An investigation of 140 deaths associated with volatile substance abuse in the United Kingdom (1971-1981)

Butane-related deaths in post-mortem investigations: A systematic review

Volatile substance abuse is widespread among adolescents due to its easy availability and methods of consumption. Inhalant abuse represents a current problematic issue, causing significant morbidity and mortality due to direct toxicity on several target organs and displacement of gas which results in a lack of oxygen. This review aims to evaluate post-mortem and toxicological investigations in cases of suspected butane intoxication. We performed comprehensive research using the Preferred Reporting Items for Systematic Review (PRISMA) standards. Forty scientific papers fulfilled the inclusion criteria. A total of 58 cases of butane-related deaths were found. Among these, we found 11 cases of suicide (18%), 1 case of homicide (2%), 44 cases of accidental poisoning (76%), and 2 cases of work-related deaths (4%). Autopsy and post-mortem examinations were performed in 54 cases, whereas toxicological analyses were presented in 56 cases. In autopsy, pulmonary edema (51%) and poli-visceral congestion (59%) were the most common findings. When death by butane inhalation is hypothesized, autopsy and histological findings may be nonspecific, therefore toxicological investigations assume a crucial role along with attention to the methods used to collect biological samples.

The last two decades on preclinical and clinical research on inhalant effects

This paper reviews the scientific evidence generated in the last two decades on the effects and mechanisms of action of most commonly misused inhalants. In the first section, we define what inhalants are, how they are used, and their prevalence worldwide. The second section presents specific characteristics that define the main groups of inhalants: (a) organic solvents; (b) aerosols, gases, and volatile anesthetics; and (c) alkyl nitrites. We include a table with the molecular formula, structure, synonyms, uses, physicochemical properties and exposure limits of representative compounds within each group. The third and fourth sections review the direct acute and chronic effects of common inhalants on health and behavior with a summary of mechanisms of action, respectively. In the fifth section, we address inhalant intoxication signs and available treatment. The sixth section examines the health effects, intoxication, and treatment of nitrites. The seventh section reviews current intervention strategies. Finally, we propose a research agenda to promote the study of (a) solvents other than toluene; (b) inhalant mixtures; (c) effects in combination with other drugs of abuse; (d) age and (e) sex differences in inhalant effects; (f) the long-lasting behavioral effects of animals exposed in utero to inhalants; (g) abstinence signs and neurochemical changes after interrupting inhalant exposure; (h) brain networks involved in inhalant effects; and finally (i) strategies to promote recovery of inhalant users.

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.

Dilated Cardiomyopathy Associated with Toluene Abuse

The use of paint thinner and glue to achieve an euphoric state has been associated with serious social and health problems in children and young adults. We present the case of a 21-year-old man with dilated cardiomyopathy occurring following abuse of paint thinner and glue containing toluene as main compound. After cessation of toluene abuse, the patient recovered rapidly and completely. Because of the increasing prevalence of toluene abuse, harmful effects of this volatile agent on the heart are also discussed.

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.

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.

Freon inhalational abuse presenting with ventricular fibrillation

Inhalation of volatile halogenated hydrocarbons may produce life-threatening cardiac and neurological toxicity. A 15-year-old boy developed ventricular fibrillation immediately after intentional inhalation of a fluorinated hydrocarbon from an automobile air conditioner recharge unit. After the use of intravenous bretylium, a hemodynamically stable sinus tachycardia was restored. Aspiration pneumonitis and rhabdomyolysis complicated his hospital course before complete neurological recovery. The mechanism and treatment of cardiac arrhythmias after volatile fluorinated hydrocarbon inhalation are reviewed.

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.

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.

Volatile substance misuse in children and youth: a consideration of theories

A paucity of research exists in the social sciences regarding the theories explaining volatile substance misuse behavior in children and adolescent. Volatile substances include solvents and inhalants such as modeling glue, aerosol sprays, and gasoline. The explanations found in the literature neither sufficiently nor adequately explain possible motivation and causation. Cultural ideas about life and alcohol, as perceived by adult community members, are significant contributing and motivating variables in children's choices to misuse volatile substances. The social forces within cultural frameworks must be acknowledged to better understand youthful choices to misuse substances.

Glue sniffing deaths in Singapore--volatile aromatic hydrocarbons in post-mortem blood by headspace gas chromatography

Over a period from 1983 to 1991, of a total of 19,000 post-mortems, 33 were found to have at least one aromatic hydrocarbon (benzene, toluene or xylenes) in the blood. Of the 33 deceased, 22 had a history of toluene or petrol abuse while most of the remaining 11 were suspected to be glue sniffers through evidence found at the scene. This number, which represented 0.17 per cent of all the unnatural deaths, is considered small for a nation having a glue sniffing epidemic. The low death rate, as compared to 2.1 per cent through drug and chemical poisoning during the same period, is attributed to the timely intervention by the Government who outlawed glue sniffing and the effectiveness of compulsory rehabilitation. The male gender predominates (81.8 per cent) among the 33 deceased with a mean age of 20.1 years (range 15 to 33). The mean age for the female gender is 17.7 years (range 16 to 20). The blood toluene levels were found to be in the range 0.2 to 92 micrograms per ml blood. The causes of death are: 63.6 per cent due to falling or suicide by jumping; 18.2 per cent drowning; 6.1 per cent hanging; 6.1 per cent homicide; and 6.1 per cent acute toluene poisoning. The high proportion of traumatic deaths are discussed. Headspace gas chromatography with a suitable GC column was used for the analysis. Calibration blood standards were prepared in situ or in bulk stabilized by 10 per cent (v/v) methanol to overcome the hydrophobic and volatile nature of the aromatic hydrocarbons.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

The effect of hexane on the ventricular fibrillation threshold of the isolated perfused rat heart

This investigation was conducted to determine the influence of hexane on the ventricular fibrillation threshold of the isolated perfused rat heart and myocardial electrolyte levels. Ventricular fibrillation threshold was measured using the Langendorff perfusion apparatus. Heart rate was measured by a universal digital counter and the cardiac flow by collecting the outflow of the heating chamber below the heart into a graduated measuring cylinder. Magnesium and zinc were measured by atomic absorption spectrophotometry and potassium by flame photometry. Two groups of rats were studied; those in the experimental group were given 0.2 ml of hexane and the control group 0.2 ml olive oil subcutaneously for 90 days. Their hearts were removed under anaesthesia. Half of the experimental and control hearts were mounted on the Langendorff perfusion apparatus and the heart rate, coronary flow and ventricular fibrillation threshold were measured. The hearts of the other half were used to measure myocardial electrolyte levels. In the experimental group the ventricular fibrillation threshold decreased (4.72 (S.D. +/- 1.87) vs 9.48 (S.D. +/- 2.98); P less than 0.001). There was no change in the coronary flow and heart rate in between the groups. The mean myocardial potassium levels (2586 (S.D. +/- 162) vs 2968 (S.D. +/- 218) micrograms/g; P less than 0.001), magnesium levels (164 (S.D. +/- 28) vs 208 (S.D. +/- 18) micrograms/g; P less than 0.001) and zinc levels (19.6 (S.D. +/- 4) vs 33.8 (S.D. +/- 6.8) micrograms/g; P less than 0.001) were significantly lower in the hexane-treated group compared to controls. Hexane, a constituent of glue and benzine, is cardiotoxic; marked derangement in myocardial electrolytes and a reduced ventricular fibrillation threshold, indicating an increased myocardial vulnerability to arrhythmias, was noted in the experimental animals.

Fatal accidental inhalation of bromochlorodifluoromethane (Halon 1211)

Bromochlorodifluoromethane (Halon 1211) is a widely used fire extinguishing agent. Several cases of sudden death in teenagers associated with BCF abuse have been reported. BCF is used as a fire extinguisher in battle tanks. Two young previously healthy male soldiers were accidentally exposed to BCF in a battle tank. The tank driver died, but the gunner survived the event with no medial complications. It is concluded that BCF should be used in confined chambers only after the evacuation of all personnel.

Chronic solvent abuse. 2. Relationship with depression

Twelve adolescent males with a history of chronic solvent abuse were compared with 12 delinquent controls on a structured interview concerning their history of solvent abuse, drug and alcohol abuse, and on a self-report inventory of depression. Solvent abusers had histories of severe social and emotional deprivation, and reported higher rates of depression. This was particularly true of the most chronic abusers of solvents. These findings do not reflect any referral bias and it is concluded that the association between chronic solvent abuse and depression is a real one. Psychological, social work and psychiatric services need to take the presentation of chronic solvent abuse more seriously.

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.

Volatile substance abuse in relation to alcohol and illicit drugs: psychosocial perspectives

1. Volatile substance abusers are a heterogeneous population despite some demographic and social characteristics which appear similar. 2. Though predominantly an adolescent group activity, adult cases have been reported. Family disruption, alcohol misuse and antisocial behaviour feature prominently. 3. Evidence currently available suggests that only a minority of cases progress to illicit drug use; however a review of literature reveals serious discrepancies. 4. Further research of a longitudinal nature using standardized criteria of psychiatric morbidity and social adjustment and long-term follow-up is indicated to examine the extent of progression to heavy alcohol or illicit drug use.

Increased plasma free fatty acid and triglyceride levels after single administration of toluene in rabbits

Changes of plasma lipids (triglyceride, TG: total cholesterol, Cho; and phospholipids, PL), free fatty acid (FFA), and blood glucose (BG) were studied in male rabbits after toluene administration (0.5 g/kg per os). Hypertriglyceridemia was observed at and after 2 h. Plasma FFA and BG were elevated temporarily during the early stage and lowered gradually thereafter. Initially, plasma Cho and PL were virtually unchanged, but the Cho level increased slowly after 6 h. The hypertriglyceridemia observed may have some adverse effects on heart function.

Volatile substance abuse: a review of possible long-term neurological, intellectual and psychiatric sequelae

The possibility that chronic abuse of volatile substances can cause permanent neurological, psychiatric, and intellectual sequelae is critically reviewed. Toluene, present in the commonly used adhesives, is most often implicated in 'glue sniffing'; this review focuses on its potential long-term effects. Many criticisms--particularly poor matching of control samples and inability to distinguish between acute and chronic effects--can be levelled at the available studies, while no adequate follow-up studies have been performed. In the light of present knowledge, the possibility that permanent structural brain damage, with accompanying psychiatric manifestations, results from solvent abuse remains inconclusive.

Deaths from abuse of volatile substances: a national epidemiological study

A survey of the United Kingdom detected 282 deaths from abuse of volatile substances during 1971-83. Deaths appeared to have increased in the most recent years, reaching 80 in 1983. Age at death ranged from 11 to 76 years but most deaths (72%) occurred under 20 years. Ninety five per cent of the subjects were male, and in 1983 deaths from volatile substance abuse accounted for 2% of all deaths in males aged 10-19. All areas of the United Kingdom were affected, the rates being highest in Scotland and urban areas. All social classes were affected, though rates were highest in social class V and the armed forces. The volatile substances abused were gas fuels (24%), mainly butane; aerosol sprays (17%); solvents in glues (27%); and other volatile substances, such as cleaning agents (31%). In 51% of cases death was attributed to the direct toxic effects of the substance abused, in 21% to plastic bag asphyxia, in 18% to inhalation of stomach contents, and in 11% to trauma. Deaths associated with the abuse of glues were more likely to be traumatic, but all substances appeared capable of killing directly by their toxic effects, probably by a cardiac mechanism. Only a small proportion of deaths (6%) were due to the abuse of glues among children under 16; hence current attempts to limit access of children to glues will probably have little impact on overall mortality.

Solvent abuse from a health education perspective

1 The development of health education and preventive strategies for solvent abuse requires the adaptation of findings and data from other fields and other countries. Experience with illicit drugs suggests that simply denying access to a particularly abused substance may only serve to shift abusers towards other substances. It is, therefore, necessary to acquire evidence on which to judge the relative harmfulness of different substances. Data from the USA on the overall mortality from solvent abuse and on the relative involvement of different solvents is summarized. 2 Findings from health education researches lead to the conclusion that (a) health education is not an effective way of preventing experimentation with solvents, but (b) health education can be effective in modifying abusers' choices of substance and styles of use. 3 Combining these different types of information led to the production of a leaflet suggesting health education strategies that might reduce the likelihood of physical harm befalling solvent abusers. 4 Finally, a plea is made for reports of toxic effects from abused substances to include the kind of data that would assist the development of preventive strategies.

Suspected solvent abuse in cases referred to the Poisons Unit, Guy's Hospital, July 1980-June 1981

1 From July 1980 to June 1981, requests for information as to management or prognosis were received concerning 324 patients (219 male, 91 female) aged 3-31 y (median 15 y) in whom 'solvent abuse' was suspected.

2 The principal symptoms reported were unconsciousness (37), drowsiness (62), 'collapse' (7), convulsions (6), ataxia (35), chest pain (9), nausea/vomiting (20), renal impairment (3) and behavioural disturbances (84). At least 105 patients were admitted to hospital, and 1 was dead on arrival.

3 The products abused in 290 clinically diagnosed cases were: adhesives (214), correcting fluids (23), chlorinated solvents (17), fuel gases (18), petrol (5), BCF fire extinguishing agent (5) and others (17). The co-ingestion of alcohol or other drugs was suspected in only 27 cases.

4 Specimens of blood and/or urine were received for analysis from 117 patients. The clinical diagnosis of solvent abuse was confirmed in 71 cases and solvents were detected in 2 further instances. Ethanol/other drugs were detected in 18 instances, either together with solvent(s) (9) or alone (9), although no compounds were detected in the remaining 35 cases.

5 Toluene (and/or raised urinary hippurate/creatinine ratio) was detected in 52 of the analyses, 1,1,1-trichloroethane in 14 and trichloroethylene (and/or trichloroethanol) in 12. Ethanol was detected in 7 instances, and other drugs (principally benzodiazepines) in 13.

6 Although the presenting symptoms and outcome were usually unremarkable, these results emphasise that some patients can develop serious illness such as collapse or convulsions, which may prove fatal, while chronic solvent abuse can be associated with renal impairment.

Abuse of aerosol products by inhalation

1 The nature of an aerosol and the techniques that have been used to obtain altered states of consciousness by deliberately inhaling the contents are described. 2 The development of the phenomenon, first in the USA, and subsequently in the UK is traced. 3 The consultation between Government Departments and the British Aerosol Manufacturers Association (BAMA) is outlined, and the decisions reached are detailed. 4 Reference is made to the ingredients contained in aerosols which when abused, cause altered states of consciousness and a brief review of their properties is included. 5 The mortality statistics in the UK collected by BAMA are described and analysed in detail and finally the approach of manufacturers to the problem is defined.