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Abuse of Organic Solvents
Abuse of Organic Solvents LoUIS A. FAILLACE, M.D., and ROBERT W. GUYNN, M.D. Intoxication caused by the inhalation of industrial solvents, airplane glue, gasoline, paint and paint thinner in adolescents has been well documented in the literature. l -" Chronic abusers of solvents have been described as being a fairly homogeneous group: usually males aged 7-17, average age 14-15, underprivileged and with a poor school performance, who have inhaled daily for years and usually stop inhaling solvents in their late teens.'; Early intentional inhalation of solvents was considered to be relatively harmless.' However, it has become increasingly clear that this view must be reconsidered"·/!-lU Grabski!! reported a patient who deliberately inhaled toluene for several years and who developed cerebellar degeneration. Several other cases have been reported with physical damage attributed to solvent abuse including cerebral damage, !2- H hepatorenal damage,!;; renal tubular acidosis,ll; and polyneuropathy.l'.lll A case of permanent brain damage due to toluene inhalation has been reported. 12 This latter patient showed clinical symptoms of ataxia, tremulousness, emotional lability and marked snout reflex accompanied by diffuse electroencephalographic changes and evidence of widespread cerebral atrophy on pneumoencephalogram. On the other hand, Satran and Dodson!:1 have described a patient who inhaled to:uene for ten years who showed diffuse electroencephalographic slowing but no apparent overt clinical abnormalities. Factors which predispose to permanent damage in some patients, but not in others, is unclear. Evidence for human addiction is available, however. For example, Lindstrom 20 and Nylander 21 have described a withdrawal syndrome similar to delirium tremens occurring after abrupt cessation of chronic inhalation.
Case report.-The following case is illustrative of the psychological dependence and acute behavioral problems caused by the inhalation of organic solvents. A 24-year-old, white middle-class male was hospitalized after a three-day binge of sniffing toluene and ingestion of an unknown quantity of mescaline and psilocybin. The patient had had one previous psychiatric hospitalization four years ago for chronic glue sniffing. The patient and family stated he had been abstinent from abusing drugs since then, except for the intermittent use of marijuana. During this period of time he was gainfully employed and had a common-law marriage of two years' duration. Four days prior to admission the patient began to sniff glue just for "kicks-to see if he could handle it again". The patient
From Department of Psychiatry, The University of Texas Medical School at Houston, 6400 W. Cullen, Houston, Texas 77025. 188
apparently convinced a paint store operator he was a contractor and obtained a gallon of toluene. He sniffed the whole gallon over several days and also ingested an unknown amount of mescaline and "mushrooms." According to his wife, once he started he sniffed almost constantly. By the third day the patient began to have visual hallucinations. However, the reason for seeking treatment was that he began to experience increasing difficulty in breathing. The patient is the middle of five children. His parents relate that the patient always had difficulty in elementary school and failed two grades. He dropped out of high school in the ninth grade even though, according to his parents, he had an IQ of 126 by testing. On admission to the hospital he was generally uncooperative. He was oriented to time, place and person when one was able to get his attention. Appearance was disheveled. Affect was labile. He was actively hallucinating. He stated that the hallucinations were pleasant. Speech was usually incoherent and his associations were loose. The patient was concerned primarily with his hallucinations. Physical examination, routine laboratory tests and EEG were within normal limits. The patient was given 100 mg. thorazine p.o. on admission. On the second day of hospitalization the thorazine was increased to 50 mg. q.i.d. His speech was still incoherent and his associations were loose. On the third hospital day the patient was more cooperative. Speech was more coherent. That evening the patient left the hospital against medical advice, and returned two days later to get his clothing. He denied taking any drugs since leaving. At that time he was cooperative, alert and oriented to time, place and person. There was no evidence of hallucinations. Speech was coherent. Associations were intact. The patient stated he was going to return to work the next day.
DISCUSSION Toluene appears to be one of the drugs of choice among juveniles who are habitual abusers of other drugs such as marihuana and heroin. They tend to use toluene when other drugs are not available. We have had reports in our own institution of patients who are drug abusers stealing toluene from the research laboratories and even sniffing scintillation vials. A clinical study in Sweden has been carried out to find the euphoria-producing drug of choice among habitual drug abusers and among hospital professionals. The hospital professionals rated marihuana as the drug of choice while habitual drug abusers rated toluene as the preferred drug. 22 What is particularly disturbing about such reports and about solvent use in general is the ready availability and virtual uncontrollability of these ubiquitous agents. In addition, the high degree of psychological dependence from inhaling organic solvents in a susceptible person is shown by our 24-year old patient. Although he was four years abstinent from inhaling toluene he rapidly deteriorated once he resumed sniffing this substance. Volume XVII
ABUSE OF
SOLYENT~FAILLACE AND
It has been estimated that 14.2% of college students have abused volatile hydrocarbons at least once." The exact extent of use among less educated, younger individuals is unknown, but is probably at least as extensive since use of solvents is generally associated with the underprivileged young.1, I... Because the abuse of solvents is relatively non-crime linked (probably because of its easy availability), the problem has been unfortunately the subject of relatively little attention. In spite of the widespread use and in spite of the relationship between solvent abuse and abuse of other drugs (as typified by our patient), there has been extremely little reported in the literature towards the acknowledgement of the extent of the problem. It is also likely that patients are seldom asked about solvent abuse simply because the extent of the problem is not realized by the average physician. "Glue-sniffing" is still very much a problem, a problem not restricted to the adolescent.
9. 10.
II. 12.
13. 14.
15.
16.
REF/:R/:'NCES I. Glaser, H. H. and Massengale, O.N.: Glue-sniffing in children. JAMA 181 :300-303, 196:!. 2. Tolan, E. J. and Lingl, F.A.: "Model psychosis" produced hy inhalation of gasoline fumes. A III. J. Psychiatry no: 757-761, 1964. 3. Ackerly, W. C. and Gihson, G.: Lighter fluid "sniffing". Alii. J. Psychiatry I:!O: 1056-1061, 1964. 4. Brozovsky. M. and Winkler, E. G. :Glue sniffing in children and adolescents. N. Y. SlIIte J. Met!. 65: 1984-1989. 1965. 5. Wyse, D. G.: Deliherate inhalation of volatile hydrocarbons: A review. (muul. M. A.Hol". J. 101!:71-74, 1973. 6. Cohen, S.: Glue sniffing. JAMA 231 :653-654, 1975. 7. Massengale. O. N., Glazer. H. H., and Lelievre, R. E.: Physical and psychologic factors in glue sniffing. N. Eng. J. Met!. :!69: 1340-1344. 1963. I!. Baerg, R. D. and Kimherg. D. Y.: Centrilobular necrosis
17.
II!.
19. :!O.
21. 2:!.
GUYNN
and acute renal failure in "solvent sniffers". Ann. Intnn. Med. 73:713-720,1970. Bass. M.: Sudden sniffing death. JAMA 212:2075-2079. 1970. Reinhardt, C. F .. Azar, A., Maxfield,M. E., Smith, P. E., Mullins, L. S. and Wilmington, D.: Cardiac arrhythmias and aerosol "sniffing". Arch. Enl'iron. Health 22:265-279, 1971. Grahski, D. A.: Toluene sniffing producing cere he liar degeneration. Alii. J. Psychiatry 118:461-46:!, 1961. Baker, A. B., and Ticky, F. Y.: The effects of the organic solvents on the central nervous system. A,HOI". Nt·s. Nnw Mellt. Dis. 32:475-505, 1953. Sat ran. R., and Dodson, Y. N.: Toluene habituation. Report of a case. N. Engl. J. Met!. :!61!:719-721. 1963. Knox, J. W., and Nelson, J. R.: Permanent encephalopathy from toluene inhalation. N. Engl. J. Mt·t!. 275: 1494-1496, 1966. O·Brien. F.. T., Yeoman. W. B.• and Hohby. J.A.E.: Hepatorenal damage from toluene in a "glue sniffer". Brit. Mal. J. 2:29-30, 1971. Taher. S. M., Anderson, R. J.. McCartney. R., Popovtzer. M. M. and Schrier, R. W.: Renal tuhular acidosis associated with toluene "sniffing". N. I:'ngl J. Met!. :!90:765. 1974. Shira he, T., Tsuda, T., Terao. A.. and Araki. S.: Toxic polyneuropathy due to glue sniffing. J. Neurol. Sci. 21: 101-113, 1974. Goto. I.. Matsumura, M.. Inoue. N., Kuroiwa. Y.• MuraL Y.. Shida, W., and Santa. T.: Toxic polyneuropathy due to glue sniffing. J. Nt'urol. NellfO.lurg. P,lycllO. 37:848-853. 1974. Heuser, M.: Toluolsuchl. Mt'd. Klin. 63: 11!88-11!90. 1968. Lindstrom, F.: Delirium tremens as a symptom in ahstinence in thinner-sniffing. S"en. Lalillrtit!n. 57: :!214-2219, 1960. Nylander. I.: "Thinner" addiction in children and adolescents. Acta. Paet!opsychi/llr. (Basel) 29: 273-284, 1962. Gottfries. I., and Hansson. K.: How does drug intoxication work') A comparison between perceptions of drug intoxication hy medical experts and 'raby' hoys. SocialIIIt·d. T. 50:515-519. 1973.
Ahstainer-a weak person who yields to the temptation of denying himself a pleasure. A total abstainer is one who abstains from everything but abstention, and especially from inactivity in the affairs of others. Ambroise Bierce The Devil's Dictionary
OctoberINovember / December. 1976
189
Case report.-The following case is illustrative of the psychological dependence and acute behavioral problems caused by the inhalation of organic solvents. A 24-year-old, white middle-class male was hospitalized after a three-day binge of sniffing toluene and ingestion of an unknown quantity of mescaline and psilocybin. The patient had had one previous psychiatric hospitalization four years ago for chronic glue sniffing. The patient and family stated he had been abstinent from abusing drugs since then, except for the intermittent use of marijuana. During this period of time he was gainfully employed and had a common-law marriage of two years' duration. Four days prior to admission the patient began to sniff glue just for "kicks-to see if he could handle it again". The patient
From Department of Psychiatry, The University of Texas Medical School at Houston, 6400 W. Cullen, Houston, Texas 77025. 188
apparently convinced a paint store operator he was a contractor and obtained a gallon of toluene. He sniffed the whole gallon over several days and also ingested an unknown amount of mescaline and "mushrooms." According to his wife, once he started he sniffed almost constantly. By the third day the patient began to have visual hallucinations. However, the reason for seeking treatment was that he began to experience increasing difficulty in breathing. The patient is the middle of five children. His parents relate that the patient always had difficulty in elementary school and failed two grades. He dropped out of high school in the ninth grade even though, according to his parents, he had an IQ of 126 by testing. On admission to the hospital he was generally uncooperative. He was oriented to time, place and person when one was able to get his attention. Appearance was disheveled. Affect was labile. He was actively hallucinating. He stated that the hallucinations were pleasant. Speech was usually incoherent and his associations were loose. The patient was concerned primarily with his hallucinations. Physical examination, routine laboratory tests and EEG were within normal limits. The patient was given 100 mg. thorazine p.o. on admission. On the second day of hospitalization the thorazine was increased to 50 mg. q.i.d. His speech was still incoherent and his associations were loose. On the third hospital day the patient was more cooperative. Speech was more coherent. That evening the patient left the hospital against medical advice, and returned two days later to get his clothing. He denied taking any drugs since leaving. At that time he was cooperative, alert and oriented to time, place and person. There was no evidence of hallucinations. Speech was coherent. Associations were intact. The patient stated he was going to return to work the next day.
DISCUSSION Toluene appears to be one of the drugs of choice among juveniles who are habitual abusers of other drugs such as marihuana and heroin. They tend to use toluene when other drugs are not available. We have had reports in our own institution of patients who are drug abusers stealing toluene from the research laboratories and even sniffing scintillation vials. A clinical study in Sweden has been carried out to find the euphoria-producing drug of choice among habitual drug abusers and among hospital professionals. The hospital professionals rated marihuana as the drug of choice while habitual drug abusers rated toluene as the preferred drug. 22 What is particularly disturbing about such reports and about solvent use in general is the ready availability and virtual uncontrollability of these ubiquitous agents. In addition, the high degree of psychological dependence from inhaling organic solvents in a susceptible person is shown by our 24-year old patient. Although he was four years abstinent from inhaling toluene he rapidly deteriorated once he resumed sniffing this substance. Volume XVII
ABUSE OF
SOLYENT~FAILLACE AND
It has been estimated that 14.2% of college students have abused volatile hydrocarbons at least once." The exact extent of use among less educated, younger individuals is unknown, but is probably at least as extensive since use of solvents is generally associated with the underprivileged young.1, I... Because the abuse of solvents is relatively non-crime linked (probably because of its easy availability), the problem has been unfortunately the subject of relatively little attention. In spite of the widespread use and in spite of the relationship between solvent abuse and abuse of other drugs (as typified by our patient), there has been extremely little reported in the literature towards the acknowledgement of the extent of the problem. It is also likely that patients are seldom asked about solvent abuse simply because the extent of the problem is not realized by the average physician. "Glue-sniffing" is still very much a problem, a problem not restricted to the adolescent.
9. 10.
II. 12.
13. 14.
15.
16.
REF/:R/:'NCES I. Glaser, H. H. and Massengale, O.N.: Glue-sniffing in children. JAMA 181 :300-303, 196:!. 2. Tolan, E. J. and Lingl, F.A.: "Model psychosis" produced hy inhalation of gasoline fumes. A III. J. Psychiatry no: 757-761, 1964. 3. Ackerly, W. C. and Gihson, G.: Lighter fluid "sniffing". Alii. J. Psychiatry I:!O: 1056-1061, 1964. 4. Brozovsky. M. and Winkler, E. G. :Glue sniffing in children and adolescents. N. Y. SlIIte J. Met!. 65: 1984-1989. 1965. 5. Wyse, D. G.: Deliherate inhalation of volatile hydrocarbons: A review. (muul. M. A.Hol". J. 101!:71-74, 1973. 6. Cohen, S.: Glue sniffing. JAMA 231 :653-654, 1975. 7. Massengale. O. N., Glazer. H. H., and Lelievre, R. E.: Physical and psychologic factors in glue sniffing. N. Eng. J. Met!. :!69: 1340-1344. 1963. I!. Baerg, R. D. and Kimherg. D. Y.: Centrilobular necrosis
17.
II!.
19. :!O.
21. 2:!.
GUYNN
and acute renal failure in "solvent sniffers". Ann. Intnn. Med. 73:713-720,1970. Bass. M.: Sudden sniffing death. JAMA 212:2075-2079. 1970. Reinhardt, C. F .. Azar, A., Maxfield,M. E., Smith, P. E., Mullins, L. S. and Wilmington, D.: Cardiac arrhythmias and aerosol "sniffing". Arch. Enl'iron. Health 22:265-279, 1971. Grahski, D. A.: Toluene sniffing producing cere he liar degeneration. Alii. J. Psychiatry 118:461-46:!, 1961. Baker, A. B., and Ticky, F. Y.: The effects of the organic solvents on the central nervous system. A,HOI". Nt·s. Nnw Mellt. Dis. 32:475-505, 1953. Sat ran. R., and Dodson, Y. N.: Toluene habituation. Report of a case. N. Engl. J. Met!. :!61!:719-721. 1963. Knox, J. W., and Nelson, J. R.: Permanent encephalopathy from toluene inhalation. N. Engl. J. Mt·t!. 275: 1494-1496, 1966. O·Brien. F.. T., Yeoman. W. B.• and Hohby. J.A.E.: Hepatorenal damage from toluene in a "glue sniffer". Brit. Mal. J. 2:29-30, 1971. Taher. S. M., Anderson, R. J.. McCartney. R., Popovtzer. M. M. and Schrier, R. W.: Renal tuhular acidosis associated with toluene "sniffing". N. I:'ngl J. Met!. :!90:765. 1974. Shira he, T., Tsuda, T., Terao. A.. and Araki. S.: Toxic polyneuropathy due to glue sniffing. J. Neurol. Sci. 21: 101-113, 1974. Goto. I.. Matsumura, M.. Inoue. N., Kuroiwa. Y.• MuraL Y.. Shida, W., and Santa. T.: Toxic polyneuropathy due to glue sniffing. J. Nt'urol. NellfO.lurg. P,lycllO. 37:848-853. 1974. Heuser, M.: Toluolsuchl. Mt'd. Klin. 63: 11!88-11!90. 1968. Lindstrom, F.: Delirium tremens as a symptom in ahstinence in thinner-sniffing. S"en. Lalillrtit!n. 57: :!214-2219, 1960. Nylander. I.: "Thinner" addiction in children and adolescents. Acta. Paet!opsychi/llr. (Basel) 29: 273-284, 1962. Gottfries. I., and Hansson. K.: How does drug intoxication work') A comparison between perceptions of drug intoxication hy medical experts and 'raby' hoys. SocialIIIt·d. T. 50:515-519. 1973.
Ahstainer-a weak person who yields to the temptation of denying himself a pleasure. A total abstainer is one who abstains from everything but abstention, and especially from inactivity in the affairs of others. Ambroise Bierce The Devil's Dictionary
OctoberINovember / December. 1976
189