Alcohol and drugs week 5
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Alcohol and drugs week 5
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- Inhalant abuse is a prevalent and often overlooked form of substance abuse in adolescents. Survey results consistently show that nearly 20 percent of children in middle school and high school have experimented with inhaled substances. The method of delivery is inhalation of a solvent from its container, a soaked rag, or a bag. Solvents include almost any household cleaning agent or propellant, paint thinner, glue, and lighter fluid. Inhalant abuse typically can cause a euphoric feeling and can become addictive. Acute effects include sudden sniffing death syndrome, asphyxia, and serious injuries (e.g., falls, burns, frostbite). Chronic inhalant abuse can damage cardiac, renal, hepatic, and neurologic systems. Inhalant abuse during pregnancy can cause fetal abnormalities. Diagnosis of inhalant abuse is difficult and relies almost entirely on a thorough history and a high index of suspicion. No specific laboratory tests confirm solvent inhalation. Treatment is generally supportive, because there are no reversal agents for inhalant intoxication. Education of young persons and their parents is essential to decrease experimentation with inhalants. (Am Fam Physician 2003;68:869-74,876. Copyright© 2003 American Academy of Family Physicians.) A patient information handout on inhalant abuse, written by the authors of this article, is provided on page 876. A PDF version of this document is available. Download PDF now (6 pages /81 KB). More information on using PDF files. A lthough inhalant abuse is quite prevalent, it is an often overlooked form of substance abuse in adolescents. National surveys1 report that nearly 20 percent of young persons have experimented with inhalants at least once by the time they are in eighth grade. In the United States, the mean age of first-time inhalant abuse is 13 years.2 At present, rates of abuse are higher in Hispanics and whites than in blacks. See page 785 for definitions of strength-of-evidence levels. Because the inhalants that are abused are in common household products and are relatively inexpensive, they are accessible to children who are too poor or too young to access other drugs. Furthermore, inhalant abuse appears to be a gateway phenomenon among younger adolescents: children who abuse inhalants early in life are more likely later to use other illicit drugs.3,4 Injuries and illnesses related to inhalant abuse occur with alarming frequency. Hence, family physicians should be alert to the presence of this form of substance abuse in young patients and should provide information about its acute and chronic effects. Parents also should be educated about the warning signs and dangers of inhalant abuse. See editorial on page 811. Illustrative Case 1 A 21-year-old man is unconscious when he is brought to the emergency department. His friends report that he has been "huffing" (placing a rag soaked in a substance over his nose and mouth and then inhaling) for several months. On examination, the thin young man is briefly arousable to deep pain. He slowly becomes more arousable. Laboratory tests and a computed tomographic (CT) scan of the head are negative. At 24 hours after presentation, the patient becomes completely coherent and demands to be released from the hospital. He is released against medical advice. Three weeks later, the young man again presents to the emergency department, this time in full cardiac arrest. After extensive resuscitative efforts, the patient dies. Family and friends confirm that he had been inhaling gun cleaner daily. Signs of recent inhalant abuse include paint or oil stains on clothing or skin, spots or sores around the mouth, red eyes, rhinorrhea, chemical odor on the breath, and a dazed appearance. Illustrative Case 2 A 13-year-old girl with a primary complaint of headaches is brought to the physician's office by her mother. The patient reports headaches that have been increasing in frequency over the past year and are now present daily. The headaches have resulted in several days missed from school. The patient's mother also notes that the adolescent occasionally seems confused and uncoordinated ("clumsy"), and is "not eating much." Her grades have declined dramatically over the past semester. On physical examination, the patient is noted to have dry, cracked perioral skin with irritation and sores on the lips, and fingernail beds that appear to be stained with ink. The examination is otherwise normal. During private questioning, the patient admits to sniffing glue and spray paint "once or twice" with a friend over the past few months. Definition Inhalant abuse involves breathing in a substance directly from its container (sniffing or snorting), placing a rag soaked in the substance over the nose and mouth and inhaling ("huffing"), or pouring the substance into a plastic bag and breathing the fumes ("bagging").5(pp257-60) Abused substances include fuels, solvents, propellants, glues, adhesives, and paint thinners. The active chemicals in commonly abused inhalants are listed in Table 1 .6,7 Abuse of amyl and butyl nitrites (called "poppers") is not included in this review because of the different mechanism of action and adverse effects of these substances.8 Inhaled solvents likely share cellular actions with g-aminobutyric acidreceptor drugs (e.g., benzodiazepines, barbiturates, alcohol), resulting in a depressant effect.5(pp257-60) TABLE 1 Chemicals in Commonly Abused Inhalants Chemical Commonly abused inhalants ToluenePaint thinner, spray paint, airplane glue, rubber cement, nail polish remover, shoe polish ButaneLighter fluid, fuel, spray paint, hair spray, room freshener, deodorants PropaneGas grill fuel, spray paint, hair spray, room freshener, deodorants FluorocarbonsAsthma sprays, analgesic sprays, Freon® gas, spray paint, hair spray, deodorants, room freshenersChlorinated hydrocarbonsDry-cleaning agents, spot removers, degreasers, correction hydrocarbons fluid AcetoneNail polish remover, rubber cement, permanent markers Adapted with permission from Bowen SE, Daniel J, Balster RL. Deaths associated with inhalant abuse in Virginia from 1987 to 1996. Drug Alcohol Depend 1999;53:241, and Sharp CW, Rosenberg NL. Inhalants. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance abuse: a comprehensive textbook. 3d ed. Baltimore: Williams & Wilkins, 1997:246-64. Use of inhalants can produce a euphoric feeling similar to that experienced with other illicit drugs.9 When a person using inhalants becomes hypercapnic and hypoxic by rebreathing from a closed bag, the effects of the inhalant are intensified.8 The criteria for inhalant abuse, intoxication, and dependence are outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). These criteria are listed in Table 2 .5(p239) TABLE 2 Diagnostic Criteria for Inhalant Intoxication Recent intentional use or short-term, high-dose exposure to volatile inhalants (excluding anesthetic gases and short-acting vasodilators) Clinically significant maladaptive behavior or psychologic changes (e.g., belligerence, assaultiveness, apathy, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, use of or exposure to volatile inhalants 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, or euphoria The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Rev. Washington, D.C.: American Psychiatric Association, 2000:239. Presentation In the office setting, it is seldom obvious which preadolescent or adolescent patients are abusing inhalants. Victims of child abuse tend to be at greater risk for inhalant abuse,10 as are young persons whose friends or relatives abuse other substances. Patients who have been abusing inhalants may report dizziness, irritability, tiredness, loss of appetite, headache, photophobia, or cough.11,12 Most symptoms are nonspecific and can be mistaken for those of other illnesses or syndromes. Signs of recent inhalant abuse include paint or oil stains on clothing or skin, spots or sores around the mouth, red eyes, rhinorrhea, chemical odor on the breath, and a dazed appearance (Table 3) .13 TABLE 3 Signs and Symptoms of Inhalant Abuse Physical appearance Paint or oil stains on clothing or body Chemical odor on breath Spots or sores in or around mouth Rhinorrhea Injected sclera Nystagmus Diplopia Stained fingernails Behavior Dazed appearance Dizziness or unsteady gait Slurred speech Forgetfulness or difficulty concentrating Anorexia or nausea Irritability or excitability Anxiety Sleep disturbances Adapted with permission from Jones HE, Balster RL. Inhalant abuse in pregnancy. Obstet Gynecol Clin North Am 1998;25:161. Patients with long-term inhalant abuse can present to the emergency department or office setting with a wide range of neuropsychiatric signs and symptoms. The most commonly recognized acute presentation is sudden unconsciousness or death during known inhalation of a solvent. Other, nonspecific complaints include the following: memory loss, especially loss of short-term memory; delusions or hallucinations; slurred or changed speech; staggering, stumbling, or wide-based ataxic gait; visual and optical changes, such as nystagmus; and loss of hearing or sense of smell.8 Unfortunately, no specific syndromes or clinical presentations confirm inhalant abuse. Because of the variety of solvents that are inhaled, the range of adverse effects is quite broad9 (Table 4) .14 Furthermore, it is difficult to pinpoint which chemicals cause adverse effects, because the biologically active compound is often a metabolite of the listed active compound. TABLE 4 Adverse Effects of Inhalants Cardiovascular effects Dysrhythmias Hypoxia-induced heart block Myocardial fibrosis Sudden sniffing death syndrome Dermatologic effects Burns Contact dermatitis Perioral eczema Gastrointestinal effects Hepatotoxicity Nausea or vomiting Hematologic effects Aplastic anemia Bone marrow suppression Leukemia Neurologic effects Ataxia Cerebellar degeneration Change in speech Nystagmus Peripheral neuropathy Sensorimotor polyneuropathy Tremor White matter degeneration Neuropsychiatric effects Apathy Dementia Depression Insomnia Memory loss Poor attention Psychosis Pulmonary effects Cough or wheezing Dyspnea Emphysema Goodpasture's syndrome Pneumonitis Renal effects Acid-base disturbance Acute renal failure Fanconi's syndrome Renal tubular acidosis Adapted with permission from Brouette T, Anton R. Clinical review of inhalants. Am J Addict 2001;10:84. The most serious acute consequence of inhalant abuse is death, which usually occurs secondary to aspiration, accidental trauma, or asphyxia. Other acute causes of death include cardiac arrhythmias, anoxia, vagal inhibition, and respiratory depression. As many as 50 percent of inhalant-related deaths are caused by sudden sniffing death syndrome.15,16 This syndrome occurs when the acutely intoxicated inhalant abuser is startled, causing the release of a burst of catecholamines that can trigger ventricular fibrillation.8 Other serious acute effects include burns from accidental flash fires, hypothermic injuries from propellants, and the triggering of underlying asthma or allergic reactions. Chronic inhalant use causes toxicity to several organs, including the brain, heart, lung, kidney, liver, and bone marrow. Cardiac toxicity encompasses myocardial edema, irreversible myocarditis, fibrosis, and congestive heart failure.8 Respiratory damage often is related to toluene abuse and can include panacinar emphysema17 and Goodpasture's syndrome.18 Renal toxicity entails distal renal tubular acidosis, anion-gap acidosis, Fanconi's syndrome, renal calculi, hematuria, proteinuria, and renal failure. Toluene-induced renal tubular acidosis is reversible after cessation of inhalants. Long-term inhalant use can result in bone marrow suppression, leading to leukopenia, anemia, thrombocytopenia, and hemolysis.11 Hepatic toxicity also has been reported.19 Sudden sniffing death syndrome occurs when the acutely intoxicated inhalant abuser is startled, causing the release of a burst of catecholamines that can trigger ventricular fibrillation. Neurologic toxicity is the most recognized and reported chronic side effect of inhaled solvent abuse. Common findings on brain imaging include enlarged ventricles, widened cortical sulci, and cerebral, cerebellar, or brain stem atrophy.8 Magnetic resonance imaging suggests that these white-matter changes in chronic abusers are irreversible.20 Dementia, chronic encephalopathy, and peripheral neuropathy also occur. Peripheral neuropathy may present as proximal or distal muscle weakness, muscle wasting, absent or decreased tendon reflexes, or paresthesias. Peripheral neuropathy may be confused with Guillain-Barré syndrome but can be distinguished by sural nerve biopsy, which will show axonal swelling in inhalant abusers.8 Inhalant abuse by women who are pregnant can increase the risks of spontaneous abortion. It also can result in fetal solvent syndrome, which manifests as low birth weight, small head size, facial dysmorphology, and muscle tone abnormalities similar to those occurring in fetal alcohol syndrome.13 Diagnosis The diagnosis of inhalant abuse relies almost entirely on a high index of suspicion. A diligent history and a thorough physical examination are the mainstays of diagnosis. Only a few laboratory tests are helpful in detecting inhalant abuse. Suggested laboratory testing for a patient presenting with acute inhalant intoxication or suspected inhalant use includes a complete blood count, determination of electrolyte, phosphorous, and calcium levels, an acid-base assessment, hepatic and renal profiles, and cardiac/muscle enzyme analysis.11 Blood collected in a sealed tube containing ethylenediaminetetraacetic acid or heparin can be analyzed by gas chromatography for the presence of aliphatic hydrocarbons (the substances found in inhaled solvents).11 However, this test is usually unavailable on an emergency basis. A urine drug screen is recommended to rule out other illicit drug use. An electrocardiogram should be obtained to detect dysrhythmias, and brain imaging should be performed if neurologic findings are present. Treatment The treatment of acute inhalation-related injury and illness is generally supportive. Acute dysrhythmias should be treated according to established protocols. The use of sympathomimetics (e.g., epinephrine, norepinephrine, isoproterenol [Isuprel]) should be avoided in patients with ventricular fibrillation.21 Beta blockers should be administered early to protect the catecholamine-sensitized heart. Acid-base and metabolic disturbances should be corrected. Cardiopulmonary monitoring is recommended because of the risk of apnea and cardiac arrest after acute exposure.12 Many acute neurologic findings are reversible after cessation of inhalants. Chronic neurologic sequelae (e.g., dementia, cerebral dysfunction, cerebellar dysfunction) are often permanent and difficult to manage. Fetal solvent syndrome manifests as low birth weight, small head size, facial dysmorphology, and muscle tone abnormalities similar to those occurring in fetal alcohol syndrome. Treatment of inhalant abuse and dependence involves counseling, strict abstinence by the abuser, and other drug dependency protocols (e.g., 12-step programs, support groups, inpatient and outpatient dependency treatment). However, a survey22 of drug treatment providers concluded that most treatment programs are not yet adequately equipped to handle inhalant abuse or dependence. While addiction to inhalants has been reported in various case studies, no studies have estimated its prevalence. Tolerance to inhalants can develop with frequent use. A withdrawal syndrome has been described, although it occurs infrequently. When withdrawal occurs, it should be supported in a controlled setting, if possible. Withdrawal symptoms are similar to those that occur in withdrawal from alcohol or benzodiazepines. Symptoms can include sleep disturbance, irritability, jitteriness, diaphoresis, nausea, vomiting, tachycardia and, occasionally, hallucinations or delusions.5(pp257-60) Withdrawal can last one month or longer, and relapse rates are high.22 Currently, no specific agents can reverse acute solvent intoxication. In addition, no medications have proved helpful in the treatment of inhalant withdrawal or dependence. Prevention Prevention of inhalant abuse is a primary goal, and preadolescents and adolescents should be given extra attention. In addition to questions about tobacco, alcohol, or other drug use, the social history should include a question about "huffing" and "sniffing." For example, "Have you or your friends ever tried sniffing glue or paint thinner?" Any experimentation by the patient or the patient's friends should be considered a risk factor. The dangers of sudden death, burns, flash fires, and serious brain damage should be reiterated to patients who are at risk for inhalant abuse. Parents also should be informed about the dangers and warning signs of inhalant abuse. Promoting education of children, parents, and teachers is essential to curtailing inhalant abuse.16 [Evidence level C, expert opinion] The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. The Authors CARRIE E. ANDERSON, M.D., is associate director of the family practice residency program at St. Francis Hospital and Health Centers, Beech Grove, Ind. Dr. Anderson received her medical degree from Indiana University School of Medicine, Indianapolis, and completed a family practice residency at St. Francis Hospital. GLENN A. LOOMIS, M.D., is program director of the family practice residency program at Mercy Health System, Janesville, Wisc., and assistant clinical professor in the Department of Family Medicine at Indiana University School of Medicine. He received his medical degree from Ohio State University College of Medicine and Public Health, Columbus, and completed a family practice residency at Community Hospitals of Indianapolis. Address correspondence to Carrie E. Anderson, M.D., St. Francis Family Practice Center, 1500 Albany St., Ste. 807, Beech Grove, IN 46107 (e-mail: [email_address] ). Reprints are not available from the authors. REFERENCES 2001 Monitoring the future survey release. Smoking among teenagers decreases sharply and increase in ecstasy use slows. U.S. Department of Health and Human Services HHS News; December 19, 2001. Retrieved July 3, 2003, from www.nida. nih.gov/MedAdv/01/NR12-19.html. McGarvey EL, Clavet GJ, Mason W, Waite D. Adolescent inhalant abuse: environments of use. Am J Drug Alcohol Abuse 1999;25:731-41. Bennett ME, Walters ST, Miller JH, Woodall WG. Relationship of early inhalant use to substance use in college students. J Subst Abuse 2000;12: 227-40. Young SJ, Longstaffe S, Tenenbein M. Inhalant abuse and the abuse of other drugs. Am J Drug Alcohol Abuse 1999;25:371-5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 2000:239,257-60. Bowen SE, Daniel J, Balster RL. Deaths associated with inhalant abuse in Virginia from 1987 to 1996. Drug Alcohol Depend 1999;53:239-45. Sharp CW, Rosenberg NL. Inhalants. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance abuse: a comprehensive textbook. 3d ed. Baltimore: Williams & Wilkins, 1997:246-64. Meadows R, Verghese A. Medical complications of glue sniffing. South Med J 1996;89:455-62. Balster RL. Neural basis of inhalant abuse. Drug Alcohol Depend 1998;51:207-14. Fendrich M, Mackesy-Amiti ME, Wislar JS, Goldstein PJ. Childhood abuse and the use of inhalants: differences by degree of use. Am J Public Health 1997;87:765-9. Broussard LA. The role of the laboratory in detecting inhalant abuse. Clin Lab Sci 2000;13:205-9. Kurtzman TL, Otsuka KN, Wahl RA. Inhalant abuse by adolescents. J Adolesc Health 2001;28:170-80. Jones HE, Balster RL. Inhalant abuse in pregnancy. Obstet Gynecol Clin North Am 1998;25:153-67. Brouette T, Anton R. Clinical review of inhalants. Am J Addict 2001;10:79-94. Bass M. Sudden sniffing death. JAMA 1970;212: 2075-9. Inhalant abuse. American Academy of Pediatrics, Committee on Substance Abuse and Committee on Native American Child Health. Pediatrics 1996; 97:420-3. Schikler KN, Lane EE, Seitz K, Collins WM. Solvent abuse associated pulmonary abnormalities. Adv Alcohol Subst Abuse 1984;3:75-81. Robert R, Touchard G, Meurice JC, Pourrat O, Yver L. Severe Goodpasture's syndrome after glue sniffing. Nephrol Dial Transplant 1988;3:483-4. O'Brien E, Yeoman WB, Hobby JA. Hepatorenal damage from toluene in a "glue-sniffer." Br Med J 1971;2:29-30. Maruff P, Burns CB, Tyler P, Currie BJ, Currie J. Neurological and cognitive abnormalities associated with chronic petrol sniffing. Brain 1998;121(pt 10): 1903-17. Adgey AA, Johnston PW, McMechan S. Sudden cardiac death and substance abuse. Resuscitation 1995;29:219-21. Beauvais F, Jumper-Thurman P, Plested B, Helm H. A survey of attitudes among drug user treatment providers toward the treatment of inhalant users. Subst Use Misuse 2002;37:1391-410.
- Text Version of “general Overview” What are inhalants? Inhalants are breathable chemicals that produce psychoactive (mind-altering) vapors. People do not usually think of inhalants as drugs because most of them were never meant to be used that way. They include solvents, aerosols, some anesthetics, and other chemicals. Examples are model airplane glue, nail polish remover, lighter and cleaning fluids, and gasoline. Aerosols that are used as inhalants include paints, cookware coating agents, hair sprays, and other spray products. Anesthetics include halothane and nitrous oxide (laughing gas). Amyl nitrite and butyl nitrite are inhalants that also are abused. What is amyl nitrite? Amyl nitrite is a clear, yellowish liquid that is sold in a cloth-covered, sealed bulb. When the bulb is broken, it makes a snapping sound; thus they are nicknamed "snappers" or "poppers." Amyl nitrite is used for heart patients and for diagnostic purposes because it dilates the blood vessels and makes the heart beat faster. Reports of amyl nitrite abuse occurred before 1979, when it was available without a prescription. When it became available by prescription only, many users abused butyl nitrite instead. What is butyl nitrite? Butyl nitrite is packaged in small bottles and sold under a variety of names, such as "locker room" and "rush." It produces a "high" that lasts from a few seconds to several minutes. The immediate effects include decreased blood pressure, followed by an increased heart rate, flushed face and neck, dizziness, and headache. Who abuses inhalants? Young people, especially between the ages of 7 and 17, are more likely to abuse inhalants, in part because they are readily available and inexpensive. Sometimes children unintentionally misuse inhalant products that are often found around the house. Parents should see that these substances, like medicines, are kept away from young children. How do inhalants work? Although different in makeup, nearly all of the abused inhalants produce effects similar to anesthetics, which act to slow down the body's functions. At low doses, users may feel slightly stimulated; at higher amounts, they may feel less inhibited, less in control; at high doses, a user can lose consciousness. What are the immediate negative effects of inhalants? Initial effects include nausea, sneezing, coughing, nosebleeds, feeling and looking tired, bad breath, lack of coordination, and a loss of appetite. Solvents and aerosols also decrease the heart and breathing rate and affect judgment. The strength of these effects depends on the experience and personality of the user, how much is taken, the specific substance inhaled, and the user's surroundings. The "high" from inhalants tends to be short or can last several hours if used repeatedly. What are the most serious short-term effects of inhalants? Deep breathing of the vapors, or using a lot over a short period of time may result in losing touch with one's surroundings, a loss of self-control, violent behavior, unconsciousness, or death. Using inhalants can cause nausea and vomiting. If a person is unconscious when vomiting occurs, death can result from aspiration. Sniffing highly concentrated amounts of solvents or aerosol sprays can produce heart failure and instant death. Sniffing can cause death the first time or any time. High concentrations of inhalants cause death from suffocation by displacing the oxygen in the lungs. Inhalants also can cause death by depressing the central nervous system so much that breathing slows down until it stops. Death from inhalants is usually caused by a very high concentration of inhalant fumes. Deliberately inhaling from a paper bag greatly increases the chance of suffocation. Even when using aerosol or volatile (vaporous) products for their legitimate purposes, i.e, painting, cleaning, etc., it is wise to do so in a well-ventilated room or outdoors. What are the long-term dangers? Long-term use can cause weight loss, fatigue, electrolyte (salt) imbalance, and muscle fatigue. Repeated sniffing of concentrated vapors over a number of years can cause permanent damage to the nervous system, which means greatly reduced physical and mental capabilities. In addition, long-term sniffing of certain inhalants can damage the liver, kidneys, blood, and bone marrow. Tolerance, which means the sniffer needs more and more each time to get the same effect, is likely to develop from most inhalants when they are used regularly. What happens when inhalants are used along with other drugs? As in all drug use, taking more than one drug at a time multiplies the risks. Using inhalants while taking other drugs that slow down the body's functions, such as tranquilizers , sleeping pills , or alcohol, increases the risk of death from overdose. Loss of consciousness, coma, or death can result.
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- Drugs and Sports - Inhalants Editor's note: This is the seventh of an eight-part series of articles examining the effects of commonly abused substances on athletic performance and overall health. Dr. Gary Wadler, a New York University School of Medicine professor and lead author of the book "Drugs and the Athlete", has also won the International Olympic Committee President's Prize for his work in the area of performance-enhancing drugs in competitive sports. He joined us to address the issue of inhalant abuse. What are inhalants? Inhalant use is the deliberate inhalation or "sniffing" of common, legal substances to achieve a mind-altering state referred to as a "high. Inhalants are products with a variety of industrial, commercial, and household uses and can broadly be categorized as either solvents (liquids) or gases. Solvents include such products as paint thinners, gasoline and glue but also include such things as felt-tip marker fluid. Household inhalant gases include butane lighters, propane gases, whipped cream and hair spray aerosols, airplane glue and spray paints. Commercial inhalant gases include refrigerant gases, medical anesthetic gases, e.g., ether and nitrous oxide (so-called laughing gas), and other medical inhalants, e.g., amyl nitrate. Amyl nitrite, normally used to revive those who have fainted or been rendered unconscious, is a clear yellowish liquid that is sold in a cloth-covered, sealed bulb. When broken, the bulb makes a snapping sound, thus the nicknames of snappers or "poppers. Inhalants enter the bloodstream and are rapidly distributed to the brain as well as to other organs of the body such as the liver, kidneys and bone marrow. "While some inhalants are metabolized and then excreted by the kidneys, others are eliminated unchanged from the body, primarily through the lungs," says Wadler. "Consequently, the odor of various solvents may remain on the breath for several hours following their inhalation." Most inhalants are fat-soluble, therefore the complete elimination of inhalants may take sometime since they are released rather slowly from fatty tissues back into the blood." What are the short-term adverse effects of inhalant abuse? Although the array of inhalants varies in their effect, for the most part they behave like anesthetics to slow down various bodily functions. Short-term effects appear soon after inhalation and disappear within a few hours. Initially, the user is stimulated and disinhibited, but with successive inhalations, speech becomes slurred, the gait becomes staggered, hallucinations may appear, drowsiness ensues, respirations become depressed and the user may lapse into unconsciousness if continuously exposed to the fumes. Deaths due to suffocation, dangerous behaviors associated with intoxication, and aspiration have been associated with acute inhalant abuse. As with other drugs of abuse, the use of inhalants while taking other depressant drugs such as alcohol and tranquilizers increases the risk of loss of consciousness, coma and even death. What are the long-term adverse effects of inhalation abuse? The long-term adverse effects associated with repeated abuse of inhalants varies depending upon the specific inhalant abused and include weight loss, electrolyte imbalance, nosebleeds, and mouth sores. "Some solvents, such as aromatic hydrocarbons (e.g., gasoline) irreversibly interfere with the formation of blood cells in the bone marrow, while others (e.g., dry-cleaning fluids) may impair liver and/or kidney function", says Wadler. "Some glues may produce permanent hearing loss while others may irreversibly destroy nerve function." While the short term effects of inhalants on the central nervous system (slurred speech, euphoria, hallucinations) can last from minutes to hours, the long term adverse effects on the central nervous system are irreversible and result from the dissolving away of brain cells by the solvents. Clinically this can be manifested as irreversible dementia, gait disturbances and loss of coordination. Behavioral symptoms in regular heavy sniffers include mental confusion, fatigue, depression, irritability, hostility, and paranoia What is Sniffing Death Syndrome? One mechanism of death that may account for the largest percentage of deaths from acute inhalant abuse has been referred to as the "Sniffing Death Syndrome." Sudden sniffing deaths typically occur in association with strenuous exercise or with sudden emotional stress, e.g., being discovered inhaling by an authority figure. According to Wadler, "Inhalants sensitize the heart to epinephrine. Activities or events that acutely raise blood epinephrine levels can result in fatal rhythm disturbances of the heart. Particularly disturbing is the fact that sudden sniffing death can occur with the very first experimentation with inhalation abuse, and in fact, in one study, 22% of deaths occurred in individuals with no known prior inhalant abuse." Are inhalants addictive? Regular inhalant use induces tolerance, which means increased doses are necessary to produce the same effects. After a year, for example, a regular glue sniffer may be using from eight to ten tubes of plastic cement to maintain the "high" originally achieved with a single tube. Psychological dependence on inhalants, the compulsive need to keep taking them is fairly common. Youthful solvent abusers can be among the most difficult patients to cure. Physical dependence occurs when the body has adapted to the presence of inhalants and withdrawal symptoms occur if their use is stopped abruptly. Upon sudden discontinuation of the inhalants, some chronic users suffer chills, hallucinations, headaches, abdominal pains, or delirium tremens (DTs - the "shakes").