Unmasking the Hidden Dangers: Office Duster Abuse as an Example of Inhalant Use Disorder

Lumos sp/AdobeStock

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we discuss inhalant use—a rich topic that is often under-discussed. Inhalant use is associated with multiple metabolic sequelae and specific cognitive dysfunction akin to dementia.

Case Vignette

In the bustling landscape of the outpatient clinic, we encountered “Mary,” a 27-year-old woman who has a medical history of inhalant use disorder, hypertension, and major depressive disorder (MDD). Initially, she came to us in a state of profound sadness, struggling with medication compliance. We proposed a fresh start with her medications and recommended additional therapy. However, she missed her subsequent appointment and disappeared from our radar for 6 months.

When she resurfaced, it was under dramatic circumstances—posthospital discharge. Mary reported she missed her follow-up appointment and was noncompliant with her medications, which only deepened her feelings of sadness, hopelessness, and self-loathing. In her search for relief, she turned to a dangerous and readily available escape: inhaling office duster. A friend had suggested it for a quick high, and trapped in her despair, she found the idea appealing.

Her use of inhalants spiraled quickly. Over a mere 2 weeks, she had consumed 30 to 40 cans weekly. This hazardous practice led to several bouts of unconsciousness, persistent nausea, and frequent vomiting. During 1 such episode, she suffered a fall that resulted in a head injury. Fortunately, her brother visited unexpectedly, found her unconscious, and urgently summoned emergency services.

In the emergency department, the situation grew more dire. The rapid response team found her severely dehydrated, with critically low potassium levels, which had plummeted from 3.1 to a dangerous 1.6. An electrocardiogram revealed a perilously prolonged QTc interval over 600, indicating serious heart rhythm issues, while her eosinophil count was abnormally high at 9%. This constellation of symptoms necessitated immediate admission to telemetry, where her usual medications were temporarily discontinued.

Following a critical period of cardiac monitoring and electrolyte replacement, she was stabilized enough to be transferred back to psychiatry. There, a dual-focused treatment approach awaited her, aiming to address both her MDD and her perilous journey through substance use disorder (SUD).

This case poignantly underscores the complexities at the intersection of mental health and SUDs, highlighting the importance of comprehensive, integrated care approaches that address the full spectrum of a patient's needs.

Overview

Inhalant use disorder, also known as volatile substance misuse, is a form of SUD characterized by the intentional inhalation of volatile substances for their psychoactive effects. These substances are often found in common household, industrial, or medical products, making them easily accessible and contributing to the prevalence of the disorder. The substances commonly misused include solvents and volatile compressed gases, such as hydrocarbons, fluorocarbons, nitrites, and nitrous oxide (see Table 1 for more). The misuse of these substances can lead to significant health risks, including neurological damage, organ dysfunction, and even sudden death.¹

Table 1. Types of Inhalants

One of the new additions to these inhalants is office dusters. The easy access to office dusters in both retail and online markets has contributed significantly to their misuse as inhalants. These products, typically used for cleaning electronic equipment and hard-to-reach areas, contain compressed gases that can be misused for their psychoactive effects. The widespread availability of these dusters, often with minimal age restrictions or purchasing limits, facilitates their acquisition by individuals, including teenagers who seek a quick and inexpensive high. This accessibility raises concerns about the potential health risks associated with inhalant use disorder, as the chemicals in these products can cause severe neurological damage and other health issues when inhaled. As a result, there is a growing need for regulatory measures to control the sale and distribution of such potentially harmful substances.The disorder is often associated with significant social and health-related problems, including academic failure, family conflict, and physical and mental health issues.

Epidemiology

Research from the World Health Organization (WHO) shows that inhalant abuse is prevalent worldwide but is often overlooked due to underreporting and societal stigma. In many regions, it predominantly affects adolescents, often from marginalized backgrounds. Data indicates that youth in lower socioeconomic settings tend to be at higher risk due to easier access to products like paint, glue, and solvents.

The onset of inhalant use typically occurs in adolescence, with the peak prevalence in the mid-teen years. However, the disorder can persist into adulthood and occurs in both men and women.² The prevalence of inhalant use disorder varies widely across different regions and populations. Globally, it is estimated that tens of millions of individuals have used inhalants at least once in their lifetime.³ According to the Substance Abuse and Mental Health Services Administration, approximately 0.8% of the population aged 12 or older reported using inhalants in the past year in 2019.⁴ The prevalence is highest among adolescents and young adults, with 1.4% of individuals aged 12 to 17 reporting past-year inhalant use.⁴

However, these figures likely underestimate the true prevalence of inhalant use disorder due to underreporting and the difficulty in detecting and diagnosing the disorder. The landscape of inhalant use is dynamic, and new inhalants occasionally emerge, posing challenges in public health efforts and substance abuse prevention. Inhalant use disorder can be challenging to identify, especially in the early stages, when routine testing may not show any signs.

Pathophysiology and Health Risks

Inhalant use disorder causes damage to various organ systems. The neurotoxicity of inhalants primarily affects the central nervous system (CNS), leading to symptoms like dizziness, euphoria, and hallucinations. Chronic use can result in permanent CNS damage, cognitive impairment, and motor dysfunction. Organs such as the liver, kidneys, and lungs are also at risk, with reports of hepatitis, renal failure, and respiratory complications. Furthermore, sudden sniffing death syndrome, primarily associated with cardiac arrhythmia, can occur with even a single use.

Other clinical features may include:

Cravings: Individuals suffering from this disorder frequently exhibit a powerful compulsion or longing to use inhalants.¹

Withdrawal: Upon discontinuing the substance, the individual may undergo withdrawal symptoms such as agitation, moodiness, and physical unease.¹

Tolerance: As time passes, the individual may require greater quantities of the substance to attain the desired effect.¹

Neglecting duties: The individual's substance use may lead to the neglect of their obligations at work, school, or home.¹

Dependency: Regardless of the physical or mental health issues caused by the substance use, the individual may persist in using the substance.¹

Comorbidities: Inhalant use disorder frequently cooccurs with other psychiatric conditions. Research by Slesnick and Prestopnik highlights the high prevalence of dual diagnoses, such as depression, anxiety, and other SUDs, among runaway and homeless youth involved in inhalant use. This comorbidity complicates treatment and requires comprehensive care addressing both substance abuse and mental health.

State-Specific Regulations

Here are some state specific laws for inhalant regulation. The regulations on inhalants can vary significantly from state to state. See Table 2 for laws and regulations in different countries.

Table 2. Laws and Regulations in Different Countries

California

California Penal Code 381b: It is illegal to sell nitrous oxide (commonly known as "whippets") to anyone under the age of 18. Violations can result in fines and jail time.

Bittering agents: California requires bittering agents in certain products like model glue and solvents.

Texas

Texas Health and Safety Code, Chapter 485: Prohibits the sale of abusable volatile chemicals (such as glue, paint, and solvents) to minors under 18. Retailers must keep these products in a secure area and require proof of age.

Inhalant abuse prevention: Schools are required to include information on the dangers of inhalant abuse in their health education curricula.

New York

New York General Business Law, Section 391: Bans the sale of nitrous oxide cartridges to individuals under 21. Retailers must verify the age of purchasers and maintain records of sales.

Bittering agents: Requires certain products to contain bittering agents to prevent abuse.

Illinois

Illinois Compiled Statutes, 720 ILCS 690: Prohibits the sale of abusable volatile substances to minors. Retailers must display warning signs and require proof of age for purchase.

Public awareness campaigns: The state funds public service announcements and educational programs about the risks of inhalant abuse.

Florida

Florida Statutes, Chapter 877.111: Outlaws the sale of specific inhalants, like toluene-based glues, to minors. Violators can face criminal charges and fines.

Education programs: Schools must include inhalant abuse prevention in their health education curricula.

Medical Management

Acute inhalant intoxication requires immediate medical attention. This may involve supportive care, such as ensuring the patient's airway, breathing, and circulation are intact and treating any immediate complications, such as cardiac arrhythmias or seizures.²

For chronic inhalant users, detoxification may be necessary. This should be done under medical supervision due to the potential for withdrawal symptoms, which can include nausea, excessive sweating, hand tremors, hallucinations, and, in severe cases, seizures.²

Pharmacotherapy for inhalant use disorder is currently limited. While some medications, such as antipsychotics or mood stabilizers, may be used to manage cooccurring psychiatric conditions or specific symptoms, there are currently no US Food and Drug Administration-approved medications specifically for the treatment of inhalant use disorder.⁵

Cognitive-behavioral therapy (CBT) can be effective in treating inhalant use disorder. CBT can help individuals recognize and change patterns of thought and behavior that lead to substance use.³ Motivational interviewing, a type of counseling that helps individuals resolve ambivalence about changing their behavior, can also be beneficial.⁶

Family therapy and community-based programs can play a vital role in the long-term management of inhalant use disorder. These interventions can provide social support, improve family dynamics, and help individuals develop healthier coping mechanisms and life skills.⁶

Social rehabilitation programs provide critical support networks. Programs aimed at preventing relapse through skill development, family dynamics improvement, and community reintegration have proven effective in reducing recurrence.

Policy and Prevention Initiatives

Government agencies and public health organizations emphasize the importance of preventative education. Awareness campaigns target young populations and their guardians, advocating for safe use and storage of household products. The WHO’s report underscores the need for international cooperation to standardize regulatory measures limiting access to volatile substances.

The management of inhalant use disorder involves a comprehensive, multidisciplinary approach that includes medical, psychological, and social interventions. Prevention and education are also crucial components of managing inhalant use disorder. This includes educating individuals, families, and communities about the dangers of inhalant use and promoting healthier alternatives for stress management and recreation.³

Concluding Thoughts

Inhalant use disorder represents a complex challenge due to its accessibility and impact on vulnerable populations. Enhanced data collection, early intervention, and multifaceted therapeutic approaches are critical in tackling the issue. Further research into targeted pharmacotherapy, coupled with innovative prevention strategies, will provide better outcomes for individuals suffering from this often-overlooked substance use disorder.

DrMurtaza is a 4th year psychiatry resident at Baylor College of Medicine with a specific interest in emergency psychiatry. Ms Abdurrahman is a third-year medical student with an interest in psychiatry and cultural competence. Dr Raji is a 1st year psychiatry resident at Baylor College of Medicine with an interest in psychotherapy.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Publishing; 2013.

2. Howard MO, Bowen SE, Garland EL, et al. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract. 2011;6(1):18-31.

3. Inhalant use disorder. In: Avery JD, Hankins D, eds. Addiction Medicine. Springer; 2021:57-65.

4. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. 2020. Accessed June 25, 2024. https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf

5. Inhalants. National Institute on Drug Abuse. 2022. Accessed June 25, 2024. https://www.drugabuse.gov/drug-topics/inhalants

6. Slesnick N, Prestopnik JL. Dual and multiple diagnosis among substance using runaway youth. Am J Drug Alcohol Abuse. 2005;35(1):179-201.