INHALANTS

DR DEEPAK SINGHRESIDENTPUNE

WHAT ARE INHALANTS•Chemicals present in many house hold and industrial products

•Vapors/gases inhaled for its mind altering properties

INHALANTS-CATEGORIES

Volatile solvents Aerosols Gases Nitrites

COMMONLY ABUSED INHALANTSVolatile solvents Glues (n-hexane, toluene, xylene) Correction fluids & Marker pens(1,1,1 trichloroethane, toluene) Paint thinners & removers (dichloro methane, toluene, xylene) Dry cleaning fluids (trichloroethylene, 1,1,1 trichloroethane) Nail polish remover (acetone esters) Petrol (benzene, n-hexane, toluene, xylene)

COMMONLY ABUSED INHALANTSAerosols Deodorants, hair spray, refrigerants (freons, flurocarbon propellant)Gases Lighter fluids (butane, propane) Propellants in whipped creams (nitrous oxide) Anesthetic gases (NO, ether etc.)Nitrites Room odorizers and liquid incense (amyl, butyl, isobutyl nitrites)

MODES OF ABUSE

sniffing bagging huffing

spraying glading dusting

WHY SOLVENTS ?

A rapid high - much faster than drugs or alcohol.

Relatively cheap, easy to buy.

Not illegal, easily available.

Escape from reality and conflicts.

Novelty seeking and peer influence.

As a replacement for other substances.

(NIDA 2012)

NEUROBIOLOGICAL CONSIDERATIONS

• An abuser intakes 20-30 times exposure of substances than an accidental exposure (>6000 ppm).

• Solvents are highly lipophilic thus cross biological membranes easily.

• Affect cell membranes in a similar way to anesthetics.

• Not known to have any unique receptors or mimic an endogenous ligands.

(Lubeman et al, Br J Pharmacol 2008, May 154(2):316-326)

ACUTE EFFECTS• Inhibition of NMDA subunits• GABA agonistic activity• Increased DA in VTA & NA (addiction potential)Dysruption of :Activity of numerous voltage gated ion channelsCalcium signallingATPasesG proteins

(Lubeman et al, Br J Pharmacol 2008, May 154(2):316-326)

Stages of inhalant intoxication

Stage 1-Excitatory stage (euphoria , excitation )

Stage 2-Stage of early CNS depression (slurred speech , visual hallucination )

Stage 3-Stage of medium CNS depression (ataxia, confusion , delirium )

Stage 4-Stage of late CNS depression (stupor ,seizure ,coma ,death)

(Mathew etal, Addict Sci clin Pract 2011, Jul; 6(1):18-31)

SUDDEN SNIFFING DEATH SYNDROMES

• Severe dysarrhythmias (nitrites, toluene, benzene)• Sudden cold injury to airways (freons)• Severe burn injury to airway tracts (butane,

propane)• Suffocation (bagging) • Aspiration & choking• Severe brain hypoxemia• Accidents & falls

(NIDA 2012)

Chronic exposure

• ALLOSTASIS : Semi-chronic (4 days) exposure caused an increase in NMDA evoked responses with a decrease in GABA-evoked responses.

• Consistent with a hyper excitability / hyper-glutamatergic state during withdrawal like in ADS.

(Lubeman etal, Br J Pharmacol 2008, May 154 (2): 316-326)

CHRONIC EXPOSURE (Contd.)

• Most damage to white matter structures and the lipid component of the myelin sheath.

• Commonly observed neuropsychological deficits(impairments in processing speed, sustained attention, memory retrieval, executive function and language) are consistent with white matter pathology.

(Geibprasert etal, Am J Neuroradiol 2010, May,31:803-08)

CHRONIC EFFECTS (Contd.)

• Significant improvements in previously identified impairments(impaired associate learning and attention deficits)following 2 years abstinence from petrol sniffing.

• MRI abnormalities are however reported

to be irreversible.

MRI FINDINGS IN CHRONIC EXPOSURE

• White matter diffuse T2 hyper intensities • Atrophy • T2 hypointensities in thalami and basal ganglia

Marked atrophy of brain in inhalant abuser

(Geibprasert etal, Am J Neuroradiol 2010, May,31:803-08)

Neurological sequelae

• Diplopia, ataxia, depressed reflexes, nystagmus, tremor.• SNHL , optic neuropathy(toluene)• EEG slowing, peripheral neuropathy (n-hexane)• Trigeminal neuralgia (trichloroethylene)• Parkinsonism• Sensori motor polyneuropathy (methyl butyl ketone)

(Mathew etal, Addict Sci clin Pract 2011, Jul; 6(1):18-31)

NEUROPSYCHIATRIC SEQUELAE

• Subcortical dementia• Low IQ• Memory retrieval delay• Poor attention & concentration• Insomnia, apathy, • Aggression with trivial provocation• Depression• Psychosis ( florid hallucinations)

(Mathew etal, Addict Sci clin Pract 2011, Jul; 6(1):18-31)

Effects on other organs

• Renal : RTA(toluene), Good pasture's syndrome (toluene; n-hexane), Electrolyte imbalance

• CVS : Arrhythmias, sinusbradycardia, decreased myocardial contractility, hypoxia induced heart block, myocarditis

• RS : Dyspnea, wheezing, chemical pleuritis, emphysema (toluene).

• GIT : Nausea, vomiting , hepatotoxicity, induce CYT P-450 (toluene), Anorexia(lead).

• DERMAT : staining, perioral eczema ,contact dermatitis, burns.

• HEMATO : bone marrow suppression, leukemia, aplastic anemia (benzene).

• EMBRYOPATHY: “FETAL SOLVENT SYNDROME” Children born to mothers using toluene in pregnancy show growth retardation, craniofacial dysmorphism, hearing loss, cleft palate, developmental delay, cerebellar dysfunction.

(Guidelines on Inhalants, National Inhalant Prevention Coalition Website updated 2012)

CLINICAL FEATURES

PHYSICAL APPEARANCE BEHAVIOR

•Dazed looks & apathy•Social withdrawal•Unsteady gait•Slurred speech•Forgetfulness•Irritability aggression•Anxiety and insomnia

NIDA 2012

RISK FACTORS• Adverse socio-

economic conditions

• H/O child-abuse• Poor graders• School dropout

Less formal education

Peer pressureParental abuse Dysfunctional

families

(Gupta etal, Indian J Med Res 2014, May,139(5): 708-713)

CATEGORIES OF USERS• Transient social user ( 10-16 yr old, short history, average

intelligence, use with friends)

• Chronic social user (20-30 yr old, 5+ yr use, daily use, with friend,, with friends, brain damage)

• Transient isolate user (10-16 yr old, short history, average IQ, solo use)

• Chronic isolate user (20-30 yr old, 5+ yrs, daily use, brain damage, lonely use)

(Guidelines on Inhalants, National Inhalant Prevention Coalition Website updated 2012)

DANGER OF EARLY USE

• Increased risk of dependence• Subsequent shifting to other class of drugs

(gateway hypothesis)• ASPD & poor IP relations• Mood disorders• Poor achiever• Suicides & DSH• Early medical complications

MANAGEMENTGeneral Principles:

• Acute medical management (in case of intoxication)

• Detailed history (including products used, other substances, psychiatric symptoms).

• Physical examination including detailed Neurological (especially in chronic abusers).

• Lab investigations for Liver & Kidney function, ECG.

• Pharmacological management for withdrawal symptoms and associated medical / psychiatric conditions.

• Psychosocial interventions

Kumar etal, Indian J Psychiatry 2008, Apr-Jun; 50(2): 117-120

MANAGEMENT (contd.)

Pharmacotherapy:• Some authors recommend BZDs to be used for treatment of

withdrawal symptoms as inhalant act as CNS depressants. (Brouette. et al 2001)

• Baclofen (around 50mg/d) has been found useful in reducing craving and withdrawal symptoms in a case series.

(Muralidharan K. et al 2008)

• Buspirone (40mg/d) was found useful in reducing frequency of petrol inhalational abuse in a case report.

(Niederhofer et al 2007)

• Lamotrigine (100mg/d) was also found to reduce craving and maintain abstinence in a case of inhalant dependence.

(Shen Y. et al 2007)

Psychosocial intervention:

PREVENTION

• Tackling supply:Product elimination/modificationWarning labelsEducating manufacturers/suppliersSales controls

• Tackling demand: Legal control Information and education with skills-building

• A notification was published in Extraordinary Gazette, 17th July 2012 by Ministry of Health and Family Welfare, Government of India:

- Banning production/sale of bottled Correction fluids/Thinners.

- Mandatory warning regarding effects on health.

EXTERNALIZING & INTERNALIZING SPECTRUM

Externalizing spectrum• Less attention spans• Hyperactivity• High novelty seeking• Easy need for gratification• High impulsivity • Poor frustration tolerance• Aggression

• Internalizing spectrum - (phobias, social anxiety, depressive states , obsessions)

ADHD

Conduct disorder

Oppositional defiant disorder

Tacket , Child Development Perspectives, vol 4,3: 161-167

OPPOSITIONAL DEFIANT DISORDER(ICD -10, F 91.3)• Pattern of persistently negativistic, hostile, defiant,

provocative and disruptive behavior outside normal range of behavior for child of same age

• Does not include more serious violations of the rights of others (unlike aggressive and dissocial behavior of socialized & unsocialized conduct disorder)

• Tend to be angry, resentful, easily annoyed by other people whom they blame for their own mistakes or difficulties.

• Low frustration tolerance & readily lose temper.• More evident in interactions with adults or peers whom

child knows well (may not be evident during clinical interview)

Biopsychosocial ModelAverage

IQ,ODD traits

Impulsive Suicide in mother

Substance Use in father

Academic decline,Punitive

treatment

Death of mother in early

age, step mom

Poor socio economic state,

Dysfunctional family dynamics

Peer influence

&SUBSTANCE

USE

ALTERED DEVELOPMENTAL

TRAJECTORY

PREVENTION at INDIVIDUAL & FAMILY LEVEL (MOSTLY IGNORED)

REALISTIC APPRAISAL OF ABILITIES

(NO EXPECTATION Vs REALITY MISMATCH )

EMOTONALLY SUPPORTIVE

(EMPATHETIC) &OPEN COMMUNICATION

STYLE

REDUCING EXPRESSED

EMOTIONS (EE)

ACTIVITY SCHEDULING

ENLISTING SUPPORT SYSTEMS

UNDERSTANDING NEED

(FOR USE OF SUBSTANCES)

REALISTIC GOALS

FAMILY ORIENTATIONASSERTIVENESS

TRAINING

EARLY ATTETION

TAKE HOME POINTS

• Solvent abuse is a significant problem which is often ignored.

• It has long term neuropsychological and other medical complications.

• Simple interventions can prove fruitful.

Thank you