A review of solvent abusers and their management by a child psychiatric out-patient service

Psychosocial therapeutic interventions for volatile substance use: a systematic review

AIMS

Volatile substance use (VSU) is associated with a range of adverse outcomes, including cognitive impairment and death. It occurs disproportionately within young and marginalized populations. A previous international systematic review of VSU treatment identified no relevant studies. This paper reports on a systematic review of a range of study types concerning psychosocial interventions for VSU.

METHODS

Search parameters were developed using the Population, Intervention, Professionals, Outcomes, Health care setting and Contexts (PIPOH) tool with input from an expert committee. Included were randomized controlled trials (RCTs), comparative studies with or without concurrent controls, case series studies and grey literature, published in English during 1980-2010.

RESULTS

The initial search identified 2344 references. After two screening phases, 23 studies of VSU therapeutic interventions remained. Of these, 19 concerned psychosocial interventions, which we discuss as: case management; counselling; recreation and engagement programmes; and residential treatment. Studies were conducted in Australia, Canada, the United States, United Kingdom and Brazil. No RCTs were identified and studies were generally of low evidentiary levels.

CONCLUSIONS

Even when a range of study types are included, clear conclusions for volatile substance use psychological treatment are not supported, but three intervention types merit further examination: family therapy, activity-based programmes and Indigenous-led residential approaches. Future volatile substance use research could be enhanced by developing and validating outcome measurement tools. Robust multi-site studies are also required.

Juvenile Offences Among Hospitalized Adolescent Inhalant Users in Istanbul: A Comparison Regarding Place of Residence

In this research, juvenile offenses and associated behaviors among adolescent inhalant users in Istanbul were investigated and inhalant users living in the street were compared to inhalant users living with their families. An interview questionnaire developed by the researchers was administered to 200 male adolescent inhalant users who were hospitalized during 2002-2003. More than half of the sample had committed juvenile offenses at least once in their lifetime, 16.3% had entered a house of corrections, 91.5% had friends who committed juvenile offenses, and the majority had been taken to a police station at least once in their lifetime. The rates for juvenile offenses, being taken to the police station, committing crimes to obtain money to buy drugs, and obtaining income through illegal activities were higher among adolescents living in the street than adolescents living with their families. Although the juvenile offense rate was higher among adolescents living in the street, it can be suggested that both groups live in subcultures that have a tendency towards crime, and inhalant use is part of these subcultures. Juvenile offense interventions can be useful for all inhalant users.

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.

Trends in drug use among students in Brazil: analysis of four surveys in 1987, 1989, 1993 and 1997

The consumption of psychotropic drugs among Brazilian secondary school students was examined by comparing data from four surveys using a questionnaire adapted from the WHO's Program on Research and Reporting on the Epidemiology of Drug Dependence. Students filled out the form in their classrooms without the presence of teachers. The target population consisted of 10-18-year-old students (on average, 15,000 students responded to each survey) in Brazil's ten largest state capitals: Belém, Belo Horizonte, Brasília, Curitiba, Fortaleza, Porto Alegre, Recife, Rio de Janeiro, Salvador, and São Paulo. Among the legal drugs, lifetime use (use at least once during life) of tobacco was increased in seven cities (the exceptions were Brasília, Porto Alegre and Rio de Janeiro). There was also a significant increase in frequent use of alcohol (six times or more per month) in 6 of the cities, from an average of 9.2% in 1987 to 15.0% in 1997. With respect to illegal drugs, there was a significant increase in lifetime use of marijuana (a 3-fold increase from 2.8% in 1987 to 7.6% in 1997). Cocaine use increased 4-fold over the survey period (0.5% in 1987 to 2.0% in 1997). Lifetime use of cocaine significantly increased in eight capitals (except Recife and Rio de Janeiro). However, frequent cocaine use increased in only three capitals (Belém, Fortaleza and Porto Alegre), from an average of 1.0% in 1987 to 3.6% in 1997. Lifetime use of medications such as anxiolytics and amphetamines increased 2-fold on average over the survey period. Comparing the four studies, the main conclusion is that there were significant increases in the frequencies for lifetime use, frequent use and heavy use of many drugs.

Young people admitted on a Form 1 to a general hospital: A worrisome trend

OBJECTIVE

To assess and analyze the significance of the increase in the number of paediatric psychiatric admissions under a Form 1 (involuntary admission) to the regional paediatric unit of a general hospital.

METHODS

The authors retrospectively reviewed the charts of all child psychiatric admissions to the paediatric ward over the years 1998 to 2003. The specific data obtained was that of discharge diagnosis, age and sex of patient, application of Form 1 and transfer to a psychiatric facility.

RESULTS

BROAD DIAGNOSTIC CATEGORIES INCLUDED: mood disorder with and without suicidal behaviour, suicidal behaviour, psychosis, mood disorder with psychosis, anxiety disorder, eating disorder, behaviour disorder, personality disturbance, substance abuse, situational crisis and psychogenic disorder. Yearly admissions to the unit ranged from 25 per year to 45 per year over the five years studied. In the last three years, the rate of Form 1 application increased from one in 1999 to 2000 to 11 in 2002 to 2003 (a 10 fold increase).

DISCUSSION

Possible reasons for this dramatic increase were identified and may be relevant to other nonpsychiatric centres dealing with children.

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.

Psychiatric symptoms in drug abusing adolescents

Psychiatric symptoms and psychosocial variables were investigated in 46 adolescent drug abusers referred to a psychiatric clinic. There were high rates of behavioural symptoms (mostly oppositional and delinquent), emotional symptoms (mostly depressive) and an abundance of adverse life events and family dynamics. When compared to a control group of non-abusing adolescents, drug users were only more behaviourally disturbed. Cluster analysis of the drug abusing adolescents showed that they fell into three distinct groups of (1) behavioural dysfunction (76%); (2) family dysfunction (16%); and (3) emotional dysfunction (8). The clinical implications of these findings are discussed.

A longitudinal perspective on adolescent substance abuse

The links between adolescent substance abuse and adult alcohol and drug misuse and dependence are now well established. The vast majority of adult substance misusers start in their adolescent years. This, and the emotive nature of adolescent substance abuse generated an increased and justifiable interest in substance abuse in adolescent populations, that began in the early 1970s. This paper reviews the most relevant recent literature relating to the subject especially that which had a longitudinal design. It covers epidemiology, antecedents, course and outcome, psychopathology, treatment and prevention. Ideas for further longitudinal research are suggested.

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.

Solvent use as a precursor to intravenous drug abuse

Intravenous drug abuse (IVDA) is a significant public health threat, and ways of identifying individuals at high risk for IVDA are needed to plan strategies for intervention and treatment. Previous work had identified similarities in psychiatric diagnosis and patterns of drug use in IVDAs and solvent users. Using the same population, we found that 59 of 179 IVDAs (33.0%) reported a history of solvent use, which preceded the onset of IVDA in 41 of the 59. IVDAs with a history of solvent use were more likely to receive diagnoses of alcoholism and antisocial personality disorder (ASP) than IVDAs without solvent use. Even allowing for these coexisting psychiatric disorders, a reported history of solvent use increased the likelihood of also reporting IVDA by a factor of 3.2. Although the magnitude of risk is likely to differ in other populations, a history of solvent use may indicate individuals at high risk for IVDA, and youths who have used solvents should be considered at high risk for severe drug abuse, including IVDA.

Solvent use and psychiatric comorbidity

From a family study of 286 alcoholics, 157 felons, 60 control subjects, and 1640 of their relatives, 130 solvent users were retrospectively identified. Risk for diagnosis of antisocial personality disorder was significantly elevated for all solvent users. Relatives, though not probands, were more likely to receive diagnoses of alcoholism and secondary depression, but this relationship appeared to be mediated by the presence of antisocial personality disorder. Solvent users were not at increased risk for primary depression or other psychiatric illnesses. Subjects reporting any solvent use also had significantly increased risk of suicidal ideation and suicide attempt compared to non-users, with half of the solvent users reporting suicidal ideation and 30% reporting a history of suicide attempt. However, risk for suicidal ideation and suicide attempt among solvent users appeared to covary with presence of antisocial personality disorder, alcoholism, and secondary depression rather than being specifically associated with solvent use.

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.

Chronic solvent abuse. 1. Cognitive sequelae

Twelve adolescent males with a history of chronic solvent abuse were compared with 12 delinquent controls on a battery of neuropsychological tests. Toluene was the active constituent most commonly abused. Solvent abusers tended to have lower overall intelligence test scores. On the Bexley Maudsley Automated Screening Test, the solvent abusers scored significantly lower on tests involving visual processing, especially the Symbol Digit Coding test. These results are cautiously interpreted as indicating that chronic solvent abuse carries an increased risk of cognitive impairment.

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.

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.

Depression in solvent abusers

Previous studies mention that some solvent abusers have a depressed mood. This study sets out to determine in a formal way whether solvent abusers are more depressed than a comparison group of non-solvent abusers. Forty-seven consecutive admissions (all with delinquent histories) to the secure unit of a regional assessment centre for adolescent boys, who fulfilled certain criteria, were assessed. They completed the General Health 28 item questionnaire (GHQ-28) and the Great Ormond Street (GOS) mood questionnaire. Thereafter, they were administered a semi-structured interview covering the following areas--solvent abuse data, educational data, demographic and family data, criminal history and other drug use data. Results showed that significantly more solvent abusers were depressed than non-solvent abusers as defined by GOS-mood scores of 25 or more (P less than 0.05). Also, mean GHQ-28 total scores (P less than 0.02), GHQ-28 depression subscale scores (P less than 0.02), and GOS-mood scores (P less than 0.05) were significantly higher in the solvent abuse group. In conclusion, solvent abusers are more depressed than a comparison non-solvent abusing group.

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.

Progression of addiction careers in young adult solvent misusers

Four case histories of a representative sample of young adult glue sniffers who had progressed to using illicit drugs or abusing alcohol or both contained several common factors that may have been relevant in the transition. For example, all had suffered parental deprivation or rejection in childhood leading to a state of chronic stress, and all had progressed from sniffing glue to inhaling heroin and thence to "snorting" and injecting heroin. The exact reason for the transition from glue sniffing to misusing other substances was not clear. Nevertheless, although these cases represent only a minority of glue sniffers, the problem of transition may be more common than hitherto supposed.