Deaths from abuse of volatile substances: a national epidemiological study

Cardiac arrest by inhalation of deodorant spray

Drug abuse by inhalation of volatile household product substances is uncommon, however, it can have devastating consequences. This case report describes the fatal outcome of deodorant inhalation by a 19-year-old patient in a detoxification clinic who developed a cardiac arrest after inhaling butane from a deodorant spray. Despite initial successful resuscitation, he developed a postanoxic encephalopathy with a status epilepticus resistant to extensive treatment. Inhalant abuse can be a cause of death in young patients.

Forensic medical evaluation of deaths resulting from inhalation of cigarette lighter refill fuel in Turkey

Voluntary inhalation/abuse of volatile substances is an important public health problem which especially affects adolescent and young populations worldwide and may be encountered in all socioeconomic and cultural levels. Lighter gas abuse-related death is still an important health problem in Turkey. In this study, 25,265 case files and final reports submitted to the Institute of Forensic Medicine of the First Specialization Board between January 2011 and December 2015 were evaluated retrospectively. In 56 of these cases, lighter gas inhalation (n-butane, propane, isobutane) was recorded as the cause of death. All subjects were male with a mean age of 16.8years. According to eyewitness and crime scene investigation reports, in 48 (85.7%) of the cases, a lighter refill container was found at the scene. It was determined that 21.4% of the cases used a plastic bag to increase the effects of lighter gas and 76.8% inhaled the lighter gas via their mouth and nose. The toxicological analysis of the samples taken while hospitalized showed no lighter refill components (n-butane, propane, isobutane) in 66% of the cases, n-butane in 32.1% of the cases, and n-butane+propane+isobutane in 1.9% of the cases. The importance of lighter gas inhalation-related deaths in Turkey has been increasing. Strict measures against the abuse of these very dangerous substances should be undertaken by the mutual efforts of medical specialists and legislators.

Two serious and challenging medical complications associated with volatile substance misuse: sudden sniffing death and fetal solvent syndrome

Volatile substance misuse is a prevalent and often overlooked behavior among adolescents, including reported use among young pregnant women. Several medical repercussions can arise from the improper use of volatile substances, yet they are often underappreciated among scientists and health professionals. This brief review reports on the recent advances made in the preclinical and clinical data about two serious medical complications surrounding volatile substance misuse: sudden sniffing death and fetal solvent syndrome. Suggestions for treatment interventions are discussed. The paper's limitations are noted.

The mysterious practice of petrol sniffing in isolated indigenous groups

The practice of petrol sniffing is a unique and poorly understood phenomenon that is associated with substantial morbidity, mortality and social devastation in affected remote Indigenous communities. For these groups and for the wider community, much mystery has surrounded the practice and its effects. Here we introduce the epidemiology of petrol sniffing among Indigenous groups internationally, review its impact on the brain, behaviour and social functions and summarise related interventions.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Volatile solvent abuse caused glomerulopathy and tubulopathy in street children

Substance misuse among street children is a significant problem in developing countries. Volatile substances are the most abused agents. According to case reports, chronic renal diseases are common among substance-abusing street children. In this study, we examined the renal findings of 42 volatile substance–abusing street children and compared them with results from 49 healthy children (control). The street children’s weight, height, and blood pressure were lower than the controls’ ( P < 0.05). However, their blood alkaline phosphatase and creatinine phosphokinase levels were higher ( P < 0.05), and total blood protein, creatinine, and phosphorus levels were lower than the controls’ ( P < 0.05). Furthermore, the street children’s glomerular filtration rates were within normal limits ( P < 0.05), their urinary N-acetyl-beta-glucosaminidase (NAG), β2-microglobulin, microalbumin, protein, calcium, phosphorus, sodium, potassium, and chloride excretions were higher, and tubular phosphate reabsorption were lower than the controls’ ( P < 0.05). Volatile substances have been charged with causing distal tubular disease, but increased urinary protein, NAG, β2-microglobulin, microalbumin, and electrolyte excretions also result from glomerular, proximal, and distal tubular influences. We believe that increased volatile substance products in the renal parenchyma are responsible for glomerular and tubular damage. Volatile substance–abusing street children should be examined for glomerular and proximal tubular function and distal tubular acidosis.

Electrocardiographic and echocardiographic findings in street children known to be substance abusers

Substance abuse is prevalent in adolescent street children, and death is reported as secondary to aspiration, accidental trauma, asphyxia, cardiac arrhythmia, anoxia, vagal inhibition and respiratory depression. In this study, we examined electrocardiographic and echocardiographic findings from 53 street male adolescents, comparing our findings to those obtained from 61 controls in the same age group. The street children smoked cigarettes (98.1%) and had used, or were using, thinner (73.6%), glue (75.5%), hashish (79.2%), morphine or its products (24.5%), ecstasy (37.7%), anti-emetics (13.2%) and alcohol (60.4%). On examination, their blood pressures were lower than the control group. Electrocardiographically, PR, QRS, QT were found to be longer (p less than 0.05) than the values for healthy controls. Although it was not statistically significant, QTc duration was also longer than the control group. Echocardiography revealed increased diameters of the left ventricle and atrium, the aorta, and the coronary arteries as compared to the healthy children (p less than 0.05).

[Ventricular fibrillation following deodorant spray inhalation]

We report one case of out-of-hospital cardiac arrest with ventricular fibrillation following butane poisoning after inhalation of antiperspiration aerosol. An early management using semi-automatic defibrillator explained the success of the resuscitation. The mechanism of butane toxicity could be an increased sensitivity of cardiac receptors to circulating catecholamines, responsible for cardiac arrest during exercise and for resuscitation difficulties. The indication of epinephrine is discussed.

Measuring levels of comorbidity in drug user* emergency patients treated in Ontario hospitals

We examined the nature and extent of health problems in drug user patients initially treated in emergency departments and who were subsequently admitted to all hospitals in Ontario, using data from the Hospital Medical Records Institute (HMRI). The modified standardized morbidity ratio (modified SMR) is introduced to improve the measurement and visual display of reduced morbidity as well as excess morbidity. During 1985-86, about 75% of drug user patients entered hospital through the emergency department. There were 5077 emergency patients with primary drug use-related diagnoses and 9827 with secondary drug use-related diagnoses. Cases with poisoning diagnosis made up over 80% of all drug use cases treated in emergency departments. Cases with non-dependent abuse of drugs accounted for 8-12% of emergency drug user patients, whereas those with drug dependence accounted for about 3% of emergency drug user patients. These patients had more than three times the comorbidity experience of all hospital patients. They had excess comorbidity due to mental disorders, infectious and parasitic disorders, and injury and poisoning diagnoses. However, they had reduced comorbidity due to complications of pregnancy, childbirth, and the puerperium and from congenital anomalies and conditions originating in the perinatal period. Cocaine patients were more likely to have infectious parasitic diseases and diseases of the skin and subcutaneous tissue, while amphetamine patients were more likely to have diseases of the digestive system and of the musculo-skeletal system and connective tissue.

A fatal case of n-butane poisoning after inhaling anti-perspiration aerosol deodorant

We report a case of sudden death due to n-butane poisoning after the inhalation of anti-perspiration aerosol deodorant. The deceased was a 15-year-old boy who was found unresponsive on the road, and was pronounced dead after 1.25h. A spray can of anti-perspiration deodorant and vinyl bags were found in a thicket near the scene. An autopsy revealed pulmonary edema, cerebral edema and congestion of the organs. Using qualitative gas chromatography/mass spectrometry, the existence of n-butane was ascertained. The concentration of n-butane (in microl/ml or microl/g) was estimated to be 15.3 in the blood, 13.3 in the brain, 26.6 in the liver, 7.5 in the lung, and 13.6 in the kidney. These n-butane levels in the blood and in the tissues were higher than those of previous reports of death associated with n-butane inhalation. We concluded that the cause of death was n-butane poisoning and presumed that n-butane in the can of anti-perspiration aerosol deodorant induced fatal cardiac arrhythmia.

Upper aerodigestive tract frostbite complicating volatile substance abuse

Volatile substance abuse has become increasingly popular among today's youth. It has reportedly been used by up to 13% of teenage populations. Physicians need to be aware of the potential complications which may arise from this form of substance abuse. We describe the case of a young male who presented with massive edema affecting his lips, oral cavity, oropharynx and trachea. It was later discovered that his injury was secondary to thermal trauma related to the abuse of a fluorinated hydrocarbon propellant. This presentation may easily be confused with allergic or angioneurotic edema. Denial by the patient can lead to a further delay in diagnosis. This case is especially notable since frostbite injury involving the upper aerodigestive tract is extremely rare. We discuss the differential diagnosis and the management principals required in the care of this patient. We also present a pertinent review of the literature related to both volatile substance abuse and its complications involving the airway.

Explosive burns during abusive inhalation of butane gas

Explosion burns during abusive inhalation of butane gas rarely occurred in the past, but recently it has become a social problem among groups of teenagers. This cause constitutes 1.6% of admissions due to flame burn at the burn unit of Hallym Medical Center. A retrospective review during a five-year period identified 48 patients. The male to female ratio was 3:1. The mean age of patients was 16 years and 8 months. The places where the accidents occurred were commonly bedrooms or motel rooms. There were nine group settings of 27 patients at the time of the accident. Inhalation injury (n = 12) was noted on admission. The average burn size was 28.5 percent of the total body surface area. All patients sustained burn injury on the face, arms and hands and 24 patients among them had extended burn areas on the trunk and/or lower extremity. 22 patients (mean hospital stay; 51.6 d) required skin grafting and 12 patients (mean hospital stay; 22.3 d) were treated with conservative management. The mortality rate was 10.4 percent. Explosion burns during abusive inhalation of butane gas can result in mortality as well as major burn injuries.

Deaths associated with inhalant abuse in Virginia from 1987 to 1996

Inhalant abuse has existed for a considerable period of time and it is currently one of the most prevalent drug abuse problems in the world. One repercussion from using these compounds is that abuse may result in lethality. In an attempt to better understand the deaths associated with inhalant abuse, the authors surveyed the death records from the Commonwealth of Virginia from 1987 to 1996. Examination of the state records identified 39 deaths related to inhalant abuse during this time period. While no significant increase or decrease in the death rate was observed across the time period investigated, all regions of Virginia were affected, with the rates being highest in the northern and eastern regions of the state. Age of death ranged from 13 to 42 years with the majority of deaths (70%) occurring at 22 years of age or younger. Ninety-five per cent of the individuals were male, with volatile substance abuse deaths accounting for 0.3% of all deaths in males aged 13-22 years. The chief volatile substances used were gas fuels (46%), predominately butane and propane, chlorofluorocarbons (26%), chlorinated hydrocarbons and alkylbenzenes (21%), and other volatile substances including volatile anesthetics. Deaths associated with the abuse of butane and toluene were more likely to be traumatic, but all substances appeared capable of killing directly by their toxic effects, probably through cardiac and/or respiratory mechanisms. The ramifications of these findings for regulation and prevention are addressed.

Ventricular fibrillation following butane gas inhalation

We report a case of out of hospital defibrillation in a 15-year-old schoolgirl who developed ventricular fibrillation (VF) in association with butane gas inhalation. Although defibrillation performed by an attending paramedic was successful in restoring a cardiac output, her clinical course was complicated by severe neurological impairment. Reports of successful resuscitation following volatile substance abuse are rare and we believe this is the first documented evidence of VF associated with butane gas. This case illustrates the tragedy of such abuse in fit young people and we briefly review the literature.

Complications following butane inhalation and flash fire

Solvent inhalation is a well-documented form of drug abuse that can cause euphoria and hallucinations. Sudden death involving a volatile substance is most commonly caused by cardiac arrythmias, asphyxia, direct drug effects, and trauma. The victim in this paper suffered superficial partial thickness (12% total body surface area) burns from a flash fire that occurred when lighting a match after inhaling butane in an enclosed vehicle. The victim was admitted to the hospital for 2 days of observation but did not develop any respiratory symptoms under 2 days following her release. The victim died during her readmission, 9 days after the flash fire. Postmortem examination showed extensive epithelial injury from the upper airway and trachea to the terminal bronchioles, most likely due in part to both the initial inhalation injury and the resulting adult respiratory distress syndrome (ARDS) and staphylococcal infection. Many victims with superficial burn injuries may not seek medical attention owing to either embarrassment or fear of legal prosecution. Even those who do seek medical assistance may not reveal solvent abuse as the cause of their injuries. It is possible that delayed death may occur at home following volatile substance abuse but may remain unrecognized even with a thorough scene investigation.

The central nervous system and exposure to toluene: a risk characterization

The principal health outcome of exposure to toluene is dysfunction of the central nervous system. Effects range from fatalities and severe neurological disorders in toluene abuse situations to deficits in neurobehavioral function in occupational populations. An Inhalation Reference Concentration (RfC) of 0.4 mg toluene/m3 or 0.1 ppm was developed by the U.S. EPA to protect general populations chronically exposed to toluene. The RfC was derived from results of an occupational study involving Asian workers who developed neurobehavioral deficits at a mean toluene exposure level at the time of the study of 88 ppm. The derivation incorporated several uncertainty factors, one of which was a factor of 10 to account for sensitive subpopulations. Recent evidence indicates that some Japanese and possibly other Asian populations harbor a defective gene for aldehyde dehydrogenase, and thus exhibit a decreased rate of toluene metabolism. Although it is not known if reduced metabolism by aldehyde dehydrogenase also was a factor in the occupational study, preshift blood levels of toluene were considerably higher than preshift levels from non-Asian workers exposed to similar air levels of toluene. The elevated blood levels are consistent with defective metabolism but remain to be confirmed. Inasmuch as air levels of toluene in urban environments are about 10-fold lower than the RfC, an adequate measure of protection is afforded by the RfC with or without an uncertainty factor for sensitive subgroups. However, the uncertainty factor for sensitive subgroups should be retained because there is no information regarding toluene metabolism in children.

Screening of volatile substances and determination of toluene (a thinner component) in the blood and urine in emergency medical care and autopsy cases by the pulse heating method

Screening of volatile substances was performed by pulse heating gas chromatography - mass spectrometry (GC-MS) using a GS-Q column in 211 emergency medical care and 342 autopsy cases. At least 36 standard substances could be separately detected. Six kinds of volatile substances were screened in a total of 553 cases. Toluene and/or hippuric acid were detected in the blood and/or urine in respectively, 4 emergency medical care and 8 autopsy cases. There were 11 abusers (9 males and 2 females) in these 12 positive cases. The ages of the abusers ranged from 13-26 years. There was no particular pattern to the monthly frequency distribution of identification of thinner (toluene) abuse cases, which occurred throughout the year. It is believed that these data at least partly reflect the present status of thinner/glue abuse in Japan. We conclude that pulse heating GC-MS is useful in the screening and quantitative determination of volatile substances including toluene and other thinner/glue components.

Abuse of inhalants: a review

Inhalants, a chemically heterogeneous group of psychoactive substances found in adhesives, lighter fluids, spray paints, cleaning fluids and typewriter correction fluid, may be used by up to 10% of young people. This article reviews the health effects, epidemiology, risk of other substance use and addiction and psychiatric co-morbidity associated with the practice of inhalant use.

[Toxicology of toluene: aspects related to its abuse]

Toluene, present in many industrial and domestic products, is the main solvent involved in solvent abuse and occupational exposure. The main problem in studying toluene-related pathologies is the fact that it is frequently combined with other substances. This review focuses on its potential toxicity. The following subjects are discussed: pharmacologic parameters; physico-chemical features; exposure; clinical trials; experimental research; diagnosis; tolerance and dependence; acute and chronic effects; neurotoxicity; teratogenicity; psychiatric disorders; carcinogenicity; and treatment. It is concluded that is important more research on larger population samples with a view to better definition of the consequences of chronic use should be undertaken.

Volatile substance abuse among school students of eastern Saudi Arabia

A questionnaire-based cross-sectional epidemiological survey of volatile solvent (VS) abuse in a representative sample of 1778 male Saudi students drawn from nine intermediate and nine secondary schools in three urban areas in Eastern Saudi Arabia showed a prevalence rate of 5.3%. The majority (52%) started their abuse between 112 to 14 years of age and the involvement was mostly once (45%) or occasionally (44%), while daily abuse was rare (11%). Predominantly (63%), the behavior lasted less than a month and solitary abuse prevailed (54%). The commonly abused substances were petrol (27%) and glue (23%). VS abuse was significantly associated with family troubles, truancy and smoking, but neither correlated with socioeconomic status, family structure nor with scholastic achievement. Preventive measures are suggested.

Deaths from volatile substance abuse in those under 18 years: results from a national epidemiological study

The epidemiology of deaths from volatile substance abuse (VSA) in those under 18 years that occurred in the UK from 1981-90 is described. The analysis of deaths is based on a national register, which has information obtained from a regular survey of coroners, the Office of Population Censuses and Surveys, and a press clippings agency. Altogether 605 people under 18 died from VSA during this period. Seventy per cent of deaths occurred between the ages of 14 and 16. The largest number of deaths were attributed to butane gas lighter refills. There was a large north-south gradient in age specific mortality ratios (Scotland 180, south east England 87) and nearly four times as many deaths occurred in social class V compared with social class I. Deaths from VSA are an important and preventable cause of deaths in those under 18. Strategies aimed at prevention should include measures to reduce experimentation, intervention to reduce socioeconomic deprivation, and health education campaigns aimed at schools and parents.

INHALANT ABUSE: Assessment Guidelines

It is important that nurses have full access to information that would help them identify inhalant abuse. Nurses need to take the leadership in assessing clients, in educating health care professionals and the public, and in promoting legislation to prevent minors from obtaining inhalants.

Burns following cigarette lighter fluid abuse

Seven patients with burns associated with butane cigarette lighter fluid abuse, in a group setting within an enclosed space, are presented. In all patients there was a reluctance to admit that butane vapour was in use as an intoxicant immediately prior to the injury. It is obvious from the circumstances of these injuries that the hazardous nature of cigarette lighter fluid is not fully appreciated. Since the resultant injuries are usually minor (all patients recovered spontaneously with conservative management, the hospital stay averaging 2 days), it is probable that many more occur, but do not present to accident departments as the victims are wary of repercussions should they admit to intoxicant vapour abuse. In view of the medical sequelae that can follow butane inhalation, burns unit staff should be aware of the problems, their recognition and treatment.

Psychiatric and neurological effects of chronic solvent abuse

This study is a review of the psychiatric and neurological effects of solvent inhalation on a group of 22 patients with chronic histories of solvent abuse, primarily toluene-based solvents. The findings suggest that the chronic inhalation of toluene-based adhesives can produce a paranoid psychosis which may persist. Other findings were a high incidence of temporal lobe epilepsy and decrease in IQ. We suggest that the psychiatric and neurological sequelae of chronic solvent abuse are serious and potentially irreversible. Toluene is felt to be a major factor in the morbidity associated with chronic solvent abuse, and attention is drawn to the necessity for educational programs in this area. The burden caused by the resulting psychiatric problems resulting from solvent abuse may have implications for health care budgets.

The relationship of solvent use to other substance use

One hundred thirty solvent abusers were retrospectively identified from a family study containing 286 alcoholics, 157 felons, 60 control subjects, and 1,640 of their relatives. Comprehensive data regarding psychiatric diagnosis and drug use were gathered using the Home Environment Lifetime Psychiatric Record. Solvent abuse was very strongly associated with having a diagnosis of Antisocial Personality Disorder and was consistently associated with polysubstance abuse. Solvent abusers were more likely to be male, or lower socioeconomic status, and younger than those without a reported history of solvent abuse. Contrary to current understanding, solvent use did not clearly precede other substance use; rather, alcohol and cannabis use tended to occur first, followed by use of solvents. Solvent users were 5 to 10 times more likely than nonusers to report abuse of opioids, stimulants, depressants, and hallucinogens.

Volatile substance abuse

Volatile substance abuse has been reported in the literature over the past 20 years or so, and has apparently increased as countries have become more industrialised. This review attempts to clarify trends in volatile substance abuse, problems associated with this behaviour and possible solutions. Data sources included a Medline Search on volatile substance abuse over the last five years, Commonwealth publications, recent State and Territory inhouse publications, three research monographs from the National Institute on Drug Abuse (NIDA) and an article library from the author's workplace. Some 250 articles and monographs were identified, reviewed and categorised into sections relating to epidemiology (including mortality), physiological effects and responses to the problem. Articles were used for reference where they reflected the most up-to-date information or where they were seen as authoritative statements. While the body of knowledge concerning volatile substance abuse has improved, little progress has been made in finding effective solutions to the problem. The fact that users are typically young and that there is a real risk of sudden death associated with even initial use suggests that continuing research is needed to develop innovative approaches to the problem.

An introduction to the clinical toxicology of volatile substances

Acute poisoning with organic solvents and other volatile compounds now usually follows deliberate inhalation (volatile substance abuse) or ingestion of these compounds. Solvents from adhesives, typewriter correction and dry cleaning fluids, cigarette lighter refills (butane) and aerosol propellants are commonly abused. The major risk is that of sudden death. Arrhythmias leading to cardiac arrest are thought to cause most deaths, but anoxia, respiratory depression and vagal stimulation leading to cardiac arrest may also contribute, as may indirect causes such as aspiration of vomit or trauma. In the United Kingdom (UK), 3.5 to 10% of young people have at least experimented with volatile substance abuse and mortality is more than 100 per annum. The products abused are cheap and readily available despite legislation designed to limit supply. Volatile substance abuse is not illegal and only a minority of abusers are known to progress to heavy alcohol or illicit drug use. Prevention of abuse by education, not only of children but also of parents, teachers, retailers and health care workers, is important in limiting the problem. However, volatile substance abuse-related deaths are still increasing in the UK despite many measures aimed at prevention. Clinically, volatile substance abuse is characterised by a rapid onset of intoxication and rapid recovery. Euphoria and disinhibition may be followed by hallucinations, tinnitus, ataxia, confusion, nausea and vomiting. It is important not to further alarm the patient if signs of serious toxicity are present, since a cardiac arrest may be precipitated. Further exposure should be prevented and the patient resuscitated and given supplemental oxygen if necessary. Cardiac arrhythmias should be treated conventionally and respiratory failure managed supportively. Long term exposure to n-hexane is associated with the development of peripheral neuropathy, while prolonged abuse (notably of toluene or chlorinated solvents) can cause permanent damage to the central nervous system, heart, liver, kidney and lungs. Knowledge of the routes of absorption, distribution and excretion of volatile compounds, and of the rates governing these processes, is important in understanding the rate of onset, intensity and duration of intoxication, and rate of recovery after volatile substance abuse. In addition, such knowledge is helpful when the clinician is attempting to interpret the results of toxicological analyses performed on samples (blood, other tissues, urine) from such patients. Many volatile substances are partly metabolised, the metabolites being eliminated in exhaled air or in urine. Although metabolism normally results in detoxification, enhanced toxicity may also result as with carbon tetrachloride, chloroform, dichloromethane, n-hexane, trichloroethylene and possibly halothane.(ABSTRACT TRUNCATED AT 400 WORDS)

Successful out-of-hospital defibrillation for ventricular fibrillation complicating solvent abuse

The Authors describe the case history of a child who suffered a cardiac arrest with ventricular fibrillation after deliberate inhalation of 1,1,1-Trichloroethane in typewriter correction fluid thinners. Successful out-of-hospital defibrillation was carried out and the patient made a full recovery. The literature relating to this particular form of volatile substance abuse is reviewed.

Driving under the influence of toluene

Toluene is the most common volatile used for sniffing among adolescents. During 1983-1987, 114 drivers were arrested in Norway with blood toluene concentrations (BTCs) greater than 10 microM. Only four of these drivers were women. The age range was 15-34 years, and the mean age was 21. The mean BTC was 109 microM. There was no simple relation between blood toluene concentration and degree of impairment, however, most drivers with BTCs greater than 100 microM were considered as impaired or probably impaired by toluene. In a five year prospective study of rearrests among drivers arrested for driving after toluene sniffing, 12 out of 15 drivers were rearrested. They were responsible for 40 cases of suspected driving under influence of toluene, alcohol, or other drugs. The blood levels of toluene determined in this study must be regarded as minimum concentrations, since the toluene concentration fell rapidly in samples stored at 4 degrees C or 23 degrees C. Blood samples from drivers suspected of driving under influence of toluene must therefore be kept frozen.

Mechanism of sudden death associated with volatile substance abuse

1. Sudden death is a recognized hazard of volatile substance abuse and may occur during exposure or in the subsequent hours. Intoxication may also lead to indirect deaths due to trauma. 2. Specific post-mortem features have not as yet been identified either macroscopically or microscopically in VSA-related deaths. Toxicological examination for volatile substances of all unnatural teenage deaths is strongly recommended. 3. Four mechanisms for acute, direct VSA-related deaths are discussed, viz anoxia, vagal inhibition, respiratory depression and cardiac arrhythmia. Of these, cardiac arrhythmia due to 'sensitization' of the heart to adrenaline is probably the most common and is well documented in experimental conditions. 4. Deaths from cardiac arrhythmia during or soon after VSA are unpredictable, unpreventable and resuscitation is rarely successful. Previous uneventful sessions of abuse provide no protection from this mode of death.

Chronic non-neurological toxicity from volatile substance abuse

1. Most of the evidence for chronic non-neurological toxicity from volatile substance abuse is derived from case reports. 2. Factors important in assessing these reports are the marked variations in exposure conditions and in the composition of the products abused. 3. In a young and otherwise healthy population, any chronic organ toxicity arising from VSA has to be gross in order to become clinically apparent. This may partially explain the relatively low incidence of reporting. 4. Toluene and the chlorinated hydrocarbons 1,1,1-trichloroethane and trichloroethylene can cause permanent damage to the kidney, liver, heart and lung, in certain volatile substance abusers.

Neuropsychological consequences of volatile substance abuse: a review

1. The evidence from studies of the neuropsychological consequences of chronic volatile substance abuse is reviewed. 2. Studies of occupational exposure to solvent vapour are of limited relevance when considering the effects of volatile substance abuse because occupational exposure is normally to small quantities of many different compounds over prolonged periods of time. 3. Many studies of chronic volatile substance abusers suffer from serious shortcomings such as the use of small sample sizes, inadequate controls, failure to exclude the possibility of acute toxic effects and a disregard of other factors which could account for the findings. 4. There is reasonably good evidence that neuropsychological impairment is often present amongst volatile substance abusers with definite neurological abnormalities. 5. Although most studies have found that volatile substance abusers without reported neurological abnormalities obtain lower psychometric test scores than non-abusers, it remains uncertain whether these deficits are best explained in terms of a causal effect of volatile substance abuse, rather than a reflection of other factors associated with volatile substance abuse, such as background, social disadvantages or history of delinquency.

An introduction to the practice, prevalence and chemical toxicology of volatile substance abuse

1. Volatile substance abuse is largely a teenage practice; it is estimated that in the UK 3.5-10% of young people have at least experimented and that 0.5-1% are current users. 2. The products abused are many and varied but only about 20 chemical compounds, notably toluene, chlorinated solvents such as 1,1,1-trichloroethane, fuel gases such as butane and aerosol propellants, are commonly encountered. 3. The acute hazard varies with the compound, product and mode of abuse. Mortality in the UK is now about 100 per year, from all social classes, 90% of whom are male. 4. Chronic toxicity is difficult to assess, partly because of the diversity of products abused. However it is clear that some long-term abusers suffer permanent damage to the central nervous system, heart, liver and kidney. 5. Toxicological analysis may be relied upon for confirmation of diagnosis, providing attention is paid to the kinetics of excretion and stability in the sample. 6. Responses include codes of practice for the sale of products and educational strategies; legislation has also been enacted. There is little evidence that any of these measures have made a significant impact on the problem.

Effects of toluene on protein synthesis and the interaction with ethanol in hepatocytes isolated from fed and fasted rats

The effects of three different concentrations (about 10, 100 and 1000 microM) of toluene on protein synthesis were studied in hepatocytes isolated from fed and fasted rats after 60 and 120 min. of incubation. The interaction between ethanol (60 mM) and the low and high toluene concentrations were also tested. To measure protein synthesis, 14C-valine was used as the precursor amino acid. Total valine concentration was 2 mM to ensure near-constant specific radioactivity of precursor. Toluene concentrations were measured by head-space gas chromatography. Protein synthesis was unchanged in the presence of low toluene concentrations. Intermediate toluene concentration decreased protein synthesis by about 20% and high toluene concentration decreased protein synthesis by about 60%. Protein synthesis was similar in cells from fed and fasted rats. Ethanol alone inhibited protein synthesis by 20-30%, more in fasted than in fed rats. Toluene and ethanol in combination inhibited protein synthesis additively. The high toluene concentration with or without ethanol appeared to inhibit synthesis/secretion of export proteins in hepatocytes from fasted rats. In conclusion, our study indicates that toluene in relatively high concentrations inhibits general protein synthesis in isolated rat hepatocytes. Toluene and ethanol seems to inhibit protein synthesis additively.

Analytical toxicology

1. Major advances in analytical toxicology followed the introduction of spectroscopic and chromatographic techniques in the 1940s and early 1950s and thin layer chromatography remains important together with some spectrophotometric and other tests. However, gas- and high performance-liquid chromatography together with a variety of immunoassay techniques are now widely used. 2. The scope and complexity of forensic and clinical toxicology continues to increase, although the compounds for which emergency analyses are needed to guide therapy are few. Exclusion of the presence of hypnotic drugs can be important in suspected 'brain death' cases. 3. Screening for drugs of abuse has assumed greater importance not only for the management of the habituated patient, but also in 'pre-employment' and 'employment' screening. The detection of illicit drug administration in sport is also an area of increasing importance. 4. In industrial toxicology, the range of compounds for which blood or urine measurements (so called 'biological monitoring') can indicate the degree of exposure is increasing. The monitoring of environmental contaminants (lead, chlorinated pesticides) in biological samples has also proved valuable. 5. In the near future a consensus as to the units of measurement to be used is urgently required and more emphasis will be placed on interpretation, especially as regards possible behavioural effects of drugs or other poisons. Despite many advances in analytical techniques there remains a need for reliable, simple tests to detect poisons for use in smaller hospital and other laboratories.

Acute renal failure due to interstitial nephritis induced by 'glue-sniffing' with subsequent recovery

We report a case of the deliberate inhalation of a toluene-containing adhesive which caused acute renal failure and hepatic damage. Renal biopsy disclosed a severe tubulo-interstitial nephritis, renal function recovered after 14 days' haemodialysis. The literature on renal complications of toluene exposure is reviewed, this is the only case of acute renal failure due to interstitial nephritis after toluene exposure with subsequent recovery. Recovery in this case may have been related to the avoidance of further toluene exposure.

Phenomenology of intoxication with toluene-based adhesives and butane gas

The phenomenology of solvent inhalation was investigated comparing a group of young people who misused toluene (n = 31) with a group misusing butane (n = 12). Marked changes of mental state were invariable. Most users reported elevation of mood and hallucinations but a rich variety of phenomena was elicited. Nearly one-quarter of subjects had the potentially dangerous delusion of believing they were able to fly or swim. In the toluene group thoughts were more likely to be slowed, time appeared to pass more quickly and tactile hallucinations were more commonly reported than in the butane group. Withdrawal phenomena and tolerance were also looked at.

Patterns of use and related harm with toluene-based adhesives and butane gas

The patterns of use and related harm of solvent inhalation were investigated in a group of young people who misused toluene (n = 31) and a group misusing butane (n = 12). The two groups were similar in terms of patterns of use and solvent related harm. The toluene users were more likely to sniff only in a group setting, probably because of the long duration of intoxication. The toluene group were more approving in their attitudes towards taking other drugs.