Guidelines
GENERAL
BACKGROUND INFORMATION:
Any
exploration of inhalant treatment issues must begin with a
degree of basic knowledge and understanding about this problem.
Inhalant use and abuse seems to stand in the shadow of other,
more heralded, substances of abuse. Both laypersons and professionals
have less awareness regarding inhalants compared to their
knowledge of other substances of abuse. Unfortunately, very
few treatment facilities are able to provide help and services
for this population. To clarify issues, inhalant use and abuse
should be placed in a contextual framework.
A
POPULATION AT RISK
In
2001, according to the Substance Abuse and Mental Health Administration’s
(SAMHSA) 2001 National Household Survey on Drug Abuse (NHSDA),
approximately 2 million young people ages 12 to 17 had used
an inhalant; overall, more than 18 million people have had
experience with an inhalant in their lifetime. Before the
6th or 7th grade, inhalants are the third most popular substance
of abuse after alcohol and tobacco; after the 7th grade, inhalants
decrease to fourth place on the abuse list after alcohol,
tobacco and marijuana ? but their use far exceeds that of
all other substances. With an initiation age of about 12,
inhalants are often the first substance of abuse a child will
use ? thus giving rise to the notion that inhalants are "gateway"
drugs. As these facts are noted, it is also important to remember
that inhalants are unique because even first time use or experimentation
of an inhalant could be a fatal episode.
With
these numbers in mind, it is all the more startling when the
Partnership for a Drug-Free America reports in their 2002
Parent Attitude Survey (PATS) that: parents’ awareness
of teen use of inhalants lags behind teen reports: 18 percent
of teens (ages 12-17) reported having tried inhalants; only
1 percent of parents of teens believe their child has tried
inhalants. Further, parents of school-aged children who discuss
drugs with their child are less likely to discuss inhalants
than marijuana or other drugs such as heroin, cocaine and
crack (discussed marijuana "a lot with their child":
50%; discussed drugs such as heroin, cocaine and crack: 39%;
discussed inhalants: 33%).
The
treatment needs of inhalant abusers are not being met. According
to the 2001 NHSDA, of the 141,00 persons who have abused inhalants
and are in need of treatment, approximately half are young
people 12 to 17 (77,000), while there are only an estimated
61,000 cocaine and 23,000 heroin abusers ages 12 to 17 who
are in need of treatment. Additionally, no other substance
has as high a percentage of youthful abusers in need of treatment
than inhalant abusers. Furthermore, according to SAMHSA’s
latest (2000) Treatment Episode Data Set (TEDS), only an estimated
1,272 persons are receiving inhalant treatment, almost 43
percent are youth 17 years old and younger.
Inhalant
abuse continues into the adult population. The NHSDA found
that approximately 64,000 adults also are in need of treatment
for inhalant abuse. Further, in 2001, the Drug Abuse Warning
Network (DAWN) reported that 676 persons were seen in a sample
of United States emergency departments because of inhalant
problems. Of these, 10% were ages 6 to 17, 33% were ages 18
to 25, 10% were ages 26 to 34, and 47% were aged 35 or older.
MAIN
CATEGORIES OF INHALANT ABUSERS
Dr.
Neil Rosenberg and Dr. Charles Sharp identified four main
categories of inhalant abusers:
A. Transient social user—short history of use; use with
friends; average intelligence; 10-16 years old.
B. Chronic social user—long history of use 5+ years;
daily use with friends; minor legal involvement; poor social
skills; limited education; brain damage; 20-30 years old.
C. Transient isolate user—short history of use; solo
use; 10-16 years old.
D. Chronic isolate—long history of use 5+ years; daily
solo use; legal involvement; poor social skills; limited education;
brain damage; 20-29 years old.
WHAT
ARE INHALANTS?
Inhalants
are breathable chemical vapors or gases that produce psychoactive
(mind-altering) effects when abused or misused. They include
volatile organic solvents, fuel gases, nitrites and anesthetic
gases.
Most
inhalants are part of a large group of chemicals called volatile
organic solvents. Volatility is a measure of the solvent’s
tendency to vaporize or leave the liquid state. The most common
volatile organic solvents are the aliphatic and aromatic hydrocarbons,
which are widely distributed in nature, primarily in natural
gas, petroleum and coal. Examples include: toluene, benzene,
xylene, hexane, trichloroethylene and the freons. Another
class of inhalants is anesthetic gases such as ether, nitrous
oxide, chloroform and halothane.
Everyday
people are exposed to volatile solvents and other inhalants
in the home, school and workplace. Most people do not think
of inhalable products as "drugs" their children
would use. This is because these consumer products were never
meant to be misused and people tend to heed the necessary
cautions printed on the product label. However, when consumer
products are misused or abused by intentionally inhaling them
they can become highly toxic chemicals never intended for
human consumption.
EXAMPLES
OF INHALANTS
Inhalants
fall into several categories:
A.
Solvents:
A. Industrial or household solvents or solvent containing
products such as paint thinners or solvents, degreasers, dry
cleaning fluids, spray lubricants, gasoline, kerosene, octane
boosters, glues and adhesives, liquid lighter fluid, nail
polish and remover and furniture polish and wax.
B. Art, school or office supply solvents including correction
fluids, permanent felt tip markets, enamel paints, spray computer
cleaners, dry erase makers and electronic contact cleaners
(such as computer cleaners)
B.
Gases and Propellants:
C. Gases and propellants used in household or commercial products
including butane lighters, propane, spray paints, hair and
deodorant sprays, fabric protector sprays, room deodorizer
sprays and refrigerants (note that all aerosols use fuel gas
as a propellant except canned whipping cream which uses nitrous
oxide).
D. Medical anesthetic gases such as nitrous oxide (also used
as a propellant in aerosol whipping creams), ether, chloroform
and halothane.
C.
Volatile Nitrites
E. Aliphatic nitrites including amyl, butyl and isobutyl nitrite
sold over the counter as room odorizers, and liquid incense
under such brand names as Rush, Bolt and Locker Room.
Researchers
rely heavily on toxicologic studies to decide what amount,
or dose of a chemical causes harm. By law, a product containing
a chemical must be subjected to toxicological testing before
being released into the marketplace. Pesticides, chemicals
in drug formulations and potentially toxic substances are
subjected to study. Although these tests are directed toward
human applications, using people as subjects is unfeasible
because it is not ethical. Thus toxicity assessment is done
in laboratories using animals.
MODES
OF ADMINISTRATION
Inhalants
are used either by sniffing though the nose or inhaling fumes
through the open mouth (huffing) much like a smoker breathes
in cigarette smoke. Usually the open tube of glue, nail polish
or marker is placed close to the nose and the fumes inhaled.
The user may also spray the substance into a plastic or paper
bag and huff that way. Often a product will be poured or sprayed
on to a piece of cloth, a rag, a towel, a shirt sleeve or
into a soda can and inhaled in that manner. Another method
is to paint the finger nails with a product like correction
fluid and inhaled.
SYMPTOMS
OF INHALANT USE
Lawton
and Malmquest (1961) and Wyse (1973) describe four stages
in the development of symptoms associated with solvent abuse:
A. Stage One (Excitatory Stage):
F. Symptoms may include: euphoria, excitation, exhilaration,
dizziness, hallucinations, sneezing, coughing, excess salivation,
intolerance to light, nausea and vomiting, flushed skin and
bizarre behavior.
B. Stage Two (Early Central Nervous System Depression):
G. Symptoms may include: confusion, disorientation, dullness,
loss of self-control, ringing or buzzing in the head, blurred
or double vision, cramps, headache, insensitivity to pain
and pallor or paleness.
C. Stage Three (Medium Central Nervous System Depression):
H. Symptoms may include: drowsiness, muscular uncoordination,
slurred speech, depressed reflexes and nystagmus or rapid
involuntary oscillation of the eyeballs.
D. Stage Four (Late Central Nervous System Depression);
I. Symptoms may include: unconsciousness that may be accompanied
by bizarre dreams, epileptiform seizures and EEG changes.
Barnes
(1979) notes that the major difference between alcohol drunkenness
and solvent intoxication is the occurrence of hallucinations
in the sniffers. The presence of hallucinations has been reported
in gasoline sniffers (Lawton and Malmquist, 1961; Remington
& Hoffman, 1984; Seshia et al, 1978) and Toluene sniffers
(Press & Done, 1967)
ADVERSE
EFFECTS OF USE
When
inhalant abusers inhale the toxic chemicals of common products,
the concentration of the fumes can be hundreds to thousand
times greater than the maximum permitted in industrial settings.
Although different in makeup, most of the abused inhalants
produce effects similar to anesthetics and are considered
central nervous system depressants with the exception of the
nitrites which are considered vasodialators which lower blood
pressure and cause light headedness and dizziness. These act
to slow the body’s functions. Intoxication occurs when
the chemical products are inhaled in sufficient concentrations.
At low doses users may feel slightly stimulated and light-headed.
At higher amounts, they may feel less inhibited, less in control.
Hallucinations have also been reported to occur. Intoxication
can last for only a few minutes or for several hours if the
chemicals are inhaled repeatedly.
Deep
breathing of the toxic vapors may result in losing touch with
one’s surroundings, a loss of self-control, violent behavior,
nausea, unconsciousness or even death. In certain instances
more dire consequences can occur such as: instant heart failure
("Sudden Sniffing Death"); asphyxiation, suffocation;
or the central nervous system becomes so depressed that breathing
slows down until it stops.
Additional
potential consequences (depending on the particular chemical
being used) from inhaling:
J. Central nervous system or brain damage
K. Peripheral neuropathies or limb spasms
L. Bone marrow damage (theoretical)
M. Liver and kidney damage
N. Hearing loss
O. Blood oxygen depletion
P. Heart and lung damage
Q. Vision impairment
Organic
solvents are highly lipophilic, or highly attracted to the
fatty tissue in the body. This means that they are more soluble
in fats than in water. Therefore solvents will readily leave
the blood and quickly accumulate in the fat cells of the brain,
heart, liver and muscles and remain there for a considerable
period of time. The central and peripheral nervous system,
liver, kidney, lungs, heart and adrenal gland will have a
high toxic chemical content even after a single inhalation.
Because of concentration of these toxins in the body of a
chronic abuser, detoxification of solvents from the body can
take several weeks.
HABITUAL
USE OF INHALANTS
Psychological
addiction and physiological dependence on inhalants does occur
(Criteria for diagnosing inhalant intoxication can be found
in the DSM IV, 292.89). Many users are known to be heavily
preoccupied and dependent on their favorite product or brand
to experience its effects. They may be unwilling to substitute
another product unless theirs is unavailable. Further, the
chronic abuser is likely to require greater doses of the inhalants
due to the effects on the central nervous system. Some inhalant
abusers who had stopped using for a period of time reported
intense inhalant cravings at unexpected times making continued
sobriety very difficult. Withdrawal symptoms to inhalants
have been reported. These include: hand tremors; nervousness;
excessive sweating; hallucinations; chills; headaches; abdominal
pain; and muscular cramps.
REASONS
FOR USING
A
number of reasons exist for people using inhalants, which
include:
R.
Experimentation.
S. Peer group pressure.
T. Cost effectiveness.
U. Easy availability.
V. Convenient packaging ? "It can be easily hidden in
my pocket and nobody knows."
W. Initial mood elevation - "I like the high."
X. The course of intoxication ? "It’s a quicker
drunk."
Y. Legal issues ? "It’s not illegal to buy or have
it." (Actually many states have laws making it illegal
to abuse these products as well as precluding the sale of
certain products to minors ? but they are not strictly enforced.)
Z. The "high" doesn’t last too long. Depending
on the dose, the intoxication is over in minutes (one can
huff during school time) or one can sniff all day long and
remain "high."
AA. Usually the hangover is not as bad as from alcohol, although
headaches appear to be the most common post-intoxication complaint.
BB. In some places where extreme poverty exists, inhalants
are used to dull hunger pangs and to keep from feeling cold.
Lacking
supervision, inconsistency in their family life, having a
hard time making important decisions or just being bored are
some additional common reasons young people give for using
inhalants.
SOCIAL CONSEQUENCIES OF INHALANT ABUSE
The
major socialization forces for most youth are community, schools,
family and peers. Inhalant use impacts on all of these forces:
CC.
The community provides a base within which all other socialization
occurs. Consequently, the community maintains very strong
effects by itself. When children in a community use inhalants
heavily it can suggest sniffing to the next age cohort as
they grow up as well as legitimize it with their peers.
DD. Disruptive family structures are almost always found in
studies of chronic inhalant abusers. Even if the family is
intact, family relationships, particularly with the father,
are poor. Parental alcohol and drug use is usually present,
Young inhalant abusers typically feel that the family does
not care about them. Family sanctions are usually weak.
EE. Inhalant abusers usually have educational problems. They
usually experience high truancy and dropout rates, problems
with school authorities and poor school performance. Young
inhalant abusers demonstrate less liking for school as well
as school adjustment problems.
FF. There is a strong relationship between crime and inhalant
abuse, in part, because of the progression of this addition.
Chronic inhalant abusers often have significant levels of
psychopathology, aggressive behavior, violence and they engage
in a wide variety of deviant and delinquent activities.
GG. Young inhalant users tend to be more alienated than other
youth. These feelings of alienation may be important factors
leading a young person to find other alienated youth which
may then lead to inhalant abuse. Young inhalant users are
different from other young drug users because they may be
experiencing more emotional problems. They are typically more
depressed, more anxious, feel that they are blamed and experience
greater anger than other youth. It is likely that the emotional
and social problems predated inhalant abuse and it is an attempt
to cope with these problems.
HH. Young inhalant users sniff inhalants in small groups.
A large percent of their friends and /or siblings of inhalant
users also use inhalants. They usually start abusing at the
urging of friends or relatives. Among young inhalant users
there is a strong relationship between inhalant use and peer
drug associations that involve inhalants. Peer groups operate
strongly to either encourage or suppress inhalant use.
INHALANT
TREATMENT
BACKGROUND:
Most
generic substance abuse treatment programs are not equipped
to deal with the multiplicity, intensity and complexity of
problems that the inhalant abuser presents. Chronic inhalant
abuse causes many psychological and social problems. Because
of the damage neurotoxic chemicals cause to the brain, it
may be wise to consider the regular, chronic inhalant abuser
as having a dual diagnosis of chemical dependency and mental
illness. Many approaches and techniques used in typical alcohol
and drug treatment apply but a host of other specific issues
must also be addressed.
Inhalant
abuse researchers and experts including Fred Beauvais, Ph.D.,
Angelo Bolea, Ph.D., Luis Formazarri, M.D., Mark Groves, MSW,
Steve Riedel, M.S.ED. Richard Scatterday, M.D., Milton Tenenbein,
M.D., and Pam Jumper-Thurman, Ph.D., concur on the following
critical elements in treating the volatile solvent abuser:
If
inhalant abuse is suspected, a medical examination is required.
During physical examination, several medical complications
must be assessed such as: (1) central nervous system damage;
(2) renal (kidney) and hepatic (liver) abnormalities; (3)
lead poisoning; (4) the possibilities of cardiac arrhythmia
and pulmonary (lung) distress; and (5) nutritional deficiencies.
Because
chemicals are stored in the fatty tissue of the body, the
inhalant abuser may experience residual effects for quite
some time. This could include altered affect and dullness
of intellectual functioning. Consequently, the detoxification
period will need to be longer than the typical drug abuser
? several weeks not days.
Neurological
impairment is usually present with the inhalant abuser. Determining
whether these problems predate or are the result of inhalant
abuse is difficult to decide. Nonetheless, it is important
to assess the presence of any learning difficulties that may
interfere with the treatment process or contributes to disruptive
behavior. A thorough examination of the school records or
any early neurological testing may be productive. Neurological
or neuropsychological testing should be considered early in
the treatment process. However, it is important to not confuse
the effects of acute intoxication with more enduring damage.
It is also important to repeat the testing in several months
to assess improvement. It is not known conclusively whether
neurological damage from inhalant abuse is reversible or not.
However, anecdotal evidence from some treatment professionals
indicates that dramatic improvement in functioning can occur
over the course of several weeks in treatment.
A
thorough assessment of family stability, structure and dynamics
must be a major component of any treatment program addressing
the inhalant abuser. Family involvement is critically important.
Treatment can be focused on therapeutic intervention with
the family ? providing drug education, parenting and social
bonding skills.
Alcohol
and other drug abuse are common for siblings and parents of
inhalant abusers. There is a high probability of poor communication,
sadness and possible physical, emotional and psychological
abuses occurring in the home. There is a need to assess and
address identified issues. Additionally, treatment providers
report a high level of sexual abuse among inhalant abusers.
The
exploration of peer group dynamics is very important. For
younger children, sniffing and huffing often occurs in groups.
Treatment goals that are realistic can help the child break
the bonds with their negative peer group and replace it with
a more positive peer group. This is important for recovery
and sobriety.
Treatment
programs should be prepared to engage the inhalant abuser
in an extended period of supportive care marked by abstinence
from inhalants. Non-confrontation and an emphasis on developing
basic life sills are recommended. Action therapies such as
art, music, drumming, dance and activities that involve hand-eye
are often beneficial. Therapeutic recreational activities
that encourage multi-sensory action will help to assist to
assist in recovery.
Initial
interventions should be very brief (15 to 30 minute sessions),
informal and concrete. Walking and talking sessions would
probably result in the development of rapport and encourage
interaction. The inhalant abuser’s attention span and
complexity of thinking are greatly reduced in the early stages
of treatment. Thus, cognition should be continually assessed
to decide their changing level of functioning.
The
"typical" 28 day or current treatment stay is probably
too short a time to realistically expect change. One of the
reasons for this is the prolonged time that inhalants persist
in the body. Treatment time is uncertain and typically requires
many months. Intensive aftercare and follow up are essential
to rebuild life skills and re-integrate the client with school,
family and community.
DISCUSSION:
If
treatment is suggested, McSherry (1988) stresses that mental
health workers need to possess an understanding about all
aspects of inhalant abuse to develop and apply effective treatment.
Studies on solvent abuse find that treatment is difficult
because most treatment centers apply alcohol and drug treatment
techniques with the assumption that all chemical dependencies
are similar and would respond to these modalities. Sniffers
appear to have less reasoning and resistance power than alcoholics
and other drug abusers due to interruptions in their thought
process. Fomazzari (1988) notes that these deficiencies are
generally reversible, depending upon the extent of damage.
He also stresses that, generally, sniffers are not ready for
therapy as we now apply it in the typical treatment setting
for up to 30 days. The detoxification period in chronic solvent
abusers should be as long as possible. Several weeks of close
observation are necessary for the brain of these young persons
to be rid of the effect of these chemicals. The lack of effectiveness
of long-term treatment is probably due to the lack of social
and family support, being immersed too early in treatment
programs and the reduced capacity of inhalant abusers to understand
and cooperate in treatment and recovery. It is important to
understand that inhalant abusers are often stigmatized, even
by abusers of other drugs, making their participation and
retention in a general drug treatment program very difficult
and problematic.
Mason
(1979) visited several treatment facilities to conduct a pilot
study to assess the patterns of inhalant abuse and problems
associated with treating inhalant abusers. The general impression
from treatment staff interviewed was that most clients do
not respond well to the programs. There was difficulty in
getting clients and family members to keep their appointments.
Consequently, they found more success when they went to the
homes of the inhalant abusers to engage the client and family.
Staff
studied by Mason at the different sites generally felt that
these youths: (1) were not motivated to participate in the
treatment process; (2) were cognitively impaired; (3) had
low self-esteem; (4) were immature; and (5) generally did
not respond well to therapy and other more formalized treatment
approaches. Staff agreed that group therapy in the clinical
setting did not work with the inhalant abuse clients and they
specifically avoided using confrontation techniques with inhalant
abusers. Their general approach was an ad hoc assignment of
specific counselors who got along better with these youth
and participated with them more in individual counseling sessions.
Because of the sniffers’ low motivation level, recreational
or activity therapy is needed to maintain an interest in the
program. The need for changes in the peer group of the sniffer
is crucial as is the need to maintain focus upon positive
peer group influences through continued outpatient or aftercare
efforts.
Inhalant
abusers experience higher dropout and expulsion rates than
any other type of drug abuser (Mason, 1979). These rates are
the result of the inhalant abusers being recalcitrant, erratic,
uncooperative and occasionally exhibiting violent behaviors.
This can be overcome with patience and consistent approaches.
Most agencies involved with inhalant abusers do not seem to
have a clear idea of the inhalant abuse problem and do not
know how to develop an effective treatment approach targeted
to this youthful and frequently disruptive clientele. Even
though the therapeutic process should involve the family,
many programs appear to be unsuccessful in getting families
involved in the treatment programs.
Mason
(1979) further stresses that intervention and referral must
be based on some understanding of the inhalant abuser and
their problems and needs. To serve the inhalant abuser, programs
must be prepared to move out to the community and engage these
youngsters in their natural settings. Workers must be trained
to work with young inhalant abusers in the community, using
the resources of youth clubs, recreational facilities, churches
and schools. Treatment approaches must be coordinated to take
advantage of all available resources in the community in order
to attain a degree of success with the inhalant abuser.
The
literature indicates that the clinical setting should be warm,
open and non-threatening with space and time for informal
socialization and recreation. Relapse is common among sniffers
and recidivist behavior must be tolerated to some extent in
order to keep them in the treatment program. The cognitive
demands of the typical recovery model are often beyond the
grasp of most inhalant abusing clients because their thinking
is too concrete (i. e., here and now and simplistic logic
concepts) which is typical for children and adolescents when
their cognitive abilities are impaired. In addition, most
solvent abusers do not consider themselves to be drug addicts.
Because of the multiple problems present, the counselor must
be a case manager who understands both behavioral therapy
and developmental concepts. Much of the treatment entails
endless case management ? linking the clients with such resources
as medical, legal, psychiatric, court, educational and family
services.
Treatment
of the inhalant abuser often times can be frustrating and
unrewarding. This is the result of the cognitive impairment
that often accompanies the abuse of solvents. Rogers (1982)
stresses that the foremost method of prevention is through
early education of health professionals, teachers, parents,
etc. so that they can spot the early danger signs and get
expert help when necessary.
Based
on empirical findings of a study conducted by an interdisciplinary
committee on solvent abuse among children and young adults
at a Reserve in Manitoba (Gooden, et al., 1986), the following
recommendations are suggested regarding solvent abusers:
A.
There must be networking among the different agencies within
the community including teachers, nurses, childcare workers
and counselors and the treatment program.
B.
Treatment must be social in nature. Because sniffing is usually
a group activity, treatment should include group therapy when
the client is ready. Individual counseling should be available
as well. Treatment should consist of weekly group meetings.
Topics should include: (a) medical complications for use;
(b) reasons for trying sniffing and maintaining sniffing should
be explored; (c) ex-sniffers should be used to serve as positive
role models; and (d) new recreational group activities should
be developed and encouraged particularly at those times when
sniffing occurs (after school, weekends, etc.).
C.
The program should require regular "checkups" to
detect relapses. Encouraging the youths to be honest about
"slip-up" by reassuring them they will not be removed
from the group should they relapse may promote a desire to
belong to the group. This would also ensure that members of
the group develop trust ? a condition essential to effective
therapy.
D.
Patient records, including histories, questionnaires, and
monthly progress reports, should be carefully maintained and
evaluated. A researcher should evaluate this data every six
months to determine (a) which areas of the program need to
be changed; (b) the characteristics are of youths who relapse
or drop out of treatment; and (c) the overall effectiveness
of the treatment program.
Inhalant
abusers can be difficult to treat not only because of their
cognitive impairments but also because of their tendency to
be disruptive while in treatment. Such behavior may be related
to impaired social skill and poor impulse control as a result
of the inhalant abuse. It would appear that programs would
experience more success with inhalant abusers if the abusers
were assigned them to one or two staff members who would gain
empirical experience dealing with the inhalant abusers. These
staff can gauge any successes plus obtain a reputation as
"experts" with inhalant abusers. Being more flexible
and less rigid with inhalant abusers would be wise. The families
of these inhalant abusers must obviously become involved in
the treatment program to experience more success with this
difficult clientele. Strategies must also be developed to
address the peer group influences.
TREATMENT
CONSIDERATONS:
OUTREACH
AND REFERRAL:
Inhalant
abusers tend to be a "hidden" population; their
use of inhalants tends to be undetected and rarely do abusers
seek treatment. Too often inhalant use goes undetected because
it just may not be on the "radar screen." For an
inhalant referral to be effective, staff of the facility must
carefully utilize assessment and intake procedures, be cognizant
of the inherent dangers and complexity of inhalant abuse and
have specific protocols in place for treatment. They must
also develop relationships with medical practitioners to provide
better overall care for these clients.
INTAKE
AND ASSESSMENT:
Inhalant
abusers often present with a wide variety of social, educational,
physical and cognitive problems. There must, therefore, be
an understanding of abuser characteristics to ensure that
inhalant abuse information is elicited. The interviewer must
have a sound understanding of the various products that can
be used, how these products are used and why inhalants are
attractive to users. Understanding patterns of abuse will
facilitate a conversation with a client who may be reluctant
and embarrassed to discuss his or her use or may not clearly
remember episodes of use because of memory loss and/or cognitive
impairment. The interviewer should also understand the attractions
to inhalants (i. e., very quick acting; short duration; free
or low cost; ease of availability; generally not prosecuted;
difficult to test for; enjoyable high; often overlooked as
a drug; etc.).
Along
with intake, thorough assessment must be conducted for cognitive
functioning and neurological and physical damage caused by
inhalant use. Some inhalant abusers show profound levels of
dysfunction and deterioration, but there is a great deal of
variation in this. Physical damage needs to be evaluated early
in the assessment process but other testing for cognitive
and neurologic evaluation may be postponed until after detoxification.
In some treatment populations, abusers have been found to
have higher rates of victimization by physical and sexual
abuse.
Treatment
programs need to thoroughly assess the stability, structure,
and dynamics of the family. If there is limited family support,
if feasible, develop alternatives which may include consideration
of foster care.
SPECIFIC
INTATE AND ASSESSMENT CONSIDERATIONS:
A.
Determine extent, duration, range and context of inhalant
products abused
A record of products which have been abused, approximate number
and frequency of exposures, time interval (over period of
months or years) of abuse, etc., can be important to subsequent
medical/neurological screening. Preparing specific questions
relating to inhalants will insure more accurate and complete
information. It is not sufficient to ask, "Have you ever
inhaled anything to get high?" This question may produce
a positive answer from someone who has snorted cocaine or
heroin. Asking if gas or glue was ever inhaled may not elicit
sufficient information, as these two products are not representative
of the range of abusable products. Ask about specific abusable
substances, including gas and glue, but also spray paint,
lighter fluid, nitrous oxide (whippets), "rush"
(butyl nitrite), poppers (amyl nitrite), aerosol products,
correction fluid, cleaners, and more. Add additional products
depending on known trends in the area. It is also important
to understand the context of how and why the person abuses
inhalants: alone or with a group; to get high or to become
unconscious; where and when he or she huffs.
B.
Medical Screening
Persons with a significant history of inhalant abuse should
be screened carefully. Depending on exposure, tests may be
administered to ascertain levels of toxins in the body. It
is necessary to delineate the extent of impairment of liver
function, renal/kidney function, motor coordination, central
nervous system dysfunction, lung dysfunction, cardiac arrhythmia,
hearing loss, visual impairment, reduced sense of smell or
touch.
C.
Neurological tests
Brain damage (transitory or permanent) can occur as a result
of even occasional inhalant abuse. A complete neurological
workup can reveal neurological damage and helps pinpoint need
for specific remediation.
D.
Behavior/emotional patterns
Erratic and unstable behavior is often seen in chronic inhalant
abusers. Some abusers become violent; others are unpredictable.
Wide mood swings and impulsive behavior are commonly reported.
Declining social skills have been reported among chronic inhalant
abusers.
E. Cognitive history/testing
Brain damage or dysfunction must be suspected, due to anoxia,
product toxicity and other causes. To document changes or
areas of difficulty, a complete history should be taken. Relevant
issues: major changes in school performance; short attention
span; inability to concentrate, memory problems; declining
range of vocabulary; sharp decrease in ability to communicate
clearly; inability to process information.
F.
Evaluation of other drug use
Use of alcohol and/or other drugs should be assessed.
G.
Possession/access to abusable inhalant products
Ascertain the extent of the client’s "collection"
of abusable products and ease of accessibility to product
at home, on the job and/or at school
H.
Family history
Gather information about the structure, dynamics and stability
of family life, along with family history of inhalant abuse.
To be most productive, the family must be engaged in the rehabilitation
process.
I.
Peer group
Explore the dynamics of the individual’s abuse of inhalant
products. Most often this is a group activity, so the person
needs to transition away from an inhalant-abusing peer group
to a more positive peer group.
TREATMENT
PROCESS
OVERVIEW
Treatment
must be specifically focused on inhalants. Research and practice
have determined that "standard" alcohol and drug
treatment is not appropriate or effective for inhalant abusers.
In fact, many treatment facilities refuse to treat inhalant
abusers, judging them to be "resistant to treatment."
Treatment
staff should be knowledgeable about inhalant abuse and have
realistic expectations for recovery. Counselors need to understand
the unique aspects of the problem, including a slow rate of
recovery and the very modest improvements that should be initially
expected. Because many treatment professionals are not aware
of the toxicity and lethality of inhalants (they are toxins,
poisons, pollutants, and fire hazards) there needs to be provision
for inhalant abuse prevention education.
When
solvent abusing children are admitted for treatment they are
distant and hard to reach. However, they are anxious to bond
quickly to their peer group. Some treatment facilities have
utilized this as a treatment opportunity and have developed
a "peer patient advocate" system. Utilizing a peer
who is further along in the treatment process provides the
incoming youths with someone to "teach them the ropes"
and give them support. The treatment staff should closely
supervise this relationship.
Life
skills issues need to be addressed: some abusers have started
huffing as early as elementary school which, along with the
neurological damage, can result in poorly developed life and
academic skills. Take into account cognitive deficits by using
briefer (20 minutes) and more concrete interventions.
Programs
must allow for adequate detoxification: depending on length
of use and product used, detoxification from the acute effects
of solvents and gases may last for several weeks. During this
time, program expectations may need to be reduced.
Family
involvement in the treatment plan should include education
about inhalants, removal of inhalants from the home, and the
understanding that extra support and supervision that inhalant
abusers and their families may need.
Aftercare
planning is a critical component of any inhalant treatment
plan and must take into account the special problems of inhalant
abuse. This includes easy availability of inhalants, residual
cognitive impairment, and poor social functioning. A school-based
advocate/counselor should be included in the plan.
As
a practical and policy matter, ensure that inhalants are not
accessible in the treatment program. Have a policy in place
that to preclude the availability of such items as dry erase
markers, nail polish and remover, typewriter correction fluid,
solvent-based glues, aerosol products (such as deodorants,
hair spray, shaving cream, cleaning products, and canned whipped
cream). Be sure the custodial staff lock up chemicals and
cleaning products
SPECIFIC
INHALANT TREATMENT CONSIDERATIONS:
A.
Standard" substance abuse treatment alone is generally
ineffective for inhalant abusers for these reasons:
•detoxification from poisonous chemicals must be accomplished
prior to planning for treatment. (Groves, Beavers, Sharp and
others state that because toxic chemicals remain in the body’s
fat cells, effects may linger for weeks or months, affecting
cognitive functioning and ability to participate in treatment.)
• detoxification and treatment cannot be effectively
accomplished within a 14 day, 21 day or 28 day model; providing
for an extended length of stay, allowing for a minimum patient
stay of 90 days that can be extended to 120, would be most
beneficial for the patient (Reidel, et. al, 1998)
•"talk therapy" may not be appropriate for
persons with neurological and/or cognitive dysfunction
• short attention span, poor impulse control and/or poor
social skills not appropriate for group therapy
• group therapy may not be appropriate initially, as
users of alcohol and other drugs are often reject or are contemptuous
of inhalant abusers
•
neurocognitive damage may impair decision-making skills
B.
Detoxification, medical screening, and neurological screening
must be initiated before a treatment plan can be constructed
C.
Neurocognitive assessments should be performed to assess neurocognitive
impairment and to develop an individual prescriptive neurocognitive
rehabilitation program (the assessment should be repeated
at discharge for outcome evaluation purposes)
D.
Neurocognitive rehabilitation should be provided to those
assessed as in the "impaired" range of neurocognitive
functioning and to those assessed as in the "normal"
range but who may have a specific impairment
E.
An academic should be developed and be provided during the
course of treatment which has the patient participating in
school at individually assigned levels
F.
A "peer patient advocate" system may be established
to assist incoming patients but must be closely monitored
by treatment staff
G.
Team approach is imperative: medical, neurological, psychological,
occupational, physical/motor rehabilitation, educational components
H.
Where indicated, occupational and physical therapy must be
included in a comprehensive treatment plan
I.
As far as practical, access to inhalable substances must be
eliminated or restricted
J.
Aftercare planning is a critical component of any inhalant
treatment plan and must take into account the special problems
of inhalant abuse. This includes easy availability of inhalants,
residual cognitive impairment, and poor social functioning.
A school-based advocate or counselor should be included in
the plan.
