Volatile substance abuse (VSA) is the deliberate inhalation of volatile liquids or gases. Such substances are available in a wide range of legal products for domestic, medical and industrial use.
Legal measures have been in place in England, Wales and Northern Ireland since 1985 prohibiting the sale to under 18s of substances that might be abused. The law was changed in the UK in 1999 making it illegal to sell cigarette lighter fuel refills containing butane.
However, death rates from VSA had been falling even prior to the change in the legislation in 1999.
Volatile substances are the poor relations of the substance misuse field often going under the radar of professionals as well as the public. VSA is commonest in early adolescence, especially in the white population. There is little evidence to suggest VSA in black and minority ethnic communities.
VSA is almost equal in males and females unlike other problematic drug use where there is a marked male preponderance. There is a north-south divide across the UK, with use being higher in Northern Ireland, Scotland and the north of England.
Use is generally short lived as users switch to other substances. Chronic use is more likely in socially marginalised individuals and communities, and dependence may develop.
The commonest substances of abuse are butane (in lighter fuel and used as a propellant in deodorants), toluene (paint thinners, glue), trichloroethylene (solvents, degreasers), various ethers (propellants) and fuels, such as petrol.
Inhalation can be directly into the mouth or through clothing to remove non-volatile components. The solvent (toluene, petrol) may be poured into a handkerchief or bag and then inhaled.
The effects are a brief duration of dizziness, disorientation, excitation and euphoria followed by feeling light-headed and a longer period of impaired consciousness.
There may also be hallucinations, delusions, nystagmus, slurred speech, unsteady gait and flushing.
The duration of the effects depends on the volatility of the substance - the effects of butane lasting only a few minutes and requiring frequent doses, whereas toluene's effects last much longer.
The longer-lasting effects of toluene can cause chronic CNS damage, similar to multiple sclerosis, due to demyelination of nerve sheaths.
'Poppers' is the term used for alkyl nitrites, a subgroup of solvents used in air fresheners and video head cleaners.
They are used to enhance sexual arousal, desire and pleasure and to cause a 'head rush'
and euphoria due to falling BP caused by vasodilatation. Their use is commonest in club or rave settings, with anecdotal evidence that they are used more frequently in the gay community.
Butane, while causing little chronic damage, is the commonest single cause of deaths from VSA, being responsible for around 80 per cent of gas fuel related deaths and 45 per cent of deodorant-related deaths.
Deaths from VSA can be due to direct toxic effects, especially cardiac arrhythmias and from anoxia or hypercapnia causing an adrenaline surge, asphyxiation (especially if a plastic bag is used) and trauma, for example due to falls, particularly with the longer-acting substances, or inhalation of gastric contents due to vomiting when unconscious.
It is stated that one teenager a week dies in the UK from VSA but the official figures do not bear this out, indicating five, eight and 13 deaths in under 18s in 2006, 2005 and 2004 respectively.
Not all deaths are accidental, with 20 per cent of VSA deaths in 2005 and 2006 considered to be suicides. Prior to 2005, suicides were always in single figure percentages and the reasons for the increase in 2005 and 2006 is unclear.
It requires a high index of suspicion to detect VSA because the effects of volatile substances are so short lived and because the use is transient. Users either discontinue substance misuse altogether or switch to other substances. Chronic users are likely to be marginalised.
VSA should be considered in adolescents who present with bizarre behaviour or unusual, disparate symptoms and signs, especially if they are white and from a deprived or excluded background.
Treatment of VSA is symptomatic and supportive with referral to specialist agencies where there is dependence. Primary care is well placed to provide clinical and psychosocial support as long as use is actually detected.
There is a key role for the GP in advising harm reduction for those who continue to use.
Advise the patient to avoid putting plastic bags over their head, and not to use volatile substances in poorly ventilated areas or if under the influence of alcohol, for example.
Ideally, patients should not use volatile substances alone but one needs to be careful with this advice lest it leads users to induce others into their use.
Two years ago, I reviewed a patient who was doing well with regard to his heroin dependence. We were both pleased with his progress. Five days later he was found dead with a can of butane in his hand.
Volatile substances may be the poor relation but they can still kill, especially if their use is unsuspected.
- Dr Ryan is a GPSI and shared care GP for Wolverhampton Addiction Services.