Inhalant Use Disorder

Inhalant Use Disorder

Inhalant Use Disorder

Primer

Inhalant Use Disorder is a substance use disorder characterized by a problematic pattern of inhalant (volatile hydrocarbons/gases from glues, fuels, paints, and other volatile compounds) use leading to clinically significant impairment or distress.

Epidemiology

In the United States, about 0.4% of individuals ages 12 to 17 years have a pattern of use that meets criteria for inhalant use disorder in the past year.^[1]
- About 10% of teenage American children (ages 13 to 17) report having used inhalants at least once during their lifetimes.^[2]
- The most commonly used inhalants in this group include glue, shoe polish, toluene, gasoline, lighter fluid, or spray paint.^[3]
- Only a minority of these youths will progress to an inhalant use disorder (around 20%).
- Although the prevalence of inhalant use disorder is the same in adolescent males and females, the disorder becomes extremely rare in adult females.^[4]
The prevalence declines significantly among individuals in their 20s.^[5]
In some countries, homeless children in street gangs have inhalant use problems.^[6]

Prognosis

Repeated inhalant use can result in peripheral neuropathy, cerebellar dysfunction, cranial nerve damage, cortical atrophy, encephalopathy and dementia.^[7]
In rare cases, there have been inhalant-related accidents, or “sudden sniffing death” From sudden cardiac arrhythmias.^[8]
- Fatalities can occur even on first inhalant exposure, and is not dose-related.
Those with inhalant use disorder that progress into adulthood often have severe substance use disorders, antisocial personality disorder, and increased risk for suicide.^[9]

Comorbidity

Inhalant use is associated with suicide attempts, particularly in adults with previous low mood or anhedonia.^[10]
- Individuals are also at increased risk for depression and anxiety disorders.
Routine volatile hydrocarbon leads to neurobehavioral difficulties, neurological, gastrointestinal, cardiovascular, and pulmonary problems.^[11]
Studies have shown that long-term inhalant users are at increased risk for tuberculosis, HIV/AIDS, sexually transmitted diseases, bronchitis, asthma, and sinusitis.
- Deaths can occur from variety of causes including respiratory depression, arrhythmias, asphyxiation, aspiration of vomitus, or accident and injury.

Risk Factors

The availability of inhalant gases increases the risk for misuse. Adverse childhood events is also a risk factor for progression to inhalant use disorder.
Youth with strong behavioural disinhibition traits are at increased risk for inhalant use disorder, early- onset substance use disorder, polysubstance use, and early conduct problems (leading to conduct disorder).^[12]

DSM-5 Diagnostic Criteria

Criterion A

A problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:

The inhalant substance is often taken in larger amounts or over a longer period than was intended
There is a persistent desire or unsuccessful efforts to cut down or control use of the inhalant substance
A great deal of time is spent in activities necessary to obtain the inhalant substance, use it, or recover from its effects
Craving, or a strong desire or urge to use the inhalant substance
Recurrent use of the inhalant substance resulting in a failure to fulfill major role obligations at work, school, or home
Continued use of the inhalant substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use
Important social, occupational, or recreational activities are given up or reduced because of use of the inhalant substance
Recurrent use of the inhalant substance in situations in which it is physically hazardous
Use of the inhalant substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
Tolerance, as defined by either of the following:
1. A. A need for markedly increased amounts of the inhalant substance to achieve intoxication or desired effect.
2. B. A markedly diminished effect with continued use of the same amount of the inhalant substance.

Note: Since the withdrawal symptoms in inhalant use disorder are mild, the DSM-5 neither recognizes a diagnosis of inhalant withdrawal nor counts withdrawal complaints as the diagnostic criterion for inhalant use disorder.

Specifiers

Inhalant Specifier

Specify the particular inhalant: When possible, the particular substance involved should be named (e.g. - “solvent use disorder”).

Remission Specifier

Specify if:

In early remission: After full criteria for inhalant use disorder were previously met, none of the criteria for inhalant use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the inhalant substance,” may be met).
In sustained remission: After full criteria for inhalant use disorder were previously met, none of the criteria for inhalant use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the inhalant substance,” may be met).

Environment Specifier

Specify if:

In a controlled environment: This additional specifier is used if the individual is in an environment where access to inhalant substances is restricted.

Severity Specifier

Specify if:

Mild: Presence of 2 to 3 symptoms
Moderate: Presence of 4 to 5 symptoms
Severe: Presence of 6+ symptoms

Signs and Symptoms

Tolerance and mild withdrawal are each reported by about 10% of individuals who use inhalants, but few individuals will use inhalants to avoid withdrawal.
Individuals may have lingering odours of inhalant substances.

Inhalant Types

Volatile hydrocarbons include toxic gases from glues, fuels, paints, and other volatile compounds.
However, most compounds that are inhaled are a mixture of several substances that can produce psychoactive effects, and it is often difficult to ascertain the exact substance responsible for the disorder.

Nitrous Oxide ("Whippet")

Inhalation of nitrous oxide or of amyl-, butyl-, or isobutylnitrite are actually not classified by the DSM-5 as an inhalant use disorder, but rather as an “Other (or unknown) substance use disorder.”
Nitrous oxide (“laughing gas”) is an anesthetic agent, which can lead to misuse by some medical and dental professionals.
It is also used as a propellant in commercial products (e.g. - whipped cream dispensers), and has been misused by food service workers.
- With increased widespread availability of “whippet” cartridges in home whipped cream dispensers, nitrous oxide misuse in young adults has grown significantly, especially among those who also inhale volatile hydrocarbons.
- Serious medical and psychiatric complications can result, including myeloneuropathy, spinal cord subacute combined degeneration, peripheral neuropathy, and psychosis.

Screening and Rating Scales

Inhalant Screening Tools

Name	Rater	Description	Download
Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT Screening Test)	Clinician/Patient	6-item screening tool designed to identify substance use, substance-related riding/driving risk, and substance use disorder in youth ages 12 to 21.	Link

Pathophysiology

See main article: Introduction to Addiction Medicine: Conceptualizing Addiction

See also: Lubman, D. I., Yücel, M., & Lawrence, A. J. (2008). Inhalant abuse among adolescents: neurobiological considerations. British journal of pharmacology, 154(2), 316-326.

Like with all substance use disorders, there is a complex interplay between biological, social, psychological, and cultural factors.

Differential Diagnosis

Inhalant exposure (unintentional) from industrial or other accidents
- This designation is used when findings suggest repeated or continuous inhalant exposure but the involved individual and other informants deny any history of purposeful inhalant use.
Inhalant use (intentional), without meeting criteria for inhalant use disorder
- Inhalant use is common among adolescents, but for most of those individuals, the inhalant use does not meet the diagnostic standard of 2 or more Criterion A items for inhalant use disorder in the past year.
Inhalant intoxication, without meeting criteria for inhalant use disorder
- Inhalant intoxication occurs frequently during inhalant use disorder but also may occur among individuals whose use does not meet criteria for inhalant use disorder, which requires at least 2 of the 10 diagnostic criteria in the past year.
Inhalant-induced disorders (i.e. - inhalant-induced psychotic disorder, depressive disorder, anxiety disorder, neurocognitive disorder, other inhalant-induced disorders) without meeting criteria for inhalant use disorder
- In this diagnosis criteria are met for a psychotic, depressive, anxiety, or major neurocognitive disorder, and there is evidence from history, physical examination, or laboratory findings that these deficits are related to the effects of inhalants. However, the criteria for inhalant use disorder may not be met (i.e. - fewer than 2 of the 10 criteria were present).

Other substance use disorders, especially those involving sedating substances (e.g. - alcohol, benzodiazepines, barbiturates)
- Inhalant use disorder can co-occur with other substance use disorders, and the symptoms may be similar and overlap.
Other toxic, metabolic, traumatic, neoplastic, or infectious disorders impairing central or peripheral nervous system function
- Individuals with inhalant use disorder may have symptoms of pernicious anemia, subacute combined degeneration of the spinal cord, psychosis, major or minor cognitive disorder, brain atrophy, leukoencephalopathy, and other nervous system disorders. A history about possible inhalant use helps to include or exclude inhalant use disorder as the etiology of these problems.
Disorders of other organ systems
- Individuals with inhalant use disorder may have hepatic or renal damage, rhabdomyolysis, methemoglobinemia, gastrointestinal, cardiovascular, or pulmonary diseases. A history about possible inhalant use helps to include or exclude inhalant use disorder as the etiology of these problems.

Investigations

See also: Baydala, L., Canadian Paediatric Society, & First Nations, Inuit and Métis Health Committee. (2010). Inhalant abuse. Paediatrics & child health, 15(7), 443-448.

Standard drug screens do not detect inhalants, and will show up as negative.^[13]
- Urine, breath, or saliva tests may be helpful to assess for non-inhalant substances for individuals with inhalant use disorder.^[14]
- Inhalant-specific diagnostic assays and tests are expensive, and thus not practical in routine clinical practice.
Bloodwork may show rhabdomyolysis.

Neuroimaging

There may be brain white matter pathology on neuroimaging.^[15]

Physical Exam

On physical exam, there may be a peri-oral or peri-nasal “glue-sniffer's rash.”^[16]

Treatment

Resources

For Patients

National Institute on Drug Abuse (NIDA) - Inhalants DrugFacts

For Providers

Articles

Research

¹⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

²⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

³⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁴⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁵⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁶⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

⁷⁾ Lubman, D. I., Yücel, M., & Lawrence, A. J. (2008). Inhalant abuse among adolescents: neurobiological considerations. British journal of pharmacology, 154(2), 316-326.

⁸⁾ Bass, M. (1970). Sudden sniffing death. JAMA, 212(12), 2075-2079.

⁹⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹⁰⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹¹⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹²⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹³⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹⁴⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹⁵⁾ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

¹⁶⁾ Fink, B., Landthaler, M., & Hafner, C. (2011). Skin alterations due to illegal drug abuse. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 9(8), 633-639.

¹⁷⁾ Baydala, L., Canadian Paediatric Society, & First Nations, Inuit and Métis Health Committee. (2010). Inhalant abuse. Paediatrics & child health, 15(7), 443-448.

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