- Email: [email protected]
Inhalants
C H A P T E R
73 Inhalants Li-Tzy Wu*, George E. Woody$ *
$
Duke University Medical Center, Durham, NC, USA, University of Pennsylvania and Treatment Research Institute, Philadelphia, PA, USA
O U T L I N E Introduction
723
Prevalence and Correlates of Inhalant Use Disorders 728
What is Inhalant Use?
723
Patterns of Inhalant Use Surveys of the General Population The National Poison Data System
724 724 724
Psychiatric Comorbidities, Medical Consequences, and Mortality Substance Use and Other Psychiatric Comorbidities Medical Comorbidities and Mortality
729 729 730
Incidence and Prevalence of Inhalant Use Incidence Prevalence Nitrite Inhalant Use
724 724 725 726
Prevention and Treatment Prevention Treatment
730 730 731
Assessment and Diagnosis for Inhalant Use Disorders
726
INTRODUCTION In the United States, about 16% of eighth graders, 13% of tenth graders, and 10% of twelfth graders had ever used inhalants in their lifetime. In the general population, about 10% of American adults aged 18 years or older reported a history of inhalant use (13.4% of men; 6.3% of women). Inhalant use confers a high risk for significant morbidity and mortality. It is an important public health concern worldwide because household products and office supplies subject to inhalant use or misuse are omnipresent, easily accessible (from homes, offices, and a variety of stores), relatively inexpensive, conveniently packaged, and quickly produce the onset of high and toxic effects. Inhalants are particularly attractive to children, youth, and socioeconomically disadvantaged populations. This chapter summarizes current knowledge about inhalant use, including Principles of Addiction, Volume 1 http://dx.doi.org/10.1016/B978-0-12-398336-7.00073-5
patterns of use; incidence and prevalence of use; assessment and diagnosis for inhalant use disorders according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV); comorbid psychiatric disorders, medical consequences, and mortality associated with inhalant use; and prevention and treatment. This review focuses on research data from major studies that include a large sample size (to ensure the generalizability of study findings) and have adequate coverage of respondents from diverse racial/ethnic groups and geographic regions.
WHAT IS INHALANT USE? Inhalant use is the deliberate ingestion of volatile substances via (1) sniffing or snorting fumes from containers; (2) spraying aerosols directly into the nose
723
Copyright Ó 2013 Elsevier Inc. All rights reserved.
724
73. INHALANTS
or mouth; (3) sniffing or inhaling fumes from substances sprayed or deposited inside a plastic or paper bag (i.e. bagging); (4) huffing from an inhalant-soaked rag stuffed in the mouth; or (5) inhaling from balloons filled with nitrous oxide to induce a psychoactive or mindaltering effect. Based on the profiles of pharmacological and behavioral effects, three main groups of inhalants are subject to these use patterns: (1) volatile solvents, fuels, and anesthetics; (2) nitrous oxide; and (3) volatile alkyl nitrites (e.g. amyl, butyl, and isobutyl nitrites). Some commonly used sources of inhalants include adhesives (e.g. airplane glue, rubber cement), aerosols (e.g. spray paint, hair spray, deodorant, room freshener, analgesic spray, asthma spray), cleaning agents (e.g. dry cleaning chemicals, spot remover, degreaser), solvents (e.g. nail polish remover, paint thinner, correction fluid, fuel gas, lighter, fire extinguisher), and gasoline. Any of these substances can produce a feeling of euphoria or high.
PATTERNS OF INHALANT USE
whippets for adolescents under age 18 years; nitrous oxide and whippets for young adults aged 18–25 years; and amyl nitrite (poppers or rush) for adults aged 26 years or older. Results from the NSDUH show important age and gender differences in types of inhalants used (Table 73.2). Boys are more likely than girls to use gasoline, lighter fluid, nitrous oxide, and whippets, while girls are more likely than boys to use glue, shoe polish, toluene, spray paints, correction fluid, degreaser, and aerosol sprays. Among adults, men are more likely than women to use glue, shoe polish, toluene, gasoline, lighter fluid, paint solvents, lacquer thinner, lighter gases, butane, and propane. Compared with adults, adolescents tend to use more types of inhalants and have a more frequent pattern of use. Approximately 50% of lifetime adolescent inhalant users in the United States have used multiple inhalants, while about 38% of lifetime adult inhalant users have a history of using multiple inhalants. In the sample of recent (past year) inhalant users, one-fifth of adolescents are weekly users of inhalants compared with about onetenth of adults.
Surveys of the General Population According to results from the National Survey on Drug Use and Health (NSDUH), a national survey of a representative sample of noninstitutionalized civilian residents aged 12 years and older in the United States (Table 73.1), the most commonly used inhalants are glue, shoe polish, toluene, gasoline, lighter fluid, spray paints, correction fluid, degreaser, nitrous oxide, and TABLE 73.1 Types of Inhalants Used Among Adolescents and Adults from the Most Commonly Used Inhalants to the Least Commonly Used Inhalants Types of inhalants used among adolescents aged 12e17 years
Types of inhalants used among adults aged 18 years and older
Glue, shoe polish, toluene
Nitrous oxide, whippets
Gasoline, lighter fluid
Amyl nitrite, poppers, rush
Spray paints
Glue, shoe polish, toluene
Correction fluid, degreaser
Gasoline, lighter fluid
Nitrous oxide, whippets
Correction fluid, degreaser
Aerosol sprays
Paint solvents, lacquer thinner
Amyl nitrite, poppers, rush
Aerosol sprays
Paint solvents, lacquer thinner
Spray paints
Lighter gases, butane, propane
Ether, halothane, anesthetic
Ether, halothane, anesthetic
Lighter gases, butane, propane
Notes: These data are based on research findings from Wu et al. (2004) and Wu and Ringwalt (2006).
The National Poison Data System Data from poison control centers provide additional information about individuals who seek help or treatment for inhalant use and the demographic characteristics of subgroups affected by use of harmful inhalants. According to data from the National Poison Data System (NPDS), the vast majority of inhalant cases are adolescents aged 12–17 years. Propellants (e.g. computer and electronics duster sprays, fluorocarbons), gasoline, and paint are the products most frequently implicated in inhalant cases reported to the NPDS. While there have been fewer changes in use of gasoline and paint products during the past few years, there has been a significant and steady increase in the use of propellants (computer and electronics duster sprays) over time. The NPDS data show that gasoline is the product most commonly used by children and adolescents under the age of 14 years, while propellants are the category of use most frequently cited by adolescents, especially older adolescents.
INCIDENCE AND PREVALENCE OF INHALANT USE Incidence Research findings on onset or incidence (i.e. new cases) of inhalant use can contribute important clues about the factors associated with initial use and can be
III. TYPES OF ADDICTION
725
INCIDENCE AND PREVALENCE OF INHALANT USE
TABLE 73.2
Gender Differences in Types of Inhalants Used
Adolescents aged 12e17 years
Adults aged 18 years or older
Glue, shoe polish, toluene
Girls > boys
Glue, shoe polish, toluene
Men > women
Spray paint
Girls > boys
Gasoline, lighter fluid
Men > women
Correction fluid, degreaser
Girls > boys
Paint solvent, lacquer thinner
Men > women
Aerosol spray
Girls > boys
Lighter gas, butane, propane
Men > women
Gasoline, lighter fluid
Boys > girls
e
e
Nitrous oxide, whippets
Boys > girls
e
e
Notes: These estimates are based on the results from Wu et al. (2004) and Wu and Ringwalt (2006).
useful for planning the timing and foci of prevention interventions. Onset of use can occur in children as young as 5 6 years of age. Research reports from the Monitoring the Future (MTF) study, a series of classroom surveys of eighth, tenth, and twelfth graders in the United States, show that inhalant use occurs early, with peak initiation rates in grades six to nine, and decreases with increasing age. However, it is important to note that school dropouts are not covered by a schoolbased survey like the MTF and that school dropouts in general have a high rate of illicit or nonmedical drug use, including inhalant use. Surveys of community-based or noninstitutionalized populations that include school dropouts, such as the NSDUH, reveal that the risk of initiating inhalant use is not limited to early adolescence. Among adolescent inhalant users, the vast majority (80%) initiate inhalant use before the age of 15 years, and the remaining adolescents start inhalant use between 15 and 17 years of age. In the United States, national sample of adult inhalant users, about one-third initiate use between age 15 and 17 years, and 44% start, use in adulthood. These onset patterns are in line with age-related differences in types of inhalants used. Specifically, adolescents are more likely than adults to use readily accessible household products such as glue, shoe polish, gasoline, or spray paints, as inhalants of choice. By comparison, adults tend to initiate inhalant use within the context of a severe pattern of polysubstance use and sexual risk taking, and their inhalants of choice are likely to include nitrous oxide (whippets) and amyl nitrite (poppers or rush for sex-related activities), which are much more commonly used by illicit drug users and homosexual or bisexual individuals than by the general population. Estimates from the 2007–2008 NSDUH show that approximately 730 000–770 000 Americans initiate inhalant use (first-time use) during a 12-month period, which represents slightly more than one-third of individuals who used inhalants in the past year. The level of perceived risk of using a psychoactive drug once or twice is generally considered an indicator for drug use (i.e. greater perceived risk by adolescents results in
less psychoactive drug use). In the MTF, eighth and tenth graders are asked questions about the degree of risk they associate with using an inhalant once or twice. Unfortunately, there has been a decline in the perceived risk associated with inhalant use since 2000, and a relatively low proportion of eighth and tenth graders (less than 40% in 2008) reported that there is a “great risk” in using an inhalant once or twice. The hazards of inhalant use were communicated during the mid-1990s via an anti-inhalant advertising initiative launched by the Partnership for a Drug-Free America. The decline in perceived risk for using inhalants may be related to a generational forgetting of the hazards of inhalant use as younger cohorts were not exposed to these messages. This steady decline in perceived risk is worrisome and requires close monitoring of national trends and associated problems because inhalant use in adolescence is a robust predictor for serious substance abuse problems, including polysubstance use, heroin use, drug abuse or dependence, and injection drug use.
Prevalence Of the nine main categories of illicit or nonmedical psychoactive drug use assessed by the MTF, inhalants are the second most widely used class of drugs among eighth and tenth graders (after marijuana) and are the third most widely used among twelfth graders (after marijuana and prescription opioids) with a lifetime rate similar to amphetamine use. In 2008, about 16% of eighth graders, 13% of tenth graders, and 10% of twelfth graders had ever used inhalants in their lifetime (Table 73.3). School-based MTF surveys have generally found a higher prevalence of lifetime inhalant use among eighth graders than among older students, a trend that stands in contrast with lifetime prevalence rates of other categories of illicit or nonmedical drug use, which usually increase with age. This unique finding may be related to an association between early inhalant use and dropping out of school; that is, adolescents who
III. TYPES OF ADDICTION
726
73. INHALANTS
TABLE 73.3 Lifetime Prevalence (%) of Inhalant Use in Eighth, Tenth, and Twelfth Grades: Results from the MTF Grade
2000
2001
2002
2003
2004
2005
2006
2007
2008
8th
17.9
17.1
15.2
15.8
17.3
17.1
16.1
15.6
15.7
10th
16.6
15.2
13.5
12.7
12.4
13.1
13.3
13.6
12.8
12th
14.2
13.0
11.7
11.2
10.9
11.4
11.1
10.5
9.9
Notes: These data are based on research findings from Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E. (2009). Monitoring the Future national results on adolescent drug use: overview of key findings, 2008. Bethesda, MD: National Institute on Drug Abuse.
use inhalants tend to drop out of school and are thus not included in school-based MTF surveys. Alternatively, older adolescents may be differentially more likely to under report inhalant use than use of other psychoactive drugs due to the perception that inhalants are kids’ drugs. The results of inhalant use for 10th and 12th graders are considered underestimated. This is an area warranting further research. Adolescents who are native American, native Alaskan, or of multiple races have a particularly high rate of inhalant use compared with adolescents of other racial or ethnic backgrounds; adolescents who are Asian and black have a very low rate of inhalant use. Among native American youths, inhalants are often the first psychoactive drug used. Earlier research suggests that boys are more likely than girls to use inhalants; more recent research data, however, indicate a more similar rate of inhalant use among genders. Because many adolescent girls of childbearing age are within the population of young inhalant users and there are possible adverse effects of maternal inhalant use on fetuses, the pattern and extent of inhalant use in female adolescents and youths warrant close scrutiny. Adolescent inhalant use also increases the risk for conduct problems, binge drinking, use of multiple drugs, heroin use, injection drug use, and depression. In the general population, fewer adults than adolescents use inhalants. According to data from the NSDUH, approximately 10% of noninstitutionalized civilian adults in the United States have used inhalants in their lifetime (13.4% in men; 6.3% in women), and about 0.5% (5% of lifetime inhalant users) used inhalants in the past year. Women and blacks have a lower rate of inhalant use than men and other racial or ethnic groups. Additional characteristics associated with inhalant use include younger age (less than age 34 years), being single, receipt of mental health treatment in the past year, self-reported serious psychological distress, involvement with the criminal justice system, alcohol abuse or dependence, and past year drug use (especially polydrug use).
Nitrite Inhalant Use Of all inhalants used, use of nitrite inhalants (amyl, butyl, and isobutyl nitrites or poppers) is associated with an elevated risk for infections and transmission of sexually transmitted diseases (e.g. human immunodeficiency virus (HIV)) because users often are polysubstance users or engage in unprotected or risky sexual behaviors. Inhaling nitrites can dilate blood vessels, increase the heart rate, and produce a sensation of heat and excitement that may last for several minutes. Since the early 1960s, nitrite inhalants have been used by individuals to enhance sexual activities or to get high. Although the rate of nitrite inhalant use is low in the general population, nitrite inhalant use is relatively common among drug abusers (especially individuals in addiction treatment) and homosexual or bisexual individuals, and its use is associated with risky sexual behaviors, illicit drug use, transmission of sexually transmitted diseases, suicide attempts, and drug-related overdose. Nitrite inhalants are the primary inhalant used by adults, and use in adolescents is less frequent. In the MTF, approximately 1% of twelfth graders between 2007 and 2008 used nitrite inhalants in their lifetime. In the NSDUH, about 1.5% of noninstitutionalized adolescents aged 12–17 years (including school dropouts) have ever used nitrite inhalants in their lifetime. While use in the general population of adolescents is infrequent, the rate of lifetime nitrite inhalant use increases to 15% among adolescents who have an alcohol or drug dependence or who used multiple drugs in the past year. Nitrite inhalant use in adolescents can be considered a marker for serious psychiatric problems in that users not only tend to engage in delinquent activities, use multiple types of inhalants and other substances, and have alcohol/drug dependence, but also exhibit mental health problems and have received mental health treatment in the past year. Young nitrite inhalant users thus represent a subgroup of highly troubled youth in need of help. Additional characteristics associated with nitrite inhalant use in adolescents include older age (15–17 years), white race, more than one race, and residence in a nonmetropolitan area.
ASSESSMENT AND DIAGNOSIS FOR INHALANT USE DISORDERS Assessments and diagnosis for DSM-IV inhalant abuse and dependence can be difficult since an accurate drug use history is not always possible to obtain and routine urine drug screening will not detect inhalants. Potential signs of inhalant use can be subtle and are summarized in Table 73.4.
III. TYPES OF ADDICTION
727
ASSESSMENT AND DIAGNOSIS FOR INHALANT USE DISORDERS
TABLE 73.4
Potential Signs of Inhalant Use
Odors or chemical smells on the breath or clothes Residue of the substance on clothing or skin (paint or glitter on face or hands) Burns Cans of gasoline or spray paint under an adolescent’s bed Rashes around nose or mouth (e.g. glue sniffer’s rash) Red or irritated eyes, throat, and nose Trauma or injuries Nonspecific respiratory problems (e.g. coughing, sinus discharge, dyspnea, or rale) Headache or general weakness Abdominal pain, nausea, or vomiting
According to the DSM-IV (Table 73.5), inhalant intoxication is defined as the presence of clinically maladaptive behavioral or psychological changes that develop during or shortly after intentional use of or exposure to volatile inhalants (e.g. dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor generalized muscle weakness, blurred vision or diplopia, stupor or coma, and euphoria) and that are not due to a general medical condition and are not better accounted for by another mental disorder. Inhalant abuse as defined by the DSM-IV as a maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by having one or more of the four abuse criteria (i.e. role interference, hazardous use, legal problems, and relation
TABLE 73.5
DSM-IV Criteria for Inhalant Intoxication
A
Recent intentional use or short-term high-dose exposure to volatile inhalants (excluding anesthetic gases and shortacting vasodilators)
B
Clinically maladaptive behavioral or psychological changes that developed during or shortly after use of or exposure to volatile inhalants
C
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
D
The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder
Note: These criteria are based on the DSM-IV, Text Revision (American Psychiatric Association, 2000).
problems), and the user does not meet the criteria for inhalant dependence in the past year (Table 73.6). DSM-IV inhalant dependence includes inhalant users who show a maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by having three or more of the six dependence criteria (i.e. tolerance, taking larger amounts over a longer period of time, inability to cut down, a great deal of time spent in using or recovering from its effects, important activities given up, and continued use despite resulting medical or psychological problems) that occur during a 12-month period. It is important to note that inhalant withdrawal symptoms (e.g. sleep disturbances, tremor, irritability, diaphoresis, nausea, and fleeting illusions) may occur within 1–2 days after cessation of use and may last for 2–5 days. However, because of a lack of research data
TABLE 73.6
DSM-IV Criteria for Inhalant Use Disorders
Inhalant abuse A. A maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12month period: (1) Recurrent inhalant use resulting in a failure to fulfill major obligations at work, school, or home (2) Recurrent inhalant use in situations in which it is physically hazardous (3) Recurrent inhalantrelated legal problems (4) Continued inhalant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the inhalant B. The symptoms have never met the criteria for inhalant dependence for this class of substance
Inhalant dependence A. A maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period: (1) Tolerance as defined by the need for markedly increased amounts of the inhalant to achieve intoxication or desired effects, or markedly diminished effects with continued use of the same amount of the inhalant (2) An inhalant is often taken in larger amounts or over longer periods than was intended (3) There is a persistent desire or unsuccessful effort to reduce or control inhalant use (4) A great deal of time is spent in activities necessary to obtain the inhalant, use it, or recover from its effects (5) Important social, occupational, or recreational activities are given up or reduced because of inhalant use (6) Inhalant 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 it
Note: These criteria are based on the DSM-IV, Text Revision (American Psychiatric Association, 2000).
III. TYPES OF ADDICTION
728
73. INHALANTS
to establish an inhalant withdrawal syndrome, the withdrawal criterion is not included for DSM-IV inhalant dependence. This may change in the future as more empirical data for an inhalant withdrawal syndrome accumulate.
PREVALENCE AND CORRELATES OF INHALANT USE DISORDERS National surveys of the US general population show that 10.6% of adolescents aged 12 17 years who used inhalants in the past year reported a pattern of inhalant use problems consistent with the DSM-IV criteria for a current inhalant use disorder and that 7.7% of adults aged 18 years or older who used inhalant in the past year reported a pattern of inhalant use problems consistent with the DSM-IV criteria for a current inhalant use disorder. Inhalant abuse and dependence, as well as cessation from inhalant use, have received comparatively less research attention than inhalant use. Inhalant use was not included in the Diagnostic Interview Schedule of the National Institute of Mental Health-Epidemiologic Catchment Area (NIMH ECA) study. One publication from the 1990 National Comorbidity Survey (NCS) describes the prevalence of lifetime inhalant dependence (0.3%) in the general population. More recent research data suggest that use of multiple inhalants in adolescents is common (about 50% of users) and that many have used before the age of 14 years, findings that point toward the need to identify those at risk for progressing from use to abuse or dependence. Research data from the NSDUH show that 0.2% of adolescents aged 12 years or older met the DSM-IV criteria for current inhalant abuse, and another 0.2% met the criteria for inhalant dependence in the past year. In the subsample of adolescents who used inhalants in the past year (Table 73.7), 6% met the DSM-IV criteria for current inhalant abuse and an additional 4% for inhalant dependence. Therefore, about one in ten adolescent inhalant users have an inhalant use disorder. It is also important to note that these estimates of inhalant use TABLE 73.7
disorders are all based on self-reported data from survey respondents. Different characteristics are associated with inhalant abuse and dependence in adolescents. Characteristics associated with increased odds of inhalant abuse include engaging in multiple delinquent activities, history of incarceration, and use of multiple inhalants. Characteristics associated with increased odds of inhalant dependence include early onset of first inhalant use, using inhalants weekly, history of foster care placement, receipt of mental health treatment in the past year, and the presence of other drug abuse or dependence. Data from the NSDUH provide a unique opportunity to compare inhalant use disorders in adults against estimates in adolescents. In the national sample of adults aged 18 years or older, 0.04% met the DSM-IV criteria for current inhalant abuse (0.03%) or dependence (0.01%) in the past year. In the subsample of adults who used inhalants in the past year, 8% met the DSM-IV criteria for current inhalant abuse (7%) or dependence (1%). Although adult men have a higher rate of inhalant use than adult women, there are no gender differences in inhalant use disorders. The following groups of adult inhalant users have an elevated rate of inhalant use disorders: adults aged 35–49 years, those who did not complete high school, users of mental health treatment, and weekly inhalant users. Rates of current inhalant use disorders among adolescents and adults are summarized in Table 73.7. Research data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) – presently the largest study of psychiatric comorbidity among adults in the United States – provide information about lifetime inhalant use disorders among inhalant users. In the NESARC, of respondents aged 18 years or older, 2% were identified as lifetime inhalant users, and 19% of lifetime users met the DSM-IV criteria for an inhalant use disorder in their lifetime. Most adults (88%) with a lifetime inhalant use disorder met the criteria for inhalant abuse but not inhalant dependence, and 12% met the criteria for inhalant dependence irrespective of whether they had
Prevalence of Past Year or Current DSM-IV Inhalant Use Disorders in the General Population All respondents
Individuals who used inhalants in the past year
DSM-IV inhalant use disorders (%)
Aged 12e17 years
Aged 18 years or older
Abuse
0.2
0.03
6.3
6.6
Dependence
0.2
0.01
4.3
1.1
Abuse or dependence
0.4
0.04
10.6
7.7
Note: These estimates are based on results from Wu et al. (2004) and Wu and Ringwalt (2006).
III. TYPES OF ADDICTION
Aged 12e17 years
Aged 18 years or older
PSYCHIATRIC COMORBIDITIES, MEDICAL CONSEQUENCES, AND MORTALITY
ever met criteria for inhalant abuse. The vast majority (94%) of adults with a history of inhalant use had not used inhalants in the past year, and very few (1%) met the DSM-IV criteria for an inhalant use disorder in the past year.
PSYCHIATRIC COMORBIDITIES, MEDICAL CONSEQUENCES, AND MORTALITY Substance Use and Other Psychiatric Comorbidities Adolescent inhalant users often have comorbid DSMIV substance use disorders and other mental health problems, and adolescents who used both inhalants and marijuana represent a severe set of drug users. Compared with adolescents who use inhalants but no marijuana, or adolescents who use illicit or nonmedical drugs other than inhalants and marijuana, adolescents who use both inhalants and marijuana have a particularly high rate of DSM-IV substance use disorders, including alcohol, marijuana, cocaine, hallucinogen, opioid, sedative, stimulant, tranquilizer, and heroin use disorders. Adolescents who use inhalants but no marijuana have rates of alcohol or drug use disorders similar to adolescents who use illicit or nonmedical drugs other than inhalants. Adolescent inhalant users in the NSDUH are more likely than noninhalant users to have major depression and to participate in treatment for mental or psychological problems. However, empirical data concerning other DSM-IV mental disorders in the general population of adolescents are lacking. Research data from adolescents in treatment for mental or behavioral problems show that those with a history of inhalant use, abuse, or dependence are more likely than those with other problems to have other substance use disorders, major depression, suicide attempts, and a history of physical/sexual abuse and neglect. These findings suggest that adolescent psychiatric patients with a history of inhalant use should be screened carefully for the presence of serious substance abuse or mental health problems. Similarly, psychiatric disorders among adults with a history of inhalant use also are prevalent. Research data from the 2001–2002 NESARC have documented that approximately 96% of adults with a history of inhalant use met the DSM-IV criteria for a substance use disorder in their lifetime, and that about two-thirds met the DSM-IV criteria for a substance use disorder in the past year. As shown in Table 73.8, among adults with a history of inhalant use, alcohol, marijuana, nicotine, cocaine, hallucinogen, and stimulant use disorders
729
TABLE 73.8 Prevalence of Lifetime DSM-IV Psychiatric Disorders Among Adults who Reported a History of Inhalant Use in the General Population Lifetime DSM-IV disorder
%
Nicotine use disorder
58 Any mood disorder
48
Alcohol use disorder
87 Major depression
41
Inhalant use disorder
19 Dysthymia
18
Marijuana use disorder
68 Mania
15
Hallucinogen use disorder
31 Hypomania
Stimulant use disorder
28 Any anxiety disorder
Sedative use disorder
17 Panic disorder with agoraphobia
Tranquilizer use disorder
18 Panic disorder without agoraphobia
14
Opioid use disorder
20 Social phobia
12
Cocaine use disorder
35 Specific phobia
18
Heroin use disorder
5
Lifetime DSM-IV disorder
%
8 36 4
Generalized anxiety disorder
11
Antisocial personality
32
Note: These estimates are based on the results from Wu et al. (2008) and Wu and Howard (2007).
were all more prevalent than inhalant use disorders (19%). Less education, residence in nonmetropolitan areas, early onset of inhalant use, and a history of substance abuse treatment increased the odds of having an inhalant use disorder among adult inhalant users. Other (nonaddictive) mental disorders, including mood (48%), anxiety (36%), and personality (45%) disorders, also are prevalent among adults with a history of inhalant use. Particularly common lifetime disorders are major depression and antisocial personality disorder. In addition, psychiatric disorders are highly comorbid, with approximately one in seven lifetime inhalant users meeting the DSM-IV criteria for six or more lifetime nonaddictive mental disorders, and more than one in five inhalant users meeting the criteria for three to five of such disorders. Female inhalant users were more likely than male users to meet the criteria for dysthymia and anxiety disorders, while male inhalant users were more likely than female users to have an antisocial personality disorder. Early onset of inhalant use was strongly associated with an increased likelihood of having multiple mental disorders, particularly mood and personality disorders. On average, inhalant users tend to have an earlier age of onset of mood or anxiety disorders than noninhalant users. Regarding the temporal ordering of various disorders, onset of phobia typically precedes the onset
III. TYPES OF ADDICTION
730
73. INHALANTS
of inhalant use, whereas mood and other anxiety disorders on average are likely to develop subsequent to inhalant use initiation.
Medical Comorbidities and Mortality Inhalant use is associated with increased morbidity and mortality. Most inhalants are very toxic to organs, and inhalant users are at risk for an array of long-lasting adverse or even fatal medical consequences, including substantial cardiac, renal, hepatic, and neurological morbidity or mortality. The liver and the heart are the organs most commonly affected by volatile inhalants. Sniffing highly concentrated chemicals in solvents or aerosol sprays can induce irregular and rapid heart rhythms, which can result in heart failure and death within minutes of a session of prolonged sniffing (i.e. sudden sniffing death). Inhalation of nitrites can not only increase the risk for HIV-related risky sexual behaviors but also has adverse effects on the immune system by impairing immune functioning and suppressing resistance to infection. In illicit drug users, daily use of nitrite inhalants (poppers) is also associated with overdose mortality. Inhalant use is particularly devastating to adolescents with respiratory problems because it can not only produce adverse effects on the respiratory system through irritation or inflammation of breathing passages but can also exacerbate existing respiratory conditions. Recent research data from the NSDUH show that 4 5% of adolescents who used inhalants in the past year also had one or more respiratory conditions (pneumonia, bronchitis, asthma, and sinusitis) in the same period of time. These research data, however, cannot discern whether inhalant use leads to respiratory conditions. Causes of death related to inhalant use may include suffocation, aspiration, choking, accidental injuries (e.g. car accidents, drowning, fire, trauma), or adverse drug–drug interactions; death can result from either acute (e.g. sudden sniffing death syndrome) or delayed (e.g. cardiomyopathy, central nervous system toxicity, hepatocellular carcinoma, renal toxicity) adverse effects. Recent research data from 60 poison control centers (the NPDS) in the United States provide important information about mortality associated with inhalant use. The mortality rate is defined as the number of deaths per 1000 single substance use cases involving the product. Butane (58 deaths per 1000 cases), propane (26 deaths per 1000 cases), and air fresheners (22 deaths per 1000 cases) have the highest mortality rate, followed by nitrous oxide (14 deaths per 1000 cases), carburetor cleaners (9 deaths per 1000 cases), and fluorocarbons/ FreonÒ (9 deaths per 1000 cases).
The vast majority of inhalant cases reported to the NPDS are adolescent boys, suggesting that boys might tend to use more harmful inhalant products or to engage in heavier or more chronic inhalant use. Girls are most likely to use air freshener, hair spray, and nail products (e.g. nail polish and remover), and the latter two categories have a very low rate of fatality from the analysis of the poison control data. As a group, inhalants have a fatality rate of 5.5 deaths per 1000 cases, which is much higher than the fatality rates (less than 1 death per 1000 cases) for cases of pharmaceutical substances or nonpharmaceutical exposures from the NPDS. Thus, inhalants appear to be more lethal to poison control center cases than other substances.
PREVENTION AND TREATMENT Prevention Given the serious, or even fatal, medical consequences resulting from inhalant use, and data showing that use can lead to harmful consequences, prevention efforts should begin with a renewed public information campaign as was done in the 1990s. Because household products and office supplies subject to inhalant use and abuse are omnipresent, a broad and concerted approach that incorporates prevention efforts by schools, communities, parents, and health care professionals are recommended to enhance the general population’s knowledge of the serious health consequences of inhalant use and to increase early identification of at-risk subgroups or new onset inhalant users to reduce adverse health effects. Education by means of a school-based drug abuse curriculum is considered an important component for primary prevention of substance use, and efforts should be made to make certain that inhalant use is included. School staff have the opportunity to identify students who show behavioral or psychological risks for inhalant-related problems and to work with parents of at-risk students. Informing parents and at-risk children and youth about the dangers of inhalant use (e.g. sudden death, burns, and serious brain or liver damage) can decrease experimentation with inhalants. Pediatricians or family physicians can also play an important role in prevention efforts (e.g. education about the dangers from inhalant use, early identification of inhalant users, brief intervention, and referrals to appropriate health care providers) because they see children and youth routinely for physical checkups and often have well-established relationships with family members.
III. TYPES OF ADDICTION
RELEVANT WEBSITES
Treatment According to data from 60 poison control centers in the United States, the majority (56%) of inhalant cases were treated in a health care facility (mainly emergency departments), 10% of cases were admitted to critical care units, 7% to noncritical care units, 8% to psychiatric units, and 20% received an unknown level of care. Inhalant abusers often do not seek treatment for inhalant abuse, and only when inhalant use results in life-threatening or serious consequences does the user present to a health care facility. Medical management starts with providing life support to stabilize the patient and address any acute injury or toxicity. Subsequent treatment needs and plans will depend on the history of physical, mental, and substance abuse status. There are presently no effective reversal agents for inhalant intoxication. Further, little is presently known about substance abuse treatment needs and successful treatment modalities for inhalant users; clinicians rely on available approaches to substance use problems, such as motivational enhancement techniques, cognitive behavioral therapy, family therapy, or 12-step facilitation. As shown from this review, inhalant abusers are not only affected by multiple substance abuse and mental health problems but might also have developed negative physiological and neurological damage from repeated inhalant use. These multiple comorbid problems pose challenges to effective treatment. Unfortunately, treatment for inhalant abuse or dependence is among the leaststudied areas of treatment research. There are few programs designed specifically for inhalant abuse treatment. Thus, access to effective care is limited. In conclusion, inhalant abuse can lead to serious morbidity and mortality. There is a clear need to increase research efforts on effective prevention and treatment approaches specific to addressing inhalant abuse and dependence.
Glossary DSM-IV Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. MTF monitoring the future study. NPDS National Poison Data System. NSDUH National Survey on Drug Use and Health. NESARC National Epidemiologic Survey on Alcohol and Related Conditions.
Further Reading American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. text revision). American Psychiatric Publishing, Washington, DC. Anderson, C.E., Loomis, G.A., 2003. Recognition and prevention of inhalant abuse. American Family Physician 68, 869–874. Balster, R.L., 1998. Neural basis of inhalant abuse. Drug and Alcohol Dependence 51, 207–214.
731
Brouette, T., Anton, R., 2001. Clinical review of inhalants. American Journal on Addictions 10, 79–94. Center for Substance Abuse Treatment, 2003. Inhalants. Substance Abuse Treatment Advisory 3, 1–7. Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., 2009. Monitoring the Future national Results on Adolescent Drug Use: Overview of Key Findings, 2008 (NIH Publication No. 09–7401). National Institute on Drug Abuse, Bethesda, MD. Marsolek, M.R., White, N.C., Litovitz, T.L., 2010. Inhalant abuse: monitoring trends by using poison control data, 1993–2008. Pediatrics 125, 906–913. Sakai, J.T., Hall, S.K., Mikulich-Gilbertson, S.K., Crowley, T.J., 2004. Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems. Journal of the American Academy of Child and Adolescent Psychiatry 43, 1080–1088. Sharp, C.W., Rosenberg, N.L., 1997. Inhalants. In: Lowinson, J.H., Ruiz, P., Millman, R.B., Langrod, J.G. (Eds.), Substance Abuse: A Comprehensive Textbook, third ed.). Williams & Wilkins, Baltimore, MD, pp. 246–264. Substance Abuse and Mental Health Services Administration, 2008. The NSDUH Report: Inhalant Use and Major Depressive Episode Among Youths Aged 12–17: 2004 to 2006. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Rockville, MD. Substance Abuse and Mental Health Services Administration, 2010. The NSDUH Report: Adolescent Inhalant Use and Selected Respiratory Conditions. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Rockville, MD. Williams, J.F., Storck, M., American Academy of Pediatrics Committee on Substance Abuse, American Academy of Pediatrics Committee on Native American Child Health, 2007. Inhalant abuse. Pediatrics 119, 1009–1017. Woody, G.E., Donnell, D., Seage, G.R., et al., 1999. Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET. Drug and Alcohol Dependence 53, 197–205. Wu, L.T., Howard, M.O., 2007a. Psychiatric disorders in inhalant users: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence 88, 146–155. Wu, L.T., Howard, M.O., 2007b. Is inhalant use a risk factor for heroin and injection drug use among adolescents in the United States? Addictive Behaviors 32, 265–281. Wu, L.T., Ringwalt, C.L., 2006. Inhalant use and disorders among adults in the United States. Drug and Alcohol Dependence 85, 1–11. Wu, L.T., Pilowsky, D.J., Schlenger, W.E., 2004. Inhalant abuse and dependence among adolescents in the United States. Journal of the American Academy of Child and Adolescent Psychiatry 43, 1206–1214. Wu, L.T., Pilowsky, D.J., Schlenger, W.E., 2005. High prevalence of substance use disorders among adolescents who use marijuana and inhalants. Drug and Alcohol Dependence 78, 23–32. Wu, L.T., Schlenger, W.E., Ringwalt, C.L., 2005. Use of nitrite inhalants (“poppers”) among American youth. Journal of Adolescent Health 37, 52–60. Wu, L.T., Howard, M.O., Pilowsky, D.J., 2008. Substance use disorders among inhalant users: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addictive Behaviors 33, 968–973.
Relevant Websites http://www.inhalant.org/aboutus/ – The Alliance for Consumer Education: Inhalant Abuse Prevention Program. http://www.aapcc.org/dnn/default.aspx – The American Association of Poison Control Centers (AAPCC).
III. TYPES OF ADDICTION
732
73. INHALANTS
http://www.drugfreeworld.org/about-us/about-the-foundation.html – The Foundation for a Drug-Free World. http://monitoringthefuture.org – The Monitoring the Future (MTF) survey is a series of classroom surveys of eighth, tenth, and twelfth graders conducted by researchers at the University of Michigan under a grant from the National Institute on Drug Abuse, part of the National Institutes of Health, US Department of Health and Human Services. http://www.inhalants.org/guidelines.htm – The National Inhalant Prevention Coalition (NIPC). http://teens.drugabuse.gov/facts/facts_inhale1.php – The National Institute on Drug Abuse (NIDA): information on inhalants.
http://www.oas.samhsa.gov/nhsda.htm – The National Survey on Drug Use and Health (NSDUH), formerly called the National Household Survey on Drug Abuse, is sponsored by the Substance Abuse and Mental Health Services Administration. The survey has been conducted since 1971 and serves as the primary source of information on the prevalence and incidence of illicit drug, alcohol, and tobacco use in the civilian, noninstitutionalized population aged 12 years or older in the United States. http://www.whitehousedrugpolicy.gov/about/index.html – The White House Office of National Drug Control Policy (ONDCP) is a component of the Executive Office of the President and was established by the Anti-Drug Abuse Act of 1988.
III. TYPES OF ADDICTION
73 Inhalants Li-Tzy Wu*, George E. Woody$ *
$
Duke University Medical Center, Durham, NC, USA, University of Pennsylvania and Treatment Research Institute, Philadelphia, PA, USA
O U T L I N E Introduction
723
Prevalence and Correlates of Inhalant Use Disorders 728
What is Inhalant Use?
723
Patterns of Inhalant Use Surveys of the General Population The National Poison Data System
724 724 724
Psychiatric Comorbidities, Medical Consequences, and Mortality Substance Use and Other Psychiatric Comorbidities Medical Comorbidities and Mortality
729 729 730
Incidence and Prevalence of Inhalant Use Incidence Prevalence Nitrite Inhalant Use
724 724 725 726
Prevention and Treatment Prevention Treatment
730 730 731
Assessment and Diagnosis for Inhalant Use Disorders
726
INTRODUCTION In the United States, about 16% of eighth graders, 13% of tenth graders, and 10% of twelfth graders had ever used inhalants in their lifetime. In the general population, about 10% of American adults aged 18 years or older reported a history of inhalant use (13.4% of men; 6.3% of women). Inhalant use confers a high risk for significant morbidity and mortality. It is an important public health concern worldwide because household products and office supplies subject to inhalant use or misuse are omnipresent, easily accessible (from homes, offices, and a variety of stores), relatively inexpensive, conveniently packaged, and quickly produce the onset of high and toxic effects. Inhalants are particularly attractive to children, youth, and socioeconomically disadvantaged populations. This chapter summarizes current knowledge about inhalant use, including Principles of Addiction, Volume 1 http://dx.doi.org/10.1016/B978-0-12-398336-7.00073-5
patterns of use; incidence and prevalence of use; assessment and diagnosis for inhalant use disorders according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV); comorbid psychiatric disorders, medical consequences, and mortality associated with inhalant use; and prevention and treatment. This review focuses on research data from major studies that include a large sample size (to ensure the generalizability of study findings) and have adequate coverage of respondents from diverse racial/ethnic groups and geographic regions.
WHAT IS INHALANT USE? Inhalant use is the deliberate ingestion of volatile substances via (1) sniffing or snorting fumes from containers; (2) spraying aerosols directly into the nose
723
Copyright Ó 2013 Elsevier Inc. All rights reserved.
724
73. INHALANTS
or mouth; (3) sniffing or inhaling fumes from substances sprayed or deposited inside a plastic or paper bag (i.e. bagging); (4) huffing from an inhalant-soaked rag stuffed in the mouth; or (5) inhaling from balloons filled with nitrous oxide to induce a psychoactive or mindaltering effect. Based on the profiles of pharmacological and behavioral effects, three main groups of inhalants are subject to these use patterns: (1) volatile solvents, fuels, and anesthetics; (2) nitrous oxide; and (3) volatile alkyl nitrites (e.g. amyl, butyl, and isobutyl nitrites). Some commonly used sources of inhalants include adhesives (e.g. airplane glue, rubber cement), aerosols (e.g. spray paint, hair spray, deodorant, room freshener, analgesic spray, asthma spray), cleaning agents (e.g. dry cleaning chemicals, spot remover, degreaser), solvents (e.g. nail polish remover, paint thinner, correction fluid, fuel gas, lighter, fire extinguisher), and gasoline. Any of these substances can produce a feeling of euphoria or high.
PATTERNS OF INHALANT USE
whippets for adolescents under age 18 years; nitrous oxide and whippets for young adults aged 18–25 years; and amyl nitrite (poppers or rush) for adults aged 26 years or older. Results from the NSDUH show important age and gender differences in types of inhalants used (Table 73.2). Boys are more likely than girls to use gasoline, lighter fluid, nitrous oxide, and whippets, while girls are more likely than boys to use glue, shoe polish, toluene, spray paints, correction fluid, degreaser, and aerosol sprays. Among adults, men are more likely than women to use glue, shoe polish, toluene, gasoline, lighter fluid, paint solvents, lacquer thinner, lighter gases, butane, and propane. Compared with adults, adolescents tend to use more types of inhalants and have a more frequent pattern of use. Approximately 50% of lifetime adolescent inhalant users in the United States have used multiple inhalants, while about 38% of lifetime adult inhalant users have a history of using multiple inhalants. In the sample of recent (past year) inhalant users, one-fifth of adolescents are weekly users of inhalants compared with about onetenth of adults.
Surveys of the General Population According to results from the National Survey on Drug Use and Health (NSDUH), a national survey of a representative sample of noninstitutionalized civilian residents aged 12 years and older in the United States (Table 73.1), the most commonly used inhalants are glue, shoe polish, toluene, gasoline, lighter fluid, spray paints, correction fluid, degreaser, nitrous oxide, and TABLE 73.1 Types of Inhalants Used Among Adolescents and Adults from the Most Commonly Used Inhalants to the Least Commonly Used Inhalants Types of inhalants used among adolescents aged 12e17 years
Types of inhalants used among adults aged 18 years and older
Glue, shoe polish, toluene
Nitrous oxide, whippets
Gasoline, lighter fluid
Amyl nitrite, poppers, rush
Spray paints
Glue, shoe polish, toluene
Correction fluid, degreaser
Gasoline, lighter fluid
Nitrous oxide, whippets
Correction fluid, degreaser
Aerosol sprays
Paint solvents, lacquer thinner
Amyl nitrite, poppers, rush
Aerosol sprays
Paint solvents, lacquer thinner
Spray paints
Lighter gases, butane, propane
Ether, halothane, anesthetic
Ether, halothane, anesthetic
Lighter gases, butane, propane
Notes: These data are based on research findings from Wu et al. (2004) and Wu and Ringwalt (2006).
The National Poison Data System Data from poison control centers provide additional information about individuals who seek help or treatment for inhalant use and the demographic characteristics of subgroups affected by use of harmful inhalants. According to data from the National Poison Data System (NPDS), the vast majority of inhalant cases are adolescents aged 12–17 years. Propellants (e.g. computer and electronics duster sprays, fluorocarbons), gasoline, and paint are the products most frequently implicated in inhalant cases reported to the NPDS. While there have been fewer changes in use of gasoline and paint products during the past few years, there has been a significant and steady increase in the use of propellants (computer and electronics duster sprays) over time. The NPDS data show that gasoline is the product most commonly used by children and adolescents under the age of 14 years, while propellants are the category of use most frequently cited by adolescents, especially older adolescents.
INCIDENCE AND PREVALENCE OF INHALANT USE Incidence Research findings on onset or incidence (i.e. new cases) of inhalant use can contribute important clues about the factors associated with initial use and can be
III. TYPES OF ADDICTION
725
INCIDENCE AND PREVALENCE OF INHALANT USE
TABLE 73.2
Gender Differences in Types of Inhalants Used
Adolescents aged 12e17 years
Adults aged 18 years or older
Glue, shoe polish, toluene
Girls > boys
Glue, shoe polish, toluene
Men > women
Spray paint
Girls > boys
Gasoline, lighter fluid
Men > women
Correction fluid, degreaser
Girls > boys
Paint solvent, lacquer thinner
Men > women
Aerosol spray
Girls > boys
Lighter gas, butane, propane
Men > women
Gasoline, lighter fluid
Boys > girls
e
e
Nitrous oxide, whippets
Boys > girls
e
e
Notes: These estimates are based on the results from Wu et al. (2004) and Wu and Ringwalt (2006).
useful for planning the timing and foci of prevention interventions. Onset of use can occur in children as young as 5 6 years of age. Research reports from the Monitoring the Future (MTF) study, a series of classroom surveys of eighth, tenth, and twelfth graders in the United States, show that inhalant use occurs early, with peak initiation rates in grades six to nine, and decreases with increasing age. However, it is important to note that school dropouts are not covered by a schoolbased survey like the MTF and that school dropouts in general have a high rate of illicit or nonmedical drug use, including inhalant use. Surveys of community-based or noninstitutionalized populations that include school dropouts, such as the NSDUH, reveal that the risk of initiating inhalant use is not limited to early adolescence. Among adolescent inhalant users, the vast majority (80%) initiate inhalant use before the age of 15 years, and the remaining adolescents start inhalant use between 15 and 17 years of age. In the United States, national sample of adult inhalant users, about one-third initiate use between age 15 and 17 years, and 44% start, use in adulthood. These onset patterns are in line with age-related differences in types of inhalants used. Specifically, adolescents are more likely than adults to use readily accessible household products such as glue, shoe polish, gasoline, or spray paints, as inhalants of choice. By comparison, adults tend to initiate inhalant use within the context of a severe pattern of polysubstance use and sexual risk taking, and their inhalants of choice are likely to include nitrous oxide (whippets) and amyl nitrite (poppers or rush for sex-related activities), which are much more commonly used by illicit drug users and homosexual or bisexual individuals than by the general population. Estimates from the 2007–2008 NSDUH show that approximately 730 000–770 000 Americans initiate inhalant use (first-time use) during a 12-month period, which represents slightly more than one-third of individuals who used inhalants in the past year. The level of perceived risk of using a psychoactive drug once or twice is generally considered an indicator for drug use (i.e. greater perceived risk by adolescents results in
less psychoactive drug use). In the MTF, eighth and tenth graders are asked questions about the degree of risk they associate with using an inhalant once or twice. Unfortunately, there has been a decline in the perceived risk associated with inhalant use since 2000, and a relatively low proportion of eighth and tenth graders (less than 40% in 2008) reported that there is a “great risk” in using an inhalant once or twice. The hazards of inhalant use were communicated during the mid-1990s via an anti-inhalant advertising initiative launched by the Partnership for a Drug-Free America. The decline in perceived risk for using inhalants may be related to a generational forgetting of the hazards of inhalant use as younger cohorts were not exposed to these messages. This steady decline in perceived risk is worrisome and requires close monitoring of national trends and associated problems because inhalant use in adolescence is a robust predictor for serious substance abuse problems, including polysubstance use, heroin use, drug abuse or dependence, and injection drug use.
Prevalence Of the nine main categories of illicit or nonmedical psychoactive drug use assessed by the MTF, inhalants are the second most widely used class of drugs among eighth and tenth graders (after marijuana) and are the third most widely used among twelfth graders (after marijuana and prescription opioids) with a lifetime rate similar to amphetamine use. In 2008, about 16% of eighth graders, 13% of tenth graders, and 10% of twelfth graders had ever used inhalants in their lifetime (Table 73.3). School-based MTF surveys have generally found a higher prevalence of lifetime inhalant use among eighth graders than among older students, a trend that stands in contrast with lifetime prevalence rates of other categories of illicit or nonmedical drug use, which usually increase with age. This unique finding may be related to an association between early inhalant use and dropping out of school; that is, adolescents who
III. TYPES OF ADDICTION
726
73. INHALANTS
TABLE 73.3 Lifetime Prevalence (%) of Inhalant Use in Eighth, Tenth, and Twelfth Grades: Results from the MTF Grade
2000
2001
2002
2003
2004
2005
2006
2007
2008
8th
17.9
17.1
15.2
15.8
17.3
17.1
16.1
15.6
15.7
10th
16.6
15.2
13.5
12.7
12.4
13.1
13.3
13.6
12.8
12th
14.2
13.0
11.7
11.2
10.9
11.4
11.1
10.5
9.9
Notes: These data are based on research findings from Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E. (2009). Monitoring the Future national results on adolescent drug use: overview of key findings, 2008. Bethesda, MD: National Institute on Drug Abuse.
use inhalants tend to drop out of school and are thus not included in school-based MTF surveys. Alternatively, older adolescents may be differentially more likely to under report inhalant use than use of other psychoactive drugs due to the perception that inhalants are kids’ drugs. The results of inhalant use for 10th and 12th graders are considered underestimated. This is an area warranting further research. Adolescents who are native American, native Alaskan, or of multiple races have a particularly high rate of inhalant use compared with adolescents of other racial or ethnic backgrounds; adolescents who are Asian and black have a very low rate of inhalant use. Among native American youths, inhalants are often the first psychoactive drug used. Earlier research suggests that boys are more likely than girls to use inhalants; more recent research data, however, indicate a more similar rate of inhalant use among genders. Because many adolescent girls of childbearing age are within the population of young inhalant users and there are possible adverse effects of maternal inhalant use on fetuses, the pattern and extent of inhalant use in female adolescents and youths warrant close scrutiny. Adolescent inhalant use also increases the risk for conduct problems, binge drinking, use of multiple drugs, heroin use, injection drug use, and depression. In the general population, fewer adults than adolescents use inhalants. According to data from the NSDUH, approximately 10% of noninstitutionalized civilian adults in the United States have used inhalants in their lifetime (13.4% in men; 6.3% in women), and about 0.5% (5% of lifetime inhalant users) used inhalants in the past year. Women and blacks have a lower rate of inhalant use than men and other racial or ethnic groups. Additional characteristics associated with inhalant use include younger age (less than age 34 years), being single, receipt of mental health treatment in the past year, self-reported serious psychological distress, involvement with the criminal justice system, alcohol abuse or dependence, and past year drug use (especially polydrug use).
Nitrite Inhalant Use Of all inhalants used, use of nitrite inhalants (amyl, butyl, and isobutyl nitrites or poppers) is associated with an elevated risk for infections and transmission of sexually transmitted diseases (e.g. human immunodeficiency virus (HIV)) because users often are polysubstance users or engage in unprotected or risky sexual behaviors. Inhaling nitrites can dilate blood vessels, increase the heart rate, and produce a sensation of heat and excitement that may last for several minutes. Since the early 1960s, nitrite inhalants have been used by individuals to enhance sexual activities or to get high. Although the rate of nitrite inhalant use is low in the general population, nitrite inhalant use is relatively common among drug abusers (especially individuals in addiction treatment) and homosexual or bisexual individuals, and its use is associated with risky sexual behaviors, illicit drug use, transmission of sexually transmitted diseases, suicide attempts, and drug-related overdose. Nitrite inhalants are the primary inhalant used by adults, and use in adolescents is less frequent. In the MTF, approximately 1% of twelfth graders between 2007 and 2008 used nitrite inhalants in their lifetime. In the NSDUH, about 1.5% of noninstitutionalized adolescents aged 12–17 years (including school dropouts) have ever used nitrite inhalants in their lifetime. While use in the general population of adolescents is infrequent, the rate of lifetime nitrite inhalant use increases to 15% among adolescents who have an alcohol or drug dependence or who used multiple drugs in the past year. Nitrite inhalant use in adolescents can be considered a marker for serious psychiatric problems in that users not only tend to engage in delinquent activities, use multiple types of inhalants and other substances, and have alcohol/drug dependence, but also exhibit mental health problems and have received mental health treatment in the past year. Young nitrite inhalant users thus represent a subgroup of highly troubled youth in need of help. Additional characteristics associated with nitrite inhalant use in adolescents include older age (15–17 years), white race, more than one race, and residence in a nonmetropolitan area.
ASSESSMENT AND DIAGNOSIS FOR INHALANT USE DISORDERS Assessments and diagnosis for DSM-IV inhalant abuse and dependence can be difficult since an accurate drug use history is not always possible to obtain and routine urine drug screening will not detect inhalants. Potential signs of inhalant use can be subtle and are summarized in Table 73.4.
III. TYPES OF ADDICTION
727
ASSESSMENT AND DIAGNOSIS FOR INHALANT USE DISORDERS
TABLE 73.4
Potential Signs of Inhalant Use
Odors or chemical smells on the breath or clothes Residue of the substance on clothing or skin (paint or glitter on face or hands) Burns Cans of gasoline or spray paint under an adolescent’s bed Rashes around nose or mouth (e.g. glue sniffer’s rash) Red or irritated eyes, throat, and nose Trauma or injuries Nonspecific respiratory problems (e.g. coughing, sinus discharge, dyspnea, or rale) Headache or general weakness Abdominal pain, nausea, or vomiting
According to the DSM-IV (Table 73.5), inhalant intoxication is defined as the presence of clinically maladaptive behavioral or psychological changes that develop during or shortly after intentional use of or exposure to volatile inhalants (e.g. dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor generalized muscle weakness, blurred vision or diplopia, stupor or coma, and euphoria) and that are not due to a general medical condition and are not better accounted for by another mental disorder. Inhalant abuse as defined by the DSM-IV as a maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by having one or more of the four abuse criteria (i.e. role interference, hazardous use, legal problems, and relation
TABLE 73.5
DSM-IV Criteria for Inhalant Intoxication
A
Recent intentional use or short-term high-dose exposure to volatile inhalants (excluding anesthetic gases and shortacting vasodilators)
B
Clinically maladaptive behavioral or psychological changes that developed during or shortly after use of or exposure to volatile inhalants
C
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
D
The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder
Note: These criteria are based on the DSM-IV, Text Revision (American Psychiatric Association, 2000).
problems), and the user does not meet the criteria for inhalant dependence in the past year (Table 73.6). DSM-IV inhalant dependence includes inhalant users who show a maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by having three or more of the six dependence criteria (i.e. tolerance, taking larger amounts over a longer period of time, inability to cut down, a great deal of time spent in using or recovering from its effects, important activities given up, and continued use despite resulting medical or psychological problems) that occur during a 12-month period. It is important to note that inhalant withdrawal symptoms (e.g. sleep disturbances, tremor, irritability, diaphoresis, nausea, and fleeting illusions) may occur within 1–2 days after cessation of use and may last for 2–5 days. However, because of a lack of research data
TABLE 73.6
DSM-IV Criteria for Inhalant Use Disorders
Inhalant abuse A. A maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12month period: (1) Recurrent inhalant use resulting in a failure to fulfill major obligations at work, school, or home (2) Recurrent inhalant use in situations in which it is physically hazardous (3) Recurrent inhalantrelated legal problems (4) Continued inhalant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the inhalant B. The symptoms have never met the criteria for inhalant dependence for this class of substance
Inhalant dependence A. A maladaptive pattern of inhalant use leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period: (1) Tolerance as defined by the need for markedly increased amounts of the inhalant to achieve intoxication or desired effects, or markedly diminished effects with continued use of the same amount of the inhalant (2) An inhalant is often taken in larger amounts or over longer periods than was intended (3) There is a persistent desire or unsuccessful effort to reduce or control inhalant use (4) A great deal of time is spent in activities necessary to obtain the inhalant, use it, or recover from its effects (5) Important social, occupational, or recreational activities are given up or reduced because of inhalant use (6) Inhalant 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 it
Note: These criteria are based on the DSM-IV, Text Revision (American Psychiatric Association, 2000).
III. TYPES OF ADDICTION
728
73. INHALANTS
to establish an inhalant withdrawal syndrome, the withdrawal criterion is not included for DSM-IV inhalant dependence. This may change in the future as more empirical data for an inhalant withdrawal syndrome accumulate.
PREVALENCE AND CORRELATES OF INHALANT USE DISORDERS National surveys of the US general population show that 10.6% of adolescents aged 12 17 years who used inhalants in the past year reported a pattern of inhalant use problems consistent with the DSM-IV criteria for a current inhalant use disorder and that 7.7% of adults aged 18 years or older who used inhalant in the past year reported a pattern of inhalant use problems consistent with the DSM-IV criteria for a current inhalant use disorder. Inhalant abuse and dependence, as well as cessation from inhalant use, have received comparatively less research attention than inhalant use. Inhalant use was not included in the Diagnostic Interview Schedule of the National Institute of Mental Health-Epidemiologic Catchment Area (NIMH ECA) study. One publication from the 1990 National Comorbidity Survey (NCS) describes the prevalence of lifetime inhalant dependence (0.3%) in the general population. More recent research data suggest that use of multiple inhalants in adolescents is common (about 50% of users) and that many have used before the age of 14 years, findings that point toward the need to identify those at risk for progressing from use to abuse or dependence. Research data from the NSDUH show that 0.2% of adolescents aged 12 years or older met the DSM-IV criteria for current inhalant abuse, and another 0.2% met the criteria for inhalant dependence in the past year. In the subsample of adolescents who used inhalants in the past year (Table 73.7), 6% met the DSM-IV criteria for current inhalant abuse and an additional 4% for inhalant dependence. Therefore, about one in ten adolescent inhalant users have an inhalant use disorder. It is also important to note that these estimates of inhalant use TABLE 73.7
disorders are all based on self-reported data from survey respondents. Different characteristics are associated with inhalant abuse and dependence in adolescents. Characteristics associated with increased odds of inhalant abuse include engaging in multiple delinquent activities, history of incarceration, and use of multiple inhalants. Characteristics associated with increased odds of inhalant dependence include early onset of first inhalant use, using inhalants weekly, history of foster care placement, receipt of mental health treatment in the past year, and the presence of other drug abuse or dependence. Data from the NSDUH provide a unique opportunity to compare inhalant use disorders in adults against estimates in adolescents. In the national sample of adults aged 18 years or older, 0.04% met the DSM-IV criteria for current inhalant abuse (0.03%) or dependence (0.01%) in the past year. In the subsample of adults who used inhalants in the past year, 8% met the DSM-IV criteria for current inhalant abuse (7%) or dependence (1%). Although adult men have a higher rate of inhalant use than adult women, there are no gender differences in inhalant use disorders. The following groups of adult inhalant users have an elevated rate of inhalant use disorders: adults aged 35–49 years, those who did not complete high school, users of mental health treatment, and weekly inhalant users. Rates of current inhalant use disorders among adolescents and adults are summarized in Table 73.7. Research data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) – presently the largest study of psychiatric comorbidity among adults in the United States – provide information about lifetime inhalant use disorders among inhalant users. In the NESARC, of respondents aged 18 years or older, 2% were identified as lifetime inhalant users, and 19% of lifetime users met the DSM-IV criteria for an inhalant use disorder in their lifetime. Most adults (88%) with a lifetime inhalant use disorder met the criteria for inhalant abuse but not inhalant dependence, and 12% met the criteria for inhalant dependence irrespective of whether they had
Prevalence of Past Year or Current DSM-IV Inhalant Use Disorders in the General Population All respondents
Individuals who used inhalants in the past year
DSM-IV inhalant use disorders (%)
Aged 12e17 years
Aged 18 years or older
Abuse
0.2
0.03
6.3
6.6
Dependence
0.2
0.01
4.3
1.1
Abuse or dependence
0.4
0.04
10.6
7.7
Note: These estimates are based on results from Wu et al. (2004) and Wu and Ringwalt (2006).
III. TYPES OF ADDICTION
Aged 12e17 years
Aged 18 years or older
PSYCHIATRIC COMORBIDITIES, MEDICAL CONSEQUENCES, AND MORTALITY
ever met criteria for inhalant abuse. The vast majority (94%) of adults with a history of inhalant use had not used inhalants in the past year, and very few (1%) met the DSM-IV criteria for an inhalant use disorder in the past year.
PSYCHIATRIC COMORBIDITIES, MEDICAL CONSEQUENCES, AND MORTALITY Substance Use and Other Psychiatric Comorbidities Adolescent inhalant users often have comorbid DSMIV substance use disorders and other mental health problems, and adolescents who used both inhalants and marijuana represent a severe set of drug users. Compared with adolescents who use inhalants but no marijuana, or adolescents who use illicit or nonmedical drugs other than inhalants and marijuana, adolescents who use both inhalants and marijuana have a particularly high rate of DSM-IV substance use disorders, including alcohol, marijuana, cocaine, hallucinogen, opioid, sedative, stimulant, tranquilizer, and heroin use disorders. Adolescents who use inhalants but no marijuana have rates of alcohol or drug use disorders similar to adolescents who use illicit or nonmedical drugs other than inhalants. Adolescent inhalant users in the NSDUH are more likely than noninhalant users to have major depression and to participate in treatment for mental or psychological problems. However, empirical data concerning other DSM-IV mental disorders in the general population of adolescents are lacking. Research data from adolescents in treatment for mental or behavioral problems show that those with a history of inhalant use, abuse, or dependence are more likely than those with other problems to have other substance use disorders, major depression, suicide attempts, and a history of physical/sexual abuse and neglect. These findings suggest that adolescent psychiatric patients with a history of inhalant use should be screened carefully for the presence of serious substance abuse or mental health problems. Similarly, psychiatric disorders among adults with a history of inhalant use also are prevalent. Research data from the 2001–2002 NESARC have documented that approximately 96% of adults with a history of inhalant use met the DSM-IV criteria for a substance use disorder in their lifetime, and that about two-thirds met the DSM-IV criteria for a substance use disorder in the past year. As shown in Table 73.8, among adults with a history of inhalant use, alcohol, marijuana, nicotine, cocaine, hallucinogen, and stimulant use disorders
729
TABLE 73.8 Prevalence of Lifetime DSM-IV Psychiatric Disorders Among Adults who Reported a History of Inhalant Use in the General Population Lifetime DSM-IV disorder
%
Nicotine use disorder
58 Any mood disorder
48
Alcohol use disorder
87 Major depression
41
Inhalant use disorder
19 Dysthymia
18
Marijuana use disorder
68 Mania
15
Hallucinogen use disorder
31 Hypomania
Stimulant use disorder
28 Any anxiety disorder
Sedative use disorder
17 Panic disorder with agoraphobia
Tranquilizer use disorder
18 Panic disorder without agoraphobia
14
Opioid use disorder
20 Social phobia
12
Cocaine use disorder
35 Specific phobia
18
Heroin use disorder
5
Lifetime DSM-IV disorder
%
8 36 4
Generalized anxiety disorder
11
Antisocial personality
32
Note: These estimates are based on the results from Wu et al. (2008) and Wu and Howard (2007).
were all more prevalent than inhalant use disorders (19%). Less education, residence in nonmetropolitan areas, early onset of inhalant use, and a history of substance abuse treatment increased the odds of having an inhalant use disorder among adult inhalant users. Other (nonaddictive) mental disorders, including mood (48%), anxiety (36%), and personality (45%) disorders, also are prevalent among adults with a history of inhalant use. Particularly common lifetime disorders are major depression and antisocial personality disorder. In addition, psychiatric disorders are highly comorbid, with approximately one in seven lifetime inhalant users meeting the DSM-IV criteria for six or more lifetime nonaddictive mental disorders, and more than one in five inhalant users meeting the criteria for three to five of such disorders. Female inhalant users were more likely than male users to meet the criteria for dysthymia and anxiety disorders, while male inhalant users were more likely than female users to have an antisocial personality disorder. Early onset of inhalant use was strongly associated with an increased likelihood of having multiple mental disorders, particularly mood and personality disorders. On average, inhalant users tend to have an earlier age of onset of mood or anxiety disorders than noninhalant users. Regarding the temporal ordering of various disorders, onset of phobia typically precedes the onset
III. TYPES OF ADDICTION
730
73. INHALANTS
of inhalant use, whereas mood and other anxiety disorders on average are likely to develop subsequent to inhalant use initiation.
Medical Comorbidities and Mortality Inhalant use is associated with increased morbidity and mortality. Most inhalants are very toxic to organs, and inhalant users are at risk for an array of long-lasting adverse or even fatal medical consequences, including substantial cardiac, renal, hepatic, and neurological morbidity or mortality. The liver and the heart are the organs most commonly affected by volatile inhalants. Sniffing highly concentrated chemicals in solvents or aerosol sprays can induce irregular and rapid heart rhythms, which can result in heart failure and death within minutes of a session of prolonged sniffing (i.e. sudden sniffing death). Inhalation of nitrites can not only increase the risk for HIV-related risky sexual behaviors but also has adverse effects on the immune system by impairing immune functioning and suppressing resistance to infection. In illicit drug users, daily use of nitrite inhalants (poppers) is also associated with overdose mortality. Inhalant use is particularly devastating to adolescents with respiratory problems because it can not only produce adverse effects on the respiratory system through irritation or inflammation of breathing passages but can also exacerbate existing respiratory conditions. Recent research data from the NSDUH show that 4 5% of adolescents who used inhalants in the past year also had one or more respiratory conditions (pneumonia, bronchitis, asthma, and sinusitis) in the same period of time. These research data, however, cannot discern whether inhalant use leads to respiratory conditions. Causes of death related to inhalant use may include suffocation, aspiration, choking, accidental injuries (e.g. car accidents, drowning, fire, trauma), or adverse drug–drug interactions; death can result from either acute (e.g. sudden sniffing death syndrome) or delayed (e.g. cardiomyopathy, central nervous system toxicity, hepatocellular carcinoma, renal toxicity) adverse effects. Recent research data from 60 poison control centers (the NPDS) in the United States provide important information about mortality associated with inhalant use. The mortality rate is defined as the number of deaths per 1000 single substance use cases involving the product. Butane (58 deaths per 1000 cases), propane (26 deaths per 1000 cases), and air fresheners (22 deaths per 1000 cases) have the highest mortality rate, followed by nitrous oxide (14 deaths per 1000 cases), carburetor cleaners (9 deaths per 1000 cases), and fluorocarbons/ FreonÒ (9 deaths per 1000 cases).
The vast majority of inhalant cases reported to the NPDS are adolescent boys, suggesting that boys might tend to use more harmful inhalant products or to engage in heavier or more chronic inhalant use. Girls are most likely to use air freshener, hair spray, and nail products (e.g. nail polish and remover), and the latter two categories have a very low rate of fatality from the analysis of the poison control data. As a group, inhalants have a fatality rate of 5.5 deaths per 1000 cases, which is much higher than the fatality rates (less than 1 death per 1000 cases) for cases of pharmaceutical substances or nonpharmaceutical exposures from the NPDS. Thus, inhalants appear to be more lethal to poison control center cases than other substances.
PREVENTION AND TREATMENT Prevention Given the serious, or even fatal, medical consequences resulting from inhalant use, and data showing that use can lead to harmful consequences, prevention efforts should begin with a renewed public information campaign as was done in the 1990s. Because household products and office supplies subject to inhalant use and abuse are omnipresent, a broad and concerted approach that incorporates prevention efforts by schools, communities, parents, and health care professionals are recommended to enhance the general population’s knowledge of the serious health consequences of inhalant use and to increase early identification of at-risk subgroups or new onset inhalant users to reduce adverse health effects. Education by means of a school-based drug abuse curriculum is considered an important component for primary prevention of substance use, and efforts should be made to make certain that inhalant use is included. School staff have the opportunity to identify students who show behavioral or psychological risks for inhalant-related problems and to work with parents of at-risk students. Informing parents and at-risk children and youth about the dangers of inhalant use (e.g. sudden death, burns, and serious brain or liver damage) can decrease experimentation with inhalants. Pediatricians or family physicians can also play an important role in prevention efforts (e.g. education about the dangers from inhalant use, early identification of inhalant users, brief intervention, and referrals to appropriate health care providers) because they see children and youth routinely for physical checkups and often have well-established relationships with family members.
III. TYPES OF ADDICTION
RELEVANT WEBSITES
Treatment According to data from 60 poison control centers in the United States, the majority (56%) of inhalant cases were treated in a health care facility (mainly emergency departments), 10% of cases were admitted to critical care units, 7% to noncritical care units, 8% to psychiatric units, and 20% received an unknown level of care. Inhalant abusers often do not seek treatment for inhalant abuse, and only when inhalant use results in life-threatening or serious consequences does the user present to a health care facility. Medical management starts with providing life support to stabilize the patient and address any acute injury or toxicity. Subsequent treatment needs and plans will depend on the history of physical, mental, and substance abuse status. There are presently no effective reversal agents for inhalant intoxication. Further, little is presently known about substance abuse treatment needs and successful treatment modalities for inhalant users; clinicians rely on available approaches to substance use problems, such as motivational enhancement techniques, cognitive behavioral therapy, family therapy, or 12-step facilitation. As shown from this review, inhalant abusers are not only affected by multiple substance abuse and mental health problems but might also have developed negative physiological and neurological damage from repeated inhalant use. These multiple comorbid problems pose challenges to effective treatment. Unfortunately, treatment for inhalant abuse or dependence is among the leaststudied areas of treatment research. There are few programs designed specifically for inhalant abuse treatment. Thus, access to effective care is limited. In conclusion, inhalant abuse can lead to serious morbidity and mortality. There is a clear need to increase research efforts on effective prevention and treatment approaches specific to addressing inhalant abuse and dependence.
Glossary DSM-IV Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. MTF monitoring the future study. NPDS National Poison Data System. NSDUH National Survey on Drug Use and Health. NESARC National Epidemiologic Survey on Alcohol and Related Conditions.
Further Reading American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. text revision). American Psychiatric Publishing, Washington, DC. Anderson, C.E., Loomis, G.A., 2003. Recognition and prevention of inhalant abuse. American Family Physician 68, 869–874. Balster, R.L., 1998. Neural basis of inhalant abuse. Drug and Alcohol Dependence 51, 207–214.
731
Brouette, T., Anton, R., 2001. Clinical review of inhalants. American Journal on Addictions 10, 79–94. Center for Substance Abuse Treatment, 2003. Inhalants. Substance Abuse Treatment Advisory 3, 1–7. Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., 2009. Monitoring the Future national Results on Adolescent Drug Use: Overview of Key Findings, 2008 (NIH Publication No. 09–7401). National Institute on Drug Abuse, Bethesda, MD. Marsolek, M.R., White, N.C., Litovitz, T.L., 2010. Inhalant abuse: monitoring trends by using poison control data, 1993–2008. Pediatrics 125, 906–913. Sakai, J.T., Hall, S.K., Mikulich-Gilbertson, S.K., Crowley, T.J., 2004. Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems. Journal of the American Academy of Child and Adolescent Psychiatry 43, 1080–1088. Sharp, C.W., Rosenberg, N.L., 1997. Inhalants. In: Lowinson, J.H., Ruiz, P., Millman, R.B., Langrod, J.G. (Eds.), Substance Abuse: A Comprehensive Textbook, third ed.). Williams & Wilkins, Baltimore, MD, pp. 246–264. Substance Abuse and Mental Health Services Administration, 2008. The NSDUH Report: Inhalant Use and Major Depressive Episode Among Youths Aged 12–17: 2004 to 2006. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Rockville, MD. Substance Abuse and Mental Health Services Administration, 2010. The NSDUH Report: Adolescent Inhalant Use and Selected Respiratory Conditions. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Rockville, MD. Williams, J.F., Storck, M., American Academy of Pediatrics Committee on Substance Abuse, American Academy of Pediatrics Committee on Native American Child Health, 2007. Inhalant abuse. Pediatrics 119, 1009–1017. Woody, G.E., Donnell, D., Seage, G.R., et al., 1999. Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET. Drug and Alcohol Dependence 53, 197–205. Wu, L.T., Howard, M.O., 2007a. Psychiatric disorders in inhalant users: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence 88, 146–155. Wu, L.T., Howard, M.O., 2007b. Is inhalant use a risk factor for heroin and injection drug use among adolescents in the United States? Addictive Behaviors 32, 265–281. Wu, L.T., Ringwalt, C.L., 2006. Inhalant use and disorders among adults in the United States. Drug and Alcohol Dependence 85, 1–11. Wu, L.T., Pilowsky, D.J., Schlenger, W.E., 2004. Inhalant abuse and dependence among adolescents in the United States. Journal of the American Academy of Child and Adolescent Psychiatry 43, 1206–1214. Wu, L.T., Pilowsky, D.J., Schlenger, W.E., 2005. High prevalence of substance use disorders among adolescents who use marijuana and inhalants. Drug and Alcohol Dependence 78, 23–32. Wu, L.T., Schlenger, W.E., Ringwalt, C.L., 2005. Use of nitrite inhalants (“poppers”) among American youth. Journal of Adolescent Health 37, 52–60. Wu, L.T., Howard, M.O., Pilowsky, D.J., 2008. Substance use disorders among inhalant users: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addictive Behaviors 33, 968–973.
Relevant Websites http://www.inhalant.org/aboutus/ – The Alliance for Consumer Education: Inhalant Abuse Prevention Program. http://www.aapcc.org/dnn/default.aspx – The American Association of Poison Control Centers (AAPCC).
III. TYPES OF ADDICTION
732
73. INHALANTS
http://www.drugfreeworld.org/about-us/about-the-foundation.html – The Foundation for a Drug-Free World. http://monitoringthefuture.org – The Monitoring the Future (MTF) survey is a series of classroom surveys of eighth, tenth, and twelfth graders conducted by researchers at the University of Michigan under a grant from the National Institute on Drug Abuse, part of the National Institutes of Health, US Department of Health and Human Services. http://www.inhalants.org/guidelines.htm – The National Inhalant Prevention Coalition (NIPC). http://teens.drugabuse.gov/facts/facts_inhale1.php – The National Institute on Drug Abuse (NIDA): information on inhalants.
http://www.oas.samhsa.gov/nhsda.htm – The National Survey on Drug Use and Health (NSDUH), formerly called the National Household Survey on Drug Abuse, is sponsored by the Substance Abuse and Mental Health Services Administration. The survey has been conducted since 1971 and serves as the primary source of information on the prevalence and incidence of illicit drug, alcohol, and tobacco use in the civilian, noninstitutionalized population aged 12 years or older in the United States. http://www.whitehousedrugpolicy.gov/about/index.html – The White House Office of National Drug Control Policy (ONDCP) is a component of the Executive Office of the President and was established by the Anti-Drug Abuse Act of 1988.
III. TYPES OF ADDICTION