics who sponsored a survey on inhalant abuse.

The survey found that 62% of the 10 to 17 year-olds surveyed know what huffing is. Only 67% of children 10 to 11 years of age have learned about inhalants in the classroom, and only 48% have talked with their parents about inhalant abuse. But, this age group is the most likely to have been personally exposed to inhalants.

The abuse of inhalants is widespread across the United States; however, it may be underreported because law enforcement officials and healthcare providers are often unfamiliar with the signs of inhalant abuse. Almost 17 million individuals have experimented with inhalants at some point in their lives.

Inhalants are the 4th most abused substances in the United States among 8th, 10th, and 12th graders; alcohol, cigarettes, and marijuana are the top three according.

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Facts About Inhalant Abuse

Users inhale vapors from a wide range of substances found in more than 1,000 common household products. Inhalants are breathed in through the nose or mouth in a variety of ways. Abusers begin by inhaling deeply; they then take several more breaths. Abusers may inhale, by sniffing or snorting, chemical vapors directly from open containers or by huffing fumes from rags that are soaked in a chemical substance and then held to the face or stuffed in the mouth. Other methods include spraying aerosols directly into the nose or mouth or pouring inhalants onto the user’s collar, sleeves, or cuffs and sniffing them over a period of time, such as during class. In a practice known as bagging, fumes are inhaled from substances sprayed or deposited inside a paper or plastic bag.

Alternatively, the fumes may be discharged into small containers such as soda cans and then inhaled from the can. Users may also inhale from balloons filled with nitrous oxide or other devices such as snappers and poppers in which inhalants are sold.

Inhalants are substances whose vapors can be inhaled to produce a mind-altering effect and can be categorized as:

• Volatile solvents are liquids that vaporize at room temperature when left in unsealed containers. They are found in gasoline, felt-tip markers, paint thinners, correction fluids, some nail polish removers, degreasers, and glues.

• Aerosols are spray containers containing propellants and solvents such as toluene. Common aerosols include hair spray, vegetable oil sprays used in cooking, whipping cream, paint, deodorant and fabric protector. Silver and gold paint are especially popular among inhalant abusers.

• Gases are substances with no definite shape or volume. Abusers inhale gases found in butane lighters, air conditioning units, ether, nitrous oxide, and propane tanks. The most commonly abused gas, nitrous oxide, is found in whipped cream dispensers and products that boost octane levels in racing cars. It is also sold at raves or drug paraphernalia stores in the form of balloons or as vials called "whippets"

• Nitrites such as cyclohexyl nitrite, amyl nitrite, and butyl nitrite are used mainly to enhance sexual experiences. They are available in adult bookstores and over the internet. Cyclohexyl nitrite is also found in room deodorizers.

Abusers use several different techniques to inhale:

• "Huffing" involves inhaling vapors from a cloth soaked in a volatile substance, which is then held over the mouth and nose. Huffing is preferred by 60% of youths;

• "Sniffing" implies inhaling vapors from an open container. Sometimes a substance such as glue is heated in a frying pan. Other times a small confined area, such as a closet or automobile, is filled with vapors such as butane;

• "Spraying" implies spraying an aerosol directly into the mouth;

• "Bagging" refers to placing the volatile substance into a plastic bag which is then held over the mouth and nose.

The above products are usually a mix of toxic and poisonous chemicals. Many have a strong smell and inhalants are not illegal drugs like cocaine or crack. Instead, they are used for specific purposes like cleaning, making model airplanes, or fueling cars. If used correctly, inhalants are generally safe for their intended purpose. Like illegal drugs, inhalants are dangerous for people to take into their bodies. Youths are divided between those who experiment with inhalants (50%) and those who were heavy users (50%).

|Street Terms for Inhalants |

|Amys |Bang |

|Bolt |Boppers |

|Bullet |Climax |

|Glading |Gluey |

|Hardware |Head cleaner |

|Hippie crack |Kick |

|Locker room |Poor man's pot |

|Poppers |Rush |

|Snappers |Toncho (octane booster) |

What are the Effects?

Inhalants act like a poison once inside the body. When someone sniffs or huffs, the toxic gases rush into the lungs, where it is rapidly transported to the pulmonary alveoli. The alveoli have a large capillary network that promotes the absorption of inhaled substances into the blood. Then the gases speed into the bloodstream to carry the poisons into the muscles and organs such as the brain, heart, kidneys, and liver. Once the inhalant binds with hemoglobin, (a compound in the blood that carries oxygen), it will prevent the blood cells from picking up oxygen in the lungs. As a result, the oxygen cannot reach the brain and suffocates the person who huffs the toxic chemical. Due to their easy absorption into fat, solvents are readily transported to the brain. They have direct effects on both the central nervous system (brain and spinal cord) and the peripheral nervous system (nerves throughout the body).

Some of the inhalants leave through the lungs, kidneys, and skin. You can actually smell an inhalant odor on an abuser’s skin or breath. Most of the inhalant—but not necessarily all of it—leaves the body within two weeks. Some of the toxic chemicals are stored in the body’s fat forever. They remain in the fatty tissue of the brain, nervous system, kidneys, liver, heart, and muscles and can cause permanent damage.

Death from inhalant abuse can occur after a single use or after prolonged use. The most serious hazard for inhalant abusers is a syndrome called 'sudden sniffing death', which may result within minutes of inhalant abuse from irregular heart rhythm leading to heart failure and death. Other causes of death include asphyxiation, aspiration, or suffocation. A user who is suffering from impaired judgment may also experience fatal injuries from motor vehicle accidents or sudden falls. Chronic exposure to inhalants causes widespread and long-lasting damage to the nervous system and other vital organs. The toxic chemicals damage parts of the brain that control learning, movement, vision, and hearing. Damage to the heart, lungs, liver, and kidneys may be permanent.

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Inhalant intoxication can develop within 5 minutes and generally subsides in approximately one hour. The inhalant abuser that has recently been inhaling typically presents with a disheveled appearance, chemical odor on the breath and clothes, and stains on skin and clothes.

Why are Inhalants Used?

Healthcare professionals, teachers and parents have difficulty understanding the appeal of inhalants to youths. The following are some of the reasons they have been found to be appealing:

• A rapid onset of effect--A "high" is reached within a few minutes of inhaling, much quicker than an alcohol induced high. Youths often want instant gratification and inhalants provide this;

• Quality and pattern of the high--Abusers describe effects such as euphoria, giddiness, and lightheadedness. Some users experience a surge of creativity; others describe feelings of excitement;

• Low cost--Many who abuse inhalants have limited incomes or are children who do not have the financial means to purchase other drugs. Poverty and lack of opportunity potentiate inhalant use;

• Easy to conceal--Youths frequently carry the product they abuse with them, often for use in the classroom or at social functions. Parents’ unfamiliarity with the abuse potential of inhalants contributes to their attractiveness for youngsters. They are easy to conceal from parents, there are no dealers, no paraphernalia, no needles or track marks; just a small container of frequently used products such as nail polish;

• Legality--Purchase and possession of these substances is not restricted or illegal in most areas. Some states have laws that prohibit the inhalation of these products in public places;

• Easily available--Inhalants are different from other drugs in that they are not sold illegally on street corners, parking lots and malls. Inhalants can also be purchased in numerous retail stores and sometimes are shoplifted or used in retail stores, without purchasing. Inhalants are in many rooms in our homes.

Some nitrite abusers (who tend to be adults rather than adolescents) seek to enhance the sexual experience. Inhaled nitrites dilate blood vessels, increase the pulse rate, and produce a sensation of heat and excitement that can last several minutes.

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Characteristics of Users

Parents frequently deny the possibility that their child has used inhalants. Children without support systems and positive coping mechanisms frequently look to inhalants as a method of escaping their problems. Such youths may have the following characteristics:

• Emotional stress - Sometimes a crisis has recently occurred either at school or at home;

• Dysfunctional Home - Frequently one or both parents use alcohol or drugs;

• Risk taker - Youths are frequently risk takers and use inhalants even though they have heard of the detrimental effects. Typically, they do not believe the effects will apply to them;

• Low self esteem - These individuals have a low opinion of themselves and are often vulnerable to peer pressure.

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Gender and Inhalant Use

A decade ago, inhalants were considered a drug abused by males. According to studies, these demographics have changed:

• There are no gender differences in age of onset of inhalant use, lifetime frequency of inhalant use, frequency of inhalant use in the past, or preferred method of using inhalants;

• There is a continued increase of inhalant use among females compared to males.

Ethnicity

Literature from the 80’s described the typical user of inhalants as a Native American or Hispanic male. New data has found that there is a strong pattern of decreases in inhalant use among Native American adolescents over the last decade.

Data indicates that a number of social and perceptual correlates of inhalant use operate similarly across Mexican American, Native American and non-Latino white adolescents. Peer factors appear dominant, although they are somewhat less important for Mexican American and Native American youths. Increased perception of harm has reduced inhalant use for all groups.

Reporting of inhalant usage is also affected by ethnic background. White youths (36.1%) and youths from other ethnic backgrounds (44.4%) are significantly more likely to report past inhalant use than African-American youths (1.4%).

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Where Do Inhalers Use?

Research shows that 60% of youths reported using inhalants with friends present, whereas 40% used inhalants when they were alone. Sites where youths reported inhalant use include:

• at a friend’s home (68%),

• at their own home (54%),

• on the street (40%),

• at parties (28%),

• on school grounds (26%)

• at school (18%)

Researchers categorize people who abuse substances on the basis of length of abuse and whether they use such substances alone or in the presence of others.

Transient abusers have a short-term history of abuse:

• Transient social abusers tend to be preteens or teenagers who use substances in the presence of others. Legal problems include minor offenses while intoxicated;

• Transient isolate abusers are in the same age group but tend to abuse solvents while alone. This group is unlikely to have legal problems.

Chronic abusers have used for years:

• Chronic social abusers tend to be in their 20’s and 30’s and have used substances in the presence of other for years. Legal problems include misdemeanors;

• Chronic isolate abusers are in the same age group, but abuse drugs while alone. Legal problems include significant offenses including assaults.

Chronic abusers of inhalants often starting using inhalants early in life, but instead of moving on to other drugs, choose a certain inhalant as their drug of choice. For example, they may choose to use only gold spray paint.

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Signs of Use

Signs of inhalant abuse can include:

• Unusual breath odor or chemical odor on clothing

• Sitting with a pen or marker near the nose

• Slurred or disoriented speech

• Anxiety, excitability, irritability or restlessness

• Drunk, dazed or dizzy appearance

• Constantly smelling clothing sleeves

• Showing paint or stain marks on the face, fingers or clothing

• Hiding rags, clothes or empty containers (such as air fresheners) of the potentially abused products in closets and other places

• Signs of paint or other products where they wouldn’t normally be, such as on the face or fingers

• Red or runny eyes or nose

• Spots or sores around the mouth

• Nausea or loss of appetite

• Lack of coordination

• Nausea or loss of appetite

• Failing grades, chronic absence and general apathy

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Withdrawal - Tolerance - Addiction

According to the APA, a withdrawal syndrome has been described that can begin 24-48 hours after cessation of use and last from 2 to 5 days. Symptoms include sleep disturbances, tremor, irritability, diaphoresis, nausea and fleeting illusions. Youths often complain of headaches or abdominal cramps. Parents and healthcare personnel often think these symptoms are simply symptoms of "the flu."

Additional symptoms exhibited by long-term inhalant abusers include weight loss, muscle weakness, disorientation, inattentiveness, irritability, and depression. Withdrawal symptoms include:

← Sweating

← Rapid pulse

← Hand tremors

← Insomnia

← Nausea

← Vomiting

← Grand mal seizures

← Liver disease (hepatitis or cirrhosis)

← Acute or chronic renal failure

← Sleep disturbances

← Bone marrow depression

← Cardiac arrhythmias

← Respiratory damage (lung or sinus damage, pneumonitis, emphysema, ling changes or respiratory depression)

If users inhale these substances continually and increase the amounts, they will develop a tolerance. This means that they will have to use the inhalants more frequently and in greater volume to get the desired effect. Recurrent inhalant use may result in the individual giving up or reducing important social, occupational or recreational activities. Also, substance use may continue despite the individual’s knowledge of physical problems (e.g., liver disease, central and peripheral nervous system damage) or psychological problems (e.g., severe depression). The potential for addiction as well as psychological dependence is high.

Assessment

Careful assessment of persons who are potentially using inhalants is vital in helping individuals avoid the serious complications. Due to the variety of health problems associated with inhalant use, and the vagueness of many of the symptoms of use, a thorough assessment is necessary.

Clients can be encountered in a number of health care settings, including schools, clinics, psychiatric or addictions counseling environments, emergency rooms and throughout the acute care settings. Sometimes inhalers are referred for healthcare assessment by the legal system or social service agencies.

The assessment process should include a history, physical, psychological and diagnostic evaluation.

History

The quality and quantity of data elicited will depend on the practitioner’s sensitivity to the client. The practitioner’s communication style is adapted to specific circumstances. If the client is intoxicated, the interview may have to be conducted after detoxification. Completing a history may be difficult and frequently must be carried out over a period of time. This is necessary to distinguish between manifestations that are due to intoxication versus long-term complications. Information must be collected on the inhalant abused; the manner, duration, and frequency of abuse, and the use of other chemicals—such as alcohol—in addition to the inhalant. Sample questions include:

• At what age did you start inhaling?

• When did you last inhale?

• Have you ever passed out from inhaling?

• Have you experienced hallucinations?

• Do you notice a decrease in your ability to concentrate?

• Is it difficult to stop huffing once you have started?

✓ In addition to obtaining a medical history that asks questions pertaining to the effects of inhalants, it is recommended that the person who is performing the assessment obtain information pertaining to childhood disease, history of injuries and acute or chronic infections (including STDs). Clients under the influence of chemicals often do not take precautions to protect themselves from sexually transmitted disease. Additionally, the client should be requested to sign a release of medical information. Depending on the age of the client, some of the data may need to be obtained from a parent /guardian. The following collaborative information is helpful:

✓ Change in behavior or attendance at school; teachers will frequently report a change in grades or conduct in the classroom

✓ Arrest for substance abuse offense.

✓ Youths frequently display deviant, disruptive or delinquent behavior

✓ Personality changes

Physical Assessment

Manifestations vary, depending on the types of inhalants, amount of substances used and the duration of the use. The physical assessment should include objective and subjective data. The following systems should be assessed. Objective data should be collected with consideration for the possibility of the following disorders:

• Cardiovascular - After a solvent is inhaled, a peripheral vasodilatation results, with variable degrees of hypotension and reflex tachycardia. Chronic exposure to volatile substances may cause dilated cardiomyopathy or myocarditis and additionally cases of cardiac arrhythmias and myocardial infarction;

• Neurologic - Cerebral cortex damage can cause changes in personality, memory loss, hallucinations and learning problems. Cerebellum damage can cause problems in balance and movement. Hippocampus damage may result in memory problems. Peripheral neuropathy has been reported secondary to chronic inhalant abuse;

• Respiratory - Coryza, pharyngitis, and pulmonary failure from aspiration are consequences of inhaling. Rales, rhonchi, bronchitis and pneumonia may be noted. The diagnosis of Inhalant abuse is often missed, and the respiratory condition may be treated without an evaluation of the cause;

• Gastrointestinal - Nausea, vomiting, and abdominal pain may be noted during intoxication and withdrawal. Manifestations of chronic abuse include anorexia and weight loss. Impaired liver function may be noted;

• Musculoskeletal - Muscle weakness has been noted from using products that contain toluene, such as lacquer thinner;

• Urological - The renal tubules may suffer damage from inhalants, altering electrolyte levels;

• Hematology - Bone marrow depression is a complication of inhalant abuse. Toxic effects of inhalant abuse include anemia, thrombocytopenia, leukemia, and hemolysis;

• HEENT - Often the inhalant is placed in a plastic bag and the fumes are inhaled by mouth (huffing). This causes sores in the mouth or a rash around the mouth. Sniffing causes chronic nosebleeds and sores in the nose. Freezing of the lips and mouth can occur when the substance is inhaled directly from a cylinder. Other manifestations include tinnitus, sneezing, hyper salivation and conjunctival irritation.

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Psychological Assessment

The inhalant abuser may appear apathetic or belligerent and exhibit impaired judgment. Family and school officials often dismiss these manifestations as just adolescent behavior. Other behaviors to observe for include:

• Difficulty concentrating

• Irritability

• Depression

• Apathy

• Hostility

• Violent temper outbursts

• Paranoia

• Hallucinations

• Anxiety

• Lack of motivation

• Mood swings

Specific questions should be asked in the following areas:

• Previous suicidal ideation/plan

• Actual suicide attempts in past (dates and methods)

• Current suicidal ideations/plan

• Previous psychiatric care/current psychiatric care

• Symptoms of depression

• Recent loss of significant others, including pets

• Feelings of hopelessness/helplessness

• Sleep and appetite disturbances

• Social withdrawal

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Diagnostic Evaluation

• Inhalant users should be assessed with computed tomography (CT) and magnetic resonance imaging (MRI) studies of the brain. Most inhalants contain solvents which target and dissolve fatty tissue in the brain, liver, kidneys and adrenal glands. New research suggests inhalants also dissolve the myelin sheath of neurons in the brain;

• Inhalants are not detected by routine drug screens, but a routine drug screen is recommended to rule out other drugs. Laboratory identification of inhalant abuse most often requires analysis of body fluids by gas chromatography;

• A complete blood count (CBC) should be performed to determine if any of the following are present: infection, anemia, leukocytosis, thrombocytopenia, thrombocytosis, or platelet defects;

• Creatinine, blood urea nitrogen (BUN) and urinalysis to assess kidney function should be included in the workup;

• Serum electrolytes should be assessed to determine if there is an electrolyte imbalance such as hypercholeremia, hypokalemia and hypophosphatemia;

• Electrocardiogram (ECG) and chest x-ray should be used to determine heart and lung damage;

• Visual and auditory-evoked potentials are abnormal in children who have significant abuse history;

• Neuropsychologic testing is recommended.

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Fatal Consequences of Inhalant Use

Death from using inhalants can occur from several factors:

• Injury - Impaired judgment is a consequence of inhalant abuse. Inhalers have been known to try and swim across a river or fly off a building;

• Asphyxiation and Suffocation - Asphyxiation is caused from repeated inhalations, which lead to high concentrations of inhaled fumes displacing the available oxygen in the lungs. Suffocation occurs from blocking air from entering the lungs when inhaling fumes from a plastic bag placed over the head;

• Choking - Users can choke on their own vomit;

• Suicide - A frequently used method of inhalation is for the abuser to place a plastic bag over the head or wrap the body in plastic with the inhalant enclosed. As a result, the inhaler passes out from the inhalant and suffocates to death;

• Sudden death - Sudden death is caused from a cardiac arrhythmia. According to Harvey Weiss, director of the National Inhalant Prevention Coalition, "Inhalants can cause serious central nervous system damage and death. They sensitize the heart to adrenaline, so a sudden rush of adrenaline, combined with inhalant use, can make the heart stop instantly. This phenomenon is known as sudden sniffing death syndrome and can occur the 1st, 10th, or 100th time someone uses an inhalant." Sudden sniffing death, as it is called, is responsible for more than half of all deaths due to inhalant abuse.

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Long Term Consequences

• Kaposi’s Sarcoma - Amyl and butyl nitrates have been associated with Kaposi’s sarcoma, the most common cancer reported with AIDS patients. Early studies of Kaposi’s sarcoma showed that many people with Kaposi’s sarcoma had used volatile nitrates. Researchers are continuing to explore the hypothesis that nitrates are a contributing factor to the development of Kaposi’s sarcoma in HIV-infected people;

• Inhalant Induced Persisting Dementia - In order for this type of dementia to be diagnosed, there must be evidence from the history, physical exam or laboratory findings that the deficits are etiologically related to the persisting effects of inhalants. This disorder is termed "persisting" because the dementia persists long after the individual has experienced the effects of inhalant intoxication and withdrawal;

• Burns - The highly flammable nature of inhalants leads to burns. Inhalants cause impaired judgment. Youths have received burns from lighting a cigarette while inhaling, or, in rural settings, throwing a used inhalant container in a bonfire;

• Developmental harm to fetuses - Abuse of inhalants during pregnancy may place infants and children at increased risk of developmental harm.

o Further, in these children report some evidence of retardation in growth and development and residual deficits in cognitive, speech, and motor skills;

o There is also some limited evidence of neonatal withdrawal from inhalants. It is recommended that infants born to women who have recently used inhalants be observed carefully for an alcohol-like withdrawal syndrome;

o Although it is not possible to link a specific birth defect or developmental problem in the child of an inhalant abuser to prenatal exposure to a specific chemical, it is clear that inhalant abuse places children at increased risk. Animal studies, designed to simulate human patterns of inhalant abuse, suggest that prenatal exposure to toluene or trichlorethylene (TCE) can result in reduced birth weights, occasional skeletal abnormalities, and delayed neurobehavioral development;

o A number of case reports note abnormalities in newborns of mothers who chronically abuse solvents. There is also evidence of subsequent developmental impairment in some of these children. However, no well-controlled, prospective study of the effects of prenatal exposure to inhalants in humans has been conducted, and it is not possible to link prenatal exposure to a specific chemical to a specific birth defect or developmental problem.

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Delinquent Behavior & Inhalant Use

More minor criminal activity has been reported among inhalant users and experimenters in upper (9-12) grade level students, than other drug users and experimenters of the same age. There is a similar trend for "trouble behavior." Again, the same was not found for drinking and drug-taking behavior.

The findings suggest that inhalant use is categorically different from other drug use, and that it has more in common with general delinquency than with general drug use.

Addiction Treatment Effectiveness

Treatment facilities for inhalant abusers are hard to find.

Program directors of drug user treatment programs have been surveyed, and the research shows that they perceive a great deal of neurological damage incurred through inhalant use. They also have a general pessimism about treatment effectiveness and recovery.

Detoxification averages 40 days and treatment for inhalant abusers is usually long-term, sometimes as long as 2 years. It must address the many social problems most inhalant abusers have and involves:

• Support of the child's family

• Moving the child away from unhealthy friendships with other abusers

• Teaching and fostering better coping skills

• Building self-esteem and self-confidence

• Helping the child adjust to school or another learning setting

Relapse

Patterns leading to addiction are hard to erase, and recovering from inhalation abuse involves more than simply abstinence. Inhalant abusers have high relapse rates, making aftercare and follow-up extremely important. During treatment, many of the stresses of everyday life are removed. Returning to the previous life may produce all of the old problems.

The warning signs of relapse include returning to old habits, friends, hangouts or denial. An example of denial is "I no longer have to worry about using inhalants." Without on-going support, the person’s coping mechanisms may be too fragile to resist returning to old patterns.

The following are recommended:

• Aftercare - Aftercare takes a variety of forms. It often includes a structured plan for relapse prevention and active participation in treatment issues. For many users, treatment must continue for an extended period of time—possibly up to two years.

• Support Group - Groups such as NA or AA use a 12-step approach to help the recovering person develop a different life style. Hearing the facts from those who are recovering and are willingly making the commitment to achieve a drug-free lifestyle is a particularly effective part of the person’s support.

• Sponsor - Each newly recovering person will benefit from having a sponsor. A sponsor is a recovering person who is always available to the new member by telephone for encouragement, for clarification, and as a sounding board, particularly during the early stages of recovery.

Youths need empathetic health care professionals who are committed to helping them receive appropriate treatment. They also need acceptance and understanding as they begin their recovery.

General Clinical/Nursing Interventions

During the acute phase of inhalation intoxication and detoxification, care focuses on maintaining the patient's vital functions, ensuring his/her safety, and easing discomfort. During the rehabilitation, caregivers help the patient acknowledge his/her substance abuse problem and find alternative ways to cope with stress. Health care professionals can play an important role in helping patients achieve recovery and stay drug-free. The following are clinical/nursing interventions that are appropriate for patients during and after acute intoxication:

During an Acute Episode:

Continuously monitor the patient's vital signs and urine output

Maintain a quiet safe environment. Remove harmful objects from the room.

Institute appropriate measures to prevent suicide attempts and assaults,

according to facility policy

Approach the patient in a nonthreatening way. Limit sustained eye contact which s)he may perceive as threatening

Implement seizure precautions

Give medications, as ordered, monitoring and recording their effectiveness. Medications may include Haldol (for severe agitation), sedatives (to induce sleep), anticholinergic and antidiarrheal agents (to relieve GI distress), antianxiety Rx.

During Drug Withdrawal:

← Administer medications, as ordered, to decrease withdrawal symptoms, monitoring and recording their effectives

← Maintain a quiet, safe environment because excessive noise may agitate the patient.

When the Acute Episode Has Resolved:

✓ Carefully monitor and promote adequate nutrition

✓ Administer drugs carefully to prevent hoarding. Check the patient's mouth to ensure that (s) he has swallowed oral medication. Closely monitor visitors who might supply him/her with drugs

✓ Refer the patient for rehabilitation as appropriate. Give him/her a list of available resources

✓ Encourage family members to seek help regardless of whether the abuser seeks it. Suggest private therapy or community mental health clinics

✓ Develop self-awareness and an understanding and positive attitude toward the patient. The health care professional should control their reactions to the patient's undesirable behaviors---commonly, psychological dependency, manipulation, anger, frustration and alienation

✓ Set limits when dealing with demanding, manipulative behavior

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Prevention is the Key

Prevention of inhalant abuse is the goal. This involves the entire community, including healthcare professionals, teachers, parents, peers, law enforcement and retailers. This section provides information for nurses to assist in the education of others.

Teaching children about inhalants

Children need to be able to differentiate between "good smells" (i.e., cookies baking). and "bad smells" (i.e., gas). Children who have used inhalants have said, "I had no idea that breathing in these products could hurt me." It is recommended to start anticipatory guidance early. Six year-old children are not too young to be taught the dangers of inhalants.

Talking to parents about inhalants

Parents frequently deny that inhalants could be a problem in their families, schools or communities. More than nine out of ten parents refuse to believe their children may have ever abused inhalants. While 91% of parents said they had talked to their children about substance abuse, less than half of those parents had specifically mentioned inhalants. Rural communities may deny the existence or extent of addiction, so awareness of inhalant use is often minimal.

Some states have laws to try and deal with inhalant abuse, but such laws are not always easy to enforce. Since inhalants are legal and kids can obtain them in so many different ways, it is not possible to make inhalants entirely off-limits. The American Academy of Pediatrics recommends that the best way to fight inhalant abuse is to educate children about how harmful these products are. They advocate explaining how they can cause short- and long-term health problems, further drug abuse, and death. Parents and teachers should also be able to recognize the warning signs of inhalant abuse. Some suggestions are:

✓ Do not shut children out by simply saying something is 'bad for you'.

✓ Educate yourself and then give your child the right information.

✓ Talk about dangerous behavior, such as inhalant abuse, and explain the consequences.

✓ Help your child develop refusal skills—how to say 'no'.

✓ Listen to your child. Talk with them to learn what pressures they are exposed to and what they are thinking and feeling.

✓ Ask your child questions such as 'where are you going?' or 'who will you be with?'

✓ If you think your child is into inhalant abuse, remain calm. Upsetting them may make them more violent or trigger a physical response such as sudden sniffing death. If the latter occurs, ensure a well-ventilated room and seek medical attention quickly.

Conclusion

Inhalant abuse is growing, is a frightening problem and can be challenging to recognize early. Easy accessibility and the relatively low cost of the substances abused indicate that inhalant abuse will attract new users and continue to be a problem. Although it is often a transient phase of drug experimentation, inhaling may lead to addiction or other drug usage. The statistics of inhalants usage are decreasing across America, but this is not a time to become complacent. First time usage can result in death or in permanent disability. Inhalants are dangerous poisons that were never designed for human consumption. The most effective way to prevent inhalant abuse is by educating providers, healthcare workers, teachers, and parents. Information can only increase awareness of the negative effects of inhalant abuse and may help to make this practice less appealing to our nation’s youth. Parents may not realize that they have only a few short years in which they can influence their child’s decision not to abuse inhalants.

It is important that nurses have full access to information that would help them identify inhalant abuse. The risks add up. Why do abusers take such a risk? Usually because the either are not aware of the risk or they do not think it applies to them. What the abuser fails to realize is that they are not getting 'high' but they are feeling the lack of oxygen in their brain.

Nurses need to take the leadership in assessing youth, in educating other health care professionals, educators and the public. Inhalant abuse must not remain an invisible problem. Nurses need to play an integral role in identification, prevention and education.

Classes and Examples of Inhalants

There are approximately 1400 available products that youths inhale to get high. These inhalants fall into four categories:

|Volatile solvents - These are found in various fuels and paints. |

|The glue sniffers of the 1960’s popularized this class of inhalants. Products abused in this category include gas, "goop" (a product to resole shoes), lighter |

|fluid, paint, kerosene, gun cleaning solvent, cleaning fluids, nail polish, nail polish remover, rubber cement, paint thinner, varnish, spot remover, toxic |

|markers, and propane. |

|Aerosols - These products are readily available in virtually every household. Products abused in this category include hair spray, spray paints, spray deodorants,|

|frying pan lubricants, air fresheners, freon, computer "dust-off", and fabric protectors. Asthma inhalers are also abused. Like other aerosols, they contain |

|fluorocarbons, which produce euphoric effects. Peers refer to individuals who choose this product as "spray heads." |

|Nitrates - Inhalant nitrates including amyl nitrate (street names "poppers" and "snappers"), which was originally prescribed for heart patients. Butyl nitrate |

|(street names "rush", "bolt", "locker room", "bullet" and "climax") is sold as room freshener. Nitrates are also sold as aphrodisiacs in adult bookstores and |

|through mail order catalogs. |

|Anesthetics - Products abused in this category include ether, chloroform and nitrous oxide. Nitrous oxide is commonly called "laughing gas" and used by dentists. |

|Nitrous oxide is also sold in balloons at rock concerts and available in small cylinders known as "whippets." |

The five substances most frequently used as inhalants include gasoline (by 57.4%), freon (40.45%), butane lighter fluid (38.3%), glue (29.8%), and nitrous oxide (23.4%)

Diagnostic criteria for 292.89--Inhalant Intoxication

The following is the American Psychiatric Association (APA) DSM-IV-TR (2000) criteria for inhalant Intoxication:

A. Recent intentional exposure to short-term, high dose volatile inhalants (excluding anesthetic gases and short-acting vasodilators);

B. Clinically significant maladaptive behavioral or psychological changes (for example, belligerence, assaultiveness, apathy, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, use of or exposure to volatile inhalant;

C. Two (or more) of the following signs, developing during, or shortly after, inhalant use or exposure:

1. Dizziness

2. Nystagmus

3. Incoordination

4. Slurred speech

5. Unsteady Gait

6. Lethargy

7. Depressed reflexes

8. Psychomotor retardation

9. Tremor

10. Generalized muscle weakness

11. Blurred vision or Diplopia

12. Stupor or Coma

13. Euphoria

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

According to the APA, during intoxication, acute central nervous system manifestations include euphoria accompanied with feelings of grandiosity and increased awareness, understanding and insight. Inhalers experience a distortion of space and visual perception. Common statements include "the walls are closing in" or the "the sky is falling." Some youths use inhalants specifically for their hallucinogenic effect. A popular practice is for groups of users to inhale together and then compare their hallucination. They describe such sensations as "seeing vivid colors" or "hearing sirens."

Other DSM-IV Inhalant Related Disorders

304.60 Inhalant Dependence

305.90 Inhalant Abuse

292.81 Inhalant Intoxication Delirium

292.82 Inhalant Induced Persisting Dementia

292.9 Inhalant-Related Disorder NOS

Emergency Treatment

Medical

• Airway management-- Prevention of aspiration is essential. High-flow oxygen via a mask or by endotracheal tube is recommended, if indicated;

• Vital signs and cardiac monitoring;

• IV for hydration and access for administration of emergency drugs;

• Calm environment--Inhalants cause an increased release of catecholamines leading to increased heart rate and blood pressure. If the client becomes frightened, it can lead to additional release of catecholamines;

• In the event of accidental ingestion of an inhalant, it is recommended that a nasogastric tube be placed and aspirate the stomach contents within one hour of ingestion. The contents will absorb into the bloodstream after one hour. Neither syrup of ipecac, activated charcoal or aggressive gastric lavage is recommended. Ipecac could cause aspiration of the solvent secondary to vomiting. Activated charcoal doesn’t absorb solvents well and if vomiting from activated charcoal occurs, the aspiration risk increases.

• Medication--There is no recommended medication for withdrawal of inhalant abuse. However, individual symptoms can be treated with medication for manifestations of inhalant abuse.

Mental Health

• Psychological and addiction evaluation--. The abuser may be anxious to convince healthcare personnel that they will never abuse inhalants again; denial is a common symptom of addiction. However, youths should be referred for an addiction and psychological evaluation. A psychological evaluation is necessary to rule out concurrent mental health problems.

What to Do When Someone is Huffing

. Remain calm and do not panic.

. Do not excite or argue with the abuser when they are under the

influence, as they can become aggressive or violent.

. If the person is unconscious or not breathing, call for help. CPR

should be administered until help arrives.

. If the person is conscious, keep him or her calm and in a well-

ventilated room.

. Excitement or stimulation can cause hallucinations or violence.

. Activity or stress may cause heart problems which may lead to

"Sudden Sniffing Death."

. Talk with other persons present or check the area for clues to what

was used.

. Once the person is recovered, seek professional help for abuser:

school nurse, counselor, physician, other health care worker.

. If use is suspected, adults should be frank

References

American Academy of Pediatrics: 2002, Preventing Inhalant Abuse,

American Psychiatric Association: 2000, Diagnostic and statistical manual of mental disorders (4th ed. text revision), Washington D.C.

Beauvais, Jumper-Thurman, Plested, & Helm: 2002, A survey of attitudes among drug user treatment providers toward the treatment of inhalant users, Substance Use & Misuse, 37 (11), 1391-410

Beauvais, Wayman, Jumper-Thurman, Plested, & Helm: 2002, Inhalant abuse among American Indian, Mexican American, and non-Latino white adolescents, American Journal of Alcohol Abuse, 28 (1), 171-87

Bykowski, M.:1999, Don’t miss inhalant abuse diagnosis, Pediatric News, 33 (10), 37

Cobaugh, D.:1999, Inhalant abuse, Journal of Emergency Services, 24 (10), 66-75

Cook, K.:1999, Assessment of potential inhalant use by students, Journal of School Nursing, 15 (5), 20-23

Espeland, K.:2000, Inhalant abuse, Lippincott’s Primary Care Practice, 4 (3), 336-340

Howard M. & Jenson J.:1999, Inhalant use among antisocial youth: Prevalence and correlates, Addictive Behaviors, 24 (1), 59-74

Ives R.:1997, Volatile substance misuse, Journal of Substance Misuse, 2, 54-56

Jones, H. & Balster, R.:1998, Inhalant abuse in pregnancy, Obstetrics and Gynecology Clinics of North America, 25 (1), 153-67

Lien-Munson, B.: 2002, How to recognize and treat propellant inhalation, Dimensions of Critical Care Nursing, Jan/Feb 2002, Vol 21 issue 1, p18

LoVecchio, F. & Gerkin, R.:1997, Inhalants of abuse, Topics in Emergency Medicine, 19 (4), 44-52

McPhee, A. T.:1999, High risk, Current Science, 10/8/99, Vol 85 issue 3, p10

McGarvey E., Clavet G., Mason, W., & Waite, D.:1999, Adolescent inhalant abuse: environments of use, American Journal of Drug Alcohol Abuse, 25 (4), 731-41

Mackesy-Amiti M. & Fendrich M.:1999, Inhalant use and delinquent behavior among adolescents: a comparison of inhalant users and other drug users, Addiction, 94 (4), 555-64

Munson: 2002, How to recognize and treat propellant inhalation, Dimensions of Critical Care Nursing, 21 (1), 18-19

National Clearinghouse for Alcohol and Drug Information of the United States Public Health Service: 2008

National Drug Intelligence Center, Department of Justice, 2001, Intelligence brief: huffing

National Inhalation Prevention Coalition: 2003,

National Institute of Drug Abuse: Mind over Matter,

National Institute of Drug Abuse: 2008,

National Institute of Drug Abuse, National Youth Anti-Drug media Campaign: 2008,

National Medical Society: 2008,

New Straits Times-Management Times, 20008, deadly sniff

Palmer, R.:1997, Huffers and sprayheads: managing the volatile-substance abuse patient, Emergency, 29 (6), 40-42

Preboth, Monica: 2000, Prevalence of inhalant abuse in children, American Family Physician, 02/15/2000, Vol 61 issue 4, p1206

Ravetti, L.:2000, Patient education for the recovering individual, Lippincott’s Primary Care Practice, 4 (3), 341-343

Inhalant Abuse

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