Epidemiology of inhalant use

Epidemiology of inhalant use Marı́a Elena Medina-Mora and Tania Real Instituto Nacional de Psiquiatrı́a Ramón de la Fuente (Ramon de la Fuente National Institute of Psychiatry Mexico), Mexico City, México Correspondence to Marı́a Elena Medina-Mora, National Institute of Psychiatry Mexico, Calzada México Xochimilco 101, México DF 14370, Mexico Tel: +52 55 56554268; fax: +52 55 55133446; e-mail: [email protected] Current Opinion in Psychiatry 2008, 21:247–251 Purpose of review The aim of the present article is to review recent research on the prevalence and correlates of inhalant use. Recent findings During the review period more prevalence studies have been conducted in the developing world, adding information to the ongoing studies that are periodically undertaken in the more developed countries. These studies suggest that inhalant use is widespread among children and adolescents and is increasing among females in the developing and developed world. Not all surveys report inhalants as a separate group from other illegal substances; data by type of inhalants are even rarer, and few studies address abuse or dependence. New evidence suggests lower reliability rates for the diagnostic criteria of dependence as compared with other substances, suggesting the need for a review including the evidence of withdrawal. Studies conducted in the period identify vulnerable groups and suggest an increased risk of injecting drug use, HIV, suicidality and psychiatric disorders among inhalant users. Summary The extension of inhalant abuse and its adverse consequences argues for greater efforts to advance classification and to increase knowledge through research, including the evaluation of prevention and treatment models. Keywords correlates, developed and developing world, epidemiology, inhalants Curr Opin Psychiatry 21:247–251 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 0951-7367 Introduction Inhalants are widely available and accessible to children, in whom their highly toxic effects can be more lethal than in adults. The risk of developing dependence is well established [1], with those that begin using inhalants at an early age being more likely to become dependent, while long-term users are among the most difficult to treat; nevertheless, use of these substances has received relatively less attention. Recent trends Inhalant use is a widespread practice mainly among children and adolescents in the developed and developing world. Since many epidemiological studies include inhalants in a wider group of illegal drugs, prevalence figures are not always available; nonetheless, some studies report rates that can be compared, although they need to be taken with caution as surveys vary regarding the population covered, the year they were conducted, the methods used and the way inhalants are categorized Household surveys In the United States in 2006 [2], 9.3% of the population 12 years of age and over had used inhalants in their lifetime (‘ever use’); rates of ever use reported in the 108 biggest cities in Brazil in 2005 [3] were slightly lower at 6.1%. Lifetime use in Alberta, Canada [4], in Spain [5], in Peru [6], in Mexico [7], in Paraguay [8], and in Chile [9] was significantly lower. As for annual use, in the United States in 2006 [2] the rate for the population aged 12 years and over was 0.9%; in Mexico, among those between 12 and 64 years [7], it changed from 0.26% in 1986 [10] to 0.09% in 2002 [7]. Among adolescents, data from the household surveys conducted in the US between 2002 and 2005 [11] show that inhalant use in the year prior to the survey remained stable overall, as it did for males; however, the rate of past-year inhalant use among females increased between 2002 and 2005. The overall rate of use in the past month for both males and females reported in 2006 was similar to that observed in previous years. Adult users in the United States frequently do not initiate inhalant use until adulthood, resort to inhalants less frequently, use fewer inhalants, and are less likely to engage in criminal activities. Substances of choice among adults differ from those commonly reported by adolescents: gases 0951-7367 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 248 Addictive disorders such as nitrous oxide (whipping cream aerosols or dispensers, ‘whippets’) and nitrites, substances with action primarily to dilate blood vessels and relax the muscles such as amyl nitrite (‘poppers or rush’) were the substances of choice among the older population, while glue, shoe polish and gasoline are the substances commonly reported by adolescents [12]. Other studies found that inhalant use often goes unrecognized due to lack of screening [13]. School surveys Inhalant use is a common practice among students; in 2006, the inhalant use rate for high school students in the United States came after marihuana and was higher than cocaine, crack or heroin [14]. In Europe, rates of ever use for students between 15 and 16 years old varied between 18% in Ireland and 3% in Bulgaria – while the prevalence for this age group in the United States was 13% [15]. In North America the highest rates are observed in the United States [14], significantly higher than those reported in Ontario, Canada [16], and in Mexico City [17]. National surveys conducted among students 13, 15 and 17 years of age in Central America, in Panama, Salvador, Nicaragua [18], in Colombia [19] and in Chile [20], show lower annual rates than those reported in North America. Among secondary students (14–17 years of age) in South American countries, the highest annual prevalence was reported in Brazil –the second largest rate in the Americas after the United States, considerably higher than that reported in other countries in the southern cone [21]. Inhalation among youth in Africa has also been reported in Greater Pretoria and in BelaBela [22]. The use of inhalants in the school population of the United States [14] has been rising over the past few years, in contrast to the decline in use of other drugs. In 2006, however, at the national level, use in the eighth and 12th grades showed no further increase. In Mexico City [17], the ever use rates among high school students had been more or less stable in the 1980s, decreased in 1997 and increased again by 2006. In Ontario, Canada [16], the use of glue among students from the seventh to the 12th grades decreased between 1999 and 2007, but solvent use remained stable. Use by minority status Relation between minority status and inhalant use varies across ethnic groups. An analysis of Mexican American and white non-Hispanic seventh grade and eighth grade males and females in selected sites of the United States [23] found that Mexican Americans had the highest rates of inhalant use followed by whites; this trend has also been observed in other local studies [24]. Among White and African Americans, rurality is associated with inhalation [23,25]. This association was not observed among metro Mexican American students, who reported higher rates of use than more rural students [23]. Studies conducted in the developing world [26] document higher rates of use among children and adolescents living in the streets than among those living with their families. This has been confirmed in other studies conducted in Mexico [27] and other countries [28]. Use by gender For African Americans, the gender gap between male and female inhalant use appears to have reversed, with females being more likely to have tried inhalants and to have used them in the past month, while those that had tried them showed more involvement than their male counterparts. Mexican American females had significantly greater lifetime, past-month use and higher levels of involvement than Mexican American males. For the southeast sample, white female and white male rates are not significantly different. White females living in remote western communities, however, had significantly higher prevalence in past-month use rates than their male counterparts [23]. Studies among school students from the sixth to 10th grade in Florida have documented significantly higher rates among females than males for lifetime and current use [29]. In Mexico City, the rate of increase in annual use among high school students was bigger for females, closing the gap between both genders [17]. In Ontario, Canada, the annual rates of glue and solvent use among students in the seventh to 12th grades in 2007 was higher for females than for males [16]. Use among very young girls has also been reported in southern African countries [22]. Type of substances used Inhalants can be classified into four different groups: volatile solvents, aerosols, gases, and nitrites. These groups of substances vary in their mechanisms of action and in classification according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV [30]. In spite of the differences in classification, uses and effects, few studies address inhalants per type of substance; some exceptions were found in studies conducted in the United States [2,11,31] and in New Zealand [32]. US males and females differ in the substances of choice, with females being more likely than their male counterparts to have used volatile solvents and aerosols while males were more likely than their female counterparts to have used gases such as nitrous oxide (‘whippets’). Among recent inhalant initiates, use of whippets declined while use of aerosol sprays other than spray paints increased [11]. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Epidemiology of inhalant use Medina-Mora and Real 249 Analysis of calls to the National Poisons Centre in New Zealand [32] following inhalation involved abuse of propane or butane, either alone or in combination with a synthetic pyrethroid. Inhalant abuse-related deaths were most commonly attributed to cardiac effects; 73% of deaths were in teenagers and all but one fatality involved propane and/or butane. number of different inhalants used in response to social contextual influences (i.e. ‘pressures to use and feelings of inability to refuse’, ‘met with friends and wanted to have a good time’) also score high on clinical psychiatric symptoms, suicidal ideation, impulsivity, fearlessness, and other use of drugs as compared with adolescents classified in groups of low and moderate influence of contextual factors [38]. Correlates Other studies have found that the younger the age at first use of alcohol, cigarettes and marijuana, the higher the lifetime and current prevalence of use of inhalants, the more likely to be depressed, the more likely to acknowledge deviant behavior and school truancy, and the more likely to have lower grades. These individuals are also more likely to have siblings and friends who have used illegal substances and parents with a history of antisocial behavior [26]. In the United States there is a continuing decline in ‘perceived risk’, a variable that has been associated with an increase in use [14]. In Mexico the perceived risk is high, with 98% stating it is dangerous or very dangerous [17]. Similar rates were reported by youth in southern African countries [22]. Inhalant and other drug use has been associated with stressful life events [33]. Among lifetime adult inhalant users, high lifetime prevalences of DSM-IV mood (48%), anxiety (36%), and personality (45%) disorders have been observed. Compared with male inhalant users, female users had higher prevalences of lifetime dysthymia, any anxiety disorder, panic disorder without agoraphobia and specific phobia, but a lower prevalence of antisocial personality disorder; those who developed social or specific phobia typically experienced the onset of these disorders prior to the initiation of inhalant use; all other mood and anxiety disorders usually developed following the onset of inhalant use; the prevalences of these psychiatric disorders are similar to any drug-using population [34]. Inhalant users who were women, poor, less educated, with an early onset of inhalant use and family histories of psychopathology had greater odds of psychiatric disorders [34]. Incarcerated youth, predominantly males, show a high prevalence of lifetime inhalant use; with comparatively high rates of use among Hispanics and those living in small rural towns. Inhalant users showed significantly higher levels of criminal behavior, current psychiatric symptoms, earlier onset of offending and substance use, and more extensive histories of injury and chronic illness than nonusers [35]. Abuse and dependence Studies conducted in a community sample of adolescent and young adult inhalant users who had used any type of inhalants more than five times [31] and from a nationally representative survey of adults in the United States (the NESARC) [34] confirm previous observations [1] on the risk of developing dependence from inhalants. Among adolescent and young adult inhalant users [31], lower reliabilities for dependence as compared with other substances were documented. Moreover, the authors found more persons that meet the criteria for dependence than for abuse when they analyzed the proportion that qualified for abuse diagnosis regardless of whether dependence criteria were met, suggesting that although the abuse diagnoses provided superior reliability, it was insufficient for capturing all persons with pathological inhalant use. Suicidality has been documented among adolescents who have an inhalant use disorder after adjusting for the general level of psychiatric symptoms, prior trauma, other substance use and gender [36]. Inhalant-dependent adults have higher rates of comorbid axes of psychiatric disorders than other substance-dependent patients and individuals without substance use disorders [37]. In that study [31] the most prevalent abuse criterion for each inhalant type considered, as well as when criteria were grouped across inhalant types, was use of inhalants in hazardous situations (29.0%). Legal problems resulting from inhalant use was the criterion least frequently endorsed (1.9% across inhalants). Symptoms of withdrawal or tolerance were experienced by more persons than those who met criteria for dependence. Use of inhalants in spite of a known physical or psychological problem that is caused by use was the most prevalent dependence criterion (58.6%); using inhalants in greater quantity or for a longer time than was planned (30.3%) was the second most prevalent, and reduction in important activities in order to use inhalants was by far the least prevalent dependence criterion endorsed (1.9%). Studies of inhalant users in youth services for transgressions have documented that those users who report a high Data from the study [31] suggest the need to consider an alternative configuration of criteria for abuse and Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 250 Addictive disorders dependence on inhalants at least for adolescents in future research, such as recategorizing the dependence criterion ‘use in spite of knowing a physical or psychological problem is caused by inhalants’ as an abuse criterion that would permit the abuse diagnosis to capture all pathological users. The authors found better reliabilities for composite diagnoses (i.e. qualifying for either abuse or dependence), for symptom counts, and for abuse diagnoses ignoring whether an individual qualified for dependence. Also, contrary to the conclusion drawn in the DSM-IV, evidence of withdrawal from inhalant abuse was documented with differences in symptoms across type of substances consumed. Users of aerosols, gases and solvents reported having experienced headaches, nausea and vomiting, and anxiety. Users of gases and aerosols, but not those who had used solvents, also reported having experienced runny eyes or nose, craving and hallucinations. Users of gases and solvents also reported symptoms of fatigue and difficulty concentrating, and users of aerosols reported fast heart beat, depressed mood, trembling or twitching and using gases to avoid withdrawal symptoms. The authors documented that withdrawal can occur consequent to inhalant use, although compared with other drugs it results from continuous use over a shorter time (1 day of binging) and lasts for a shorter period (1 day or 2 days) [31]. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as:  of special interest  of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 304–305). 1 Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: national findings [online]. Rockville, MD: Office of Applied Studies; 2007. NSDUH Series H-32, DHHS Publication No. SMA 07-4293. http://www.oas.samhsa.gov/nsduh/ 2k6nsduh/2k6Results.pdf. [Accessed 4 December 2007] Report of the prevalence of inhalant abuse, subgroups affected and trends over time for the general population of the United States. 2  3 Carlini EA. II Encuesta domiciliaria sobre uso de drogas psicotrópicas en Brasil: estudio en 108 ciudades del paı́s, 2005 [Household survey on psychotropic drug use in Brazil, study on 108 cities around the country] [online]. Brasilia: Centro Brasileño de Información sobre Drogas, Secretaria Nacional Antidrogas; 2006. http://www.unifesp.br/dpsicobio/cebrid/ lev_domiciliar2005/index.htm. [Accessed 4 December 2007] 4 Alberta Alcohol and Drug Abuse Commission. Canadian Addiction Survey 2004, Alberta report [online]. Edmonton, AB: Alberta Alcohol and Drug Abuse Commission; 2006. http://www.aadac.com/documents/cas2004_alberta_ detail.pdf. [Accessed 4 December 2007] 5 Observatorio Español sobre Drogas [Spanish Drug Observatory]. Informe 2004. Situación y tendencias de los problemas de drogas en España [2004 report. Extension and trends of drug problems in Spain] [online]; 2005. http://www.pnsd.msc.es/Categoria2/publica/pdf/oed-2004.pdf. [Accessed 4 December 2007] 6 DEVIDA Comisión para el Desarrollo y Vida sin Drogas, Gerencia de Prevención y Rehabilitación del Consumo de Drogas, Oficina de las Naciones Unidas contra la Droga y el Delito, Universidad Caetano Heredia, Instituto Nacional de Estadı́stica e Informática, a la Oficina de Asuntos Antinarcóticos de la Embajada de los Estados Unidos. Encuesta Nacional sobre Prevención y Consumo de Drogas, 2002. Población urbana de 12 a 64 años. Perú [National survey about drug use and prevention, 2002, urban population, 12 to 64 years, Peru] [online]; 2003. www.opd.gob.pe/cdoc/_cdocumentacion/ estadistica_opd/demanda.pdf. [Accessed 4 December 2007] 7 Villatoro J, Medina-Mora ME, Cravioto P, et al. Encuesta Nacional de Adicciones 2002. Capı́tulo sobre drogas [National Survey on Addictions 2002, chapter on drugs]. México: Consejo Nacional contra las Adicciones, CONADIC, Instituto Nacional de Psiquiatrı́a Ramón de la Fuente Muñiz INPRFM, Dirección General de Epidemiologı́a, DGE, Instituto Nacional de Estadı́stica, Geografı́a e Informática, INEGI; 2003. 8 Presidencia de la República, Secretarı́a Nacional Antidroga (SENAD), Observatorio Paraguayo de Drogas (OPD). Estudio Nacional de consumo de drogas en hogares paraguayos [National study on drug use in Paraguay] [online]. Asunción, Paraguay: SENAD/OID/CICAD/OEA; 2004. www.senad. gov.py/publicaciones/estudio-hogares-2004.pdf [Accessed 4 December 2007] 9 Gobierno de Chile, Ministerio del Interior. Consejo Nacional para el Control de Estupefacientes (CONACE) Área Evaluación y Estudios. Séptimo estudio nacional de drogas en población general de Chile. 2006, Informe de principales resultados [Seventh national study on drugs among the general population of Chile, 2006, inform on main results] [online]; 2007. http://www.conacedrogas. cl/inicio/pdf/bd928b266121a764e5ea61e6e6ab2ba3.pdf. [Accessed 4 December 2007] Risk for HIV Inhalant users, irrespective of their marijuana use histories, had greater odds of injecting drugs than drug users who had not used inhalants [39]. Having sex under the effects of poppers has been documented among gays [40]. Some reports have documented that the abuse of nitrite inhalant (‘poppers’) vasodilators increases the risk of acquiring HIV infection among men who have sex with men. 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