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How to Determine If a Death Was Caused By Inhalants

Currently, the annual number of inhalant-caused deaths remains unclear, albeit the National Inhalant Prevention Coalition (NIPC) estimation of 100- 125 deaths annually. Despite the continued professional development by medical practitioners- examiners, coroners and pathologists, they are yet to find a clear-ways of predicting inhalant use. Additionally, the intensive researches appear to be limited in accurately estimating the actual inhalant death statistics.
Although the causes of death can be provided by family members or media accounts, the picture painted is no true representation of the inhalation death statistics. This mismatch further heightening extent of the inhalant problem in our environment and the dire need to address the concerns. The NIPC has thus endeavored to provide information and guidelines that will assist the medical practitioners understand, recognize, document, and report accurately inhalant deaths.

Why is this important?•    For accurate definition of the actual nature of the problem,
•    For improved monitoring of regional variances,
•    For better assessment of prevention interventions, and
•    For evaluation of treatment interventions

Background
What are inhalants?
Inhalants refer to highly volatile, household and industrial substances that emit chemical vapors or fumes and produce psychoactive effects when inhaled. It is these mind-altering effects from inhalation that have led to their use and misuse by its users who unknowingly become addicted.
Generally, inhalants are highly volatile organic chemicals meaning they tend to vaporize once exposed to air for example fuel gases, nitrites and organic solvents. Some of the commonly abused chemicals are the aliphatic and aromatic hydrocarbons due to their ease of accessibility- natural gas and petroleum. Of particular interest however, are toluene, benzene, xylene, trichloroethylene, and freons. Another category of highly abused substances are anesthetic gases from nitrous oxide to chloroform.

Substances of Abuse
•    General provisions- glues, paints, paint thinners, and cement,
•    Cleaning agents- any aerosol canned product such as air fresheners and computer air dusters,
•    Artistic supplies- printing inks, clear finishes and spray paints,
•    Auto products- spray lubricants, brake fluids, gasoline, and degreasers, and
•    Beauty products- hair sprays, nail polish, and removers.

Modes of Administration
The most common means of taking in inhalants is through the nose and the mouth which are referred as sniffing and huffing respectively. However, people have devised new methods of inhalation with the intent of increasing their ‘dosage’ for a longer lasting psychoactive effect. Aerosol products are taken orally by spraying them directly into the mouth, bagging which is the spraying of inhalants into a plastic bag for huffing, and the pouring of substances on fingers for continuous inhalation.

Potential Inhalant Abusers
In its National Survey on Drugs and Health (NSHUH) of 2002, the Substance Abuse and Mental Health Service Administration (SAMHSA) reported approximately 22.8 million Americans have used inhalants. Of these number, 180,000 people had developed a dependency on inhalants necessitating treatment. From this statistics, inhalant abusers do not belong to a particular population grouping but rather spread throughout the entire population.
Most times, emergency rooms are filled with substance abusers in need of medical attention. Through the Emergency Department Trends from Drug Abuse Warning Network (DAWN), SAMHSA observed a drastic increase in inhalant related cases. The Final Estimates 1995- 2002 report painted a whopping increase from 522 inhalant emergencies to 1496 in 2002 representing 186.6%.

Rate of Occurrence
Amongst teenagers, the use of inhalants is developed in high schools as advancement from tobacco and alcohol consumption making up 2.6 million of inhalant abusers. Despite of the alarming number, most teenagers are said to give up the use of inhalants while others advance to harder drugs into adulthood.
The abuse of inhalants amongst adults tends to be related to their profession with nurses, dentists, anesthesiologists, cobblers, and painters proving to be more susceptible. The likelihood of abuse is fostered by the nature of their work and their direct contact with volatile solvents and chemicals.
Another group of potential abusers of inhalants are street children dwelling in urban centers of both developing and developed countries. The abuse of inhalants is also prevalent amongst male homosexuals albeit the number reducing owing to the AIDS epidemic.
Why Inhalants are Popular
the abuse of inhalants across age, gender, socioeconomic classes and nationalities is enhanced by the accessibility and legality of the products. Due to their availability in households, abusers especially teenagers discount their adverse effects on health. Additionally, the resultant ‘high’ experienced resembles that from alcohol intake.
Effects of Inhalant Use
The abuser becomes euphoric upon use as subsequent incoherence of immediate surrounding with such loss of control results in aggression. Other effects include loss of appetite, hallucination, nausea, seizures, and motor inhibition.
In addition to these health issues, inhalant abuse can have adverse effects such as suffocation from bagging, hypertension, and fire accidents. With solvents easily absorbed into one’s blood streams, key body organs such as the brain, liver and kidney begin to shut down leading to slow death. Such happenings have significantly increased the inhalant death statistics given the further heightening the severity of inhalant usage.
Mortality
The abuse of inhalants regardless of the type and mode of administration could lead to death. According to Bowen, Virginia had 39 deaths between 1987-1996 due to exposure to inhalants with 19 as the median age of the abuser. In Texas, Maxwell observed the median age was 24 of the 144 deaths recorded for the period 1988- 1998.
Clinical Considerations
Where there is no evident cause of death but there is a recorded suspected use of inhalants, death from inhalant abuse should be put into consideration during investigation. However, due care in the collection of specimen, extensive toxicology and death analysis is to be conducted to rule out any inconsistencies. Observance of such levels of caution and investigation of the scene of death aid in ascertaining the actual cause of death through consideration of all potential elements.

Table 1. Chemicals Found in Specific Products

Product

Chemicals Found

Balsa wood cement Ethyl acetate
Contact adhesives Toluene, hexane, esters
Cryoquick spray 1,1,1 Tetrafluoroethane
Bicycle tire adhesive Toluene, xylenes
PVC cement Trichloroethylene
Air freshener, deodorants, fly spray, hair lacquer, spray paints Halons, butane, dimethyl ether
Anesthetics/analgesics Nitrous oxide, ether, chloroform
Commercial dry cleaning 1,1,1-Trichloroethane,
tetrachloroethylene, trichloroethylene
Fire extinguishers Bromochlorodifluoromethane,
halons 11 & 12
Cigarette lighters/butane n-Butane, isobutane, propane
Propane Propane and butanes
Nail/varnish remover Acetone and esters
Paints/paint thinners Butanone, esters, hexane, toluene, xylene
Paint stripper Dichloromethane, toluene
Surgical plaster/chewing gum removers Trichloroethylene
Typewriter correction fluid/ paint thinners 1,1,1-Trichloroethane

Table 2. Unique Clinical Effects of Several Volatile Substances

Chemical Unique Effects
Benzene Hepatorenal toxicity, leukemia
Toluene Muscle weakness, GI symptoms,
renal tubular acidosis
Hexane Stocking-glove peripheral neuropathy
Xylene Encephalopathy, hepatorenal toxicity
Carbon tetrachloride Sudden death, arrhythmias
Gasoline Organic lead encephalopathy
Nitrites Methemoglobinemia, hypotension
Nitrous oxide Vitamin B-12 deficiency, neuropathy

Conclusion
Inadequate procedures and protocols coupled with their inhibition in the investigation of inhalant caused fatalities will continue to deter the identification of the true nature and extent of inhalant use. The set framework however, seeks to alleviate this challenge to considerable levels.

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