Day # 168: Inhalant Use Disorder

Today we will discuss inhalant use disorder. We will cover the neurobiology, epidemiology, clinical presentation, and evidence-based treatment strategies.

Today's Content Level: Intermediate to Advanced

Introduction 1, 2, 3

Intro and Formulations

• Inhalant Use Disorder should not be underestimated. They are volatile chemicals with unpredictable dosing, rapid CNS penetration, and real risk of sudden death, neurotoxicity, and long-term cognitive damage.

• Often associated with adolescents, socioeconomic vulnerability, and limited access to other substances.

• They are household chemicals with unpredictable pharmacology and dangerous physiology. Inhalants are a chemically diverse group of volatile substances, including solvents, aerosols, gases, and nitrites.

  • Solvents: Glue, gasoline, paint thinner, correction fluid, markers

  • Aerosols: Spray paint, hair spray, deodorant spray, compressed air

  • Gases: Butane, propane, nitrous oxide ("whippets"), refrigerants

  • Nitrites: Amyl nitrite, butyl nitrite (“poppers”)

  • Others: Cleaning fluids, nail polish remover

Mechanism of Action

• Despite chemical diversity, their CNS effects overlap.

• CNS depression via:

  • ↑ GABA-A receptor activity

  • ↓ NMDA (glutamate) receptor activity

• Dopaminergic activation in mesolimbic pathways → reinforcing effects

• High lipid solubility → rapid brain entry and accumulation

• Membrane fluidization (make them less rigid and more “leaky") → nonspecific neuronal dysfunction

• Bottom line: This is global CNS depression with stimulant-like reinforcement and no safe dose, making toxicity unpredictable.

Diagnostic Criteria 4

• Diagnostic criteria for all substance use disorders are the same, characterized by a ≥ 12-month period of problematic substance use that leads to impairment or distress and requires ≥2 additional criteria. See Day #160: Introduction to Substance Use Disorders for complete diagnostic criteria and severity specifiers.

Epidemiology & Pathogenesis 5

• Genetics, environmental influences, and mental health comorbidities contribute to vulnerability.

• Most common in children and adolescents

• Often the first substance used

• In the U.S., 0.4% of individuals aged 12 to 17 experienced inhalant use disorder in the past year. About 10% of teenagers (ages 13 to 17) have used inhalants at least once, and around 20% of these users develop an inhalant use disorder.

• Low cost + legal access = high availability

• Risk factors: poverty, trauma, poor supervision, limited access to other drugs, peer use, comorbid psychiatric disorders.

• Pathogenesis highlights:

  • Rapid absorption through lungs

  • Lipophilic compounds → rapid brain penetration

  • Distribution to brain white matter, liver, kidneys

  • Repeated exposure → chronic neurotoxicity (white matter injury, cortical atrophy), especially frontal lobe dysfunction, peripheral neuropathy, cranial nerve damage, cerebellar dysfunction, and encephalopathy.

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Clinical Pearls 5, 6

History

• General SUD: Obtain a detailed history (onset, frequency, quantity, last use, forms and routes), prior treatment attempts, periods of sobriety, withdrawal symptoms, impact on daily functioning, social history with triggers, legal obligations, and co-occurring psychiatric or medical conditions. Ask DSM-5 symptoms of SUD (loss of control, craving, risky use, tolerance, withdrawal, impairment). Ask about prescription misuse and illicit use. Ask about injection drug use, overdose history, co-use of other substances. Assess for other safety concerns related to use, including IV/IN use, sharing paraphernalia, needle licking, exchanging sex for drugs, body packing/stuffing, or impaired driving.

• Inhalant specific

  • Look for:

    • Chemical odors on breath or clothing

    • Paint stains on face/hands or glue residue

    • Chronic headaches, irritability, declining school performance, behavioral decline

  • “Huffing,” “sniffing,” and “bagging” all increase risk, but bagging = highest overdose risk

  • In rare cases, "sudden sniffing death" from cardiac arrhythmias can occur with inhalant use.

    • Can occur on first exposure, and is not dose-related

    • Caused by fatal ventricular arrhythmias

    • Triggered by catecholamine surge (stress, exertion)

Labs / Diagnostics

• Standard drug screens do not detect inhalants.

• Labs should be ordered when clinically indicated to evaluate end-organ damage.

• Consider EKG or telemetry if acute intoxication suspected.

Intoxication

Symptoms

• Euphoria, disinhibition

• Dizziness, ataxia, slurred speech

• Nystagmus

• Confusion, hallucinations

• Nausea/vomiting

• Severe cases:

  • Arrhythmias

  • Seizures

  • Respiratory depression

  • Sudden death

Treatment of Intoxication

• Supportive care is primary

• Remove from exposure immediately

• Oxygen as needed

• Continuous cardiac monitoring

• Avoid catecholamines if possible (↑ arrhythmia risk)

• Treat seizures with benzodiazepines

Withdrawal

• Withdrawal is usually mild compared to other substances, but still exists.

Symptoms:

• Irritability

• Anxiety

• Insomnia

• Tremor

• Nausea

• Cravings

Treatment:

• Supportive care

• Sleep and anxiety management

• No standardized detox protocol

Treatment of Inhalant Use Disorder

•Effective treatment requires a combination of medical, psychological, and social interventions. A multi-disciplinary team—often including psychiatrists, primary care providers, therapists, social workers, and peer support specialists collaborates to address all aspects of the disorder.

Determine the Appropriate Treatment Setting: Choosing the right level of care depends on substance use severity, comorbid conditions, and prior treatment history. See Day 60: Intro to SUD for a description of each level of care.

Psychosocial Interventions:

• Individual and/or group therapy should be part of every SUD treatment approach. See Day 60: Intro to SUD for a discussion of interventions that include behavioral therapies, peer support & 12-step programs, and family support resources.

• Prevention and screening is considered the best way to reduce inhalant use disorder.

• Environmental intervention is critical = restrict access + increase supervision.

• School and social services often play a key role.

• Addressing family dysfunction and comorbid psychiatric disorders may benefit individuals using inhalants.

Medications:

• There is no approved medication for inhalant use disorder.

• Address psychiatric comorbidities: mood disorders, anxiety disorders, ADHD, trauma-related disorders.

Conclusion

• Inhalant Use Disorder is dangerous and underdiagnosed. For clinicians, the key is recognition, education, and prevention. The absence of clear labs and pharmacologic treatments makes clinical suspicion and prevention the most powerful tools we have. These aren’t harmless household products. They’re fast-acting neurotoxins with a short path from use to morbidity and mortality.

Resources for today's post include:

• First Aid for Psychiatry

• Kaplan and Sadock's Synopsis of Psychiatry

• DSM-5-TR

• Articles referenced above

See our full list of book recommendations for the most up-to-date editions.

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