1
|
Dawudi Y, Azoyan L, Broucker TDE, Gendre T, Miloudi A, Echaniz-Laguna A, Mazoyer J, Zanin A, Kubis N, Dubessy AL, Gorza L, Ben Nasr H, Caré W, d'Izarny-Gargas T, Formoso A, Vilcu AM, Bonnan M. Marked increase in severe neurological disorders after nitrous oxide abuse: a retrospective study in the Greater Paris area. J Neurol 2024; 271:3340-3346. [PMID: 38478030 DOI: 10.1007/s00415-024-12264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Recreational nitrous oxide (N2O) use has become more widespread worldwide, leading to an increase in myelopathies and peripheral neuropathies. The aim of this study was to describe clinical and socioeconomical characteristics of severe N2O-induced (NI) neurological disorders (NI-NDs), to determine its incidence in the Greater Paris area and to compare it with that of similar inflammatory neurological disorders. METHODS We performed a retrospective multicentric cohort study of all adult patients with severe NI-NDs in the neurology and general internal medicine departments of the Greater Paris area from 2018 to 2021. The incidence was compared with that of non-NI-myelitis and Guillain-Barré syndrome (GBS) using a sample of 91,000 hospitalized patients sourced from health insurance data. RESULTS Among 181 patients, 25% had myelopathy, 37% had peripheral neuropathy and 38% had mixed disease. Most were aged between 20 and 25 years, lived in socially disadvantaged urban areas, and exhibited high rates of unemployment (37%). The incidence of NI-NDs increased during 2020 and reached a peak mid-2021. The 2021 incidence in 20-25-year-olds was 6.15 [4.72; 8.24] per 100,000 persons for NI-myelopathy and 7.48 [5.59; 9.37] for NI-peripheral neuropathy. This was significantly higher than for non-NI-myelitis (0.35 [0.02; 2.00]) and GBS (2.47 [0.64; 4.30]). The incidence of NI-NDs was two to three times higher in the most socially disadvantaged areas. CONCLUSION The recent increase in recreational N2O use has led to a rise in the incidence of severe NI-NDs, particularly in young adults with low socioeconomic status for whom NI-NDs strongly outweigh similar neurological disorders.
Collapse
Affiliation(s)
- Yachar Dawudi
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France.
- Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136, Sorbonne Université INSERM, Paris, France.
| | - Loris Azoyan
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France
- Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136, Sorbonne Université INSERM, Paris, France
| | - Thomas D E Broucker
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France
| | - Thierry Gendre
- Neurology Department, Hôpital Henri-Mondor, 1 Rue Gustave Eiffel, 94000, Créteil, France
| | - Amal Miloudi
- Neurology Department, Centre Hospitalier Intercommunal Robert Ballanger, Bd Robert Ballanger, 93600, Aulnay-Sous-Bois, France
| | - Andoni Echaniz-Laguna
- Neurology Department, Hôpital Bicêtre, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Julie Mazoyer
- Neurology Department, Hôpital Avicenne, 125 Route de Stalingrad, 93009, Bobigny, France
| | - Adrien Zanin
- Clinical Physiology Department, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Nathalie Kubis
- Clinical Physiology Department, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Anne-Laure Dubessy
- Neurology Department, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Lucas Gorza
- Neurology Department, Hôpital Foch, 40 Rue Worth, 92150, Suresnes, France
| | - Haifa Ben Nasr
- Neurology Department, Centre Hospitalier Sud Francilien, 40 Avenue Serge Dassault, 91100, Corbeil-Essonnes, France
| | - Weniko Caré
- Department of Internal Medicine, Bégin Military Teaching Hospital, Saint-Mandé, France
- Paris Poison Control Center, Toxicology Federation (FeTox), Hôpital Fernand Widal, AP-HP, Paris, France
| | | | - Aude Formoso
- Neurology Department, Hôpital de La Pitié Salpêtrière, 47-83 Bd de L'Hôpital, 75013, Paris, France
| | - Ana-Maria Vilcu
- Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136, Sorbonne Université INSERM, Paris, France
| | - Mickael Bonnan
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France
| |
Collapse
|
2
|
Soderstrom J, Grigg J, McWilliam O, Fatovich D. Brain and body disconnect: A retrospective case series of subacute combined degeneration of the spinal cord from chronic nitrous oxide use in Perth, Western Australia. Drug Alcohol Rev 2024. [PMID: 38740512 DOI: 10.1111/dar.13858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Chronic nitrous oxide (N2O) use causes inactivation of vitamin B12, resulting in neurological and psychiatric symptoms. This case series presents all N2O-related presentations to the emergency department at Royal Perth Hospital between June 2019 and June 2021, alongside the costs of these admissions. CASE PRESENTATION Twenty-two patients were identified; 68% (n = 15) were male. The median age was 22.4 years (interquartile range [IQR], 20-30). Median daily number of N2O bulbs inhaled was 150 (IQR, 64-300) with a median duration of use of 9 months (IQR, 3-12). Presentations included ataxia, paraesthesia and falls (n = 18), urinary retention (n = 3) and psychotic symptoms (n = 2). Fourteen patients had severe symptoms prompting a magnetic resonance imaging of brain and spine, confirming 12 cases of subacute combined degeneration of the spinal cord. All patients had IMI vitamin B12 therapy, while 14 had oral methionine therapy. The median length of admission was 4 days (IQR 1-23 days). The median cost of admission per day for patients where costs were accessible (n = 7) was $2061 (IQR, $1903-$2860). DISCUSSION AND CONCLUSIONS A case series of symptomatic chronic N2O use with severe neurological sequelae and significant costs associated per admission. Triangulation of emergency department and Ecstasy and Related Drugs Reporting System data helped prompt a swift public health response, including mandatory warning labels, limits to transaction amounts and legislative changes to the Medicines and Poisons Act to make it illegal for sale if there is a suspicion that it will be abused.
Collapse
Affiliation(s)
- Jessamine Soderstrom
- Emergency Medicine, Royal Perth Hospital, Perth, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
| | - Jodie Grigg
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | - Owen McWilliam
- Emergency Medicine, Royal Perth Hospital, Perth, Australia
| | - Daniel Fatovich
- Emergency Medicine, Royal Perth Hospital, Perth, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Emergency Medicine, University of Western Australia, Perth, Australia
| |
Collapse
|
3
|
Back S, Kroon E, Colyer-Patel K, Cousijn J. Does nitrous oxide addiction exist? An evaluation of the evidence for the presence and prevalence of substance use disorder symptoms in recreational nitrous oxide users. Addiction 2024; 119:609-618. [PMID: 37904333 DOI: 10.1111/add.16380] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/03/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Prevalence of nitrous oxide (N2 O) use appears to be increasing in numerous countries worldwide, and excessive use has been associated with physical and mental problems. Because there currently is no consensus whether N2 O has addictive potential, we aimed to evaluate the evidence for the presence and prevalence of DSM-5 substance use disorder (SUD) symptoms in N2 O users. ANALYSIS A literature search was conducted to assess the evidence for the presence of any of the 11 DSM-5 SUD symptoms in N2 O users and the prevalence experiencing those symptoms. A substantial part of the studied N2 O users use more than intended (i.e. 46% to 98%) and spend a substantial amount of time using N2 O. At least some of the studied N2 O users experience interpersonal problems (i.e. 13% to 80%) and use N2 O in risky situations, such as driving under the influence. Evidence for the other criteria is either insufficient or inconclusive. CONCLUSIONS The literature base for the presence and prevalence of DSM-5 substance use disorder (SUD) symptoms in nitrous oxide (N2 O) users is limited and largely consists of qualitative studies and case studies, but it provides consistent evidence for the presence of at least four SUD criteria in heavy N2 O users. N2 O could well be addictive and should be treated as a potentially addictive substance until systematic assessments can provide evidence-based guidance to users, healthcare professionals and legislators.
Collapse
Affiliation(s)
- Sammie Back
- Neuroscience of Addiction (NofA) Lab, Center for Substance use and Addiction Research (CESAR), Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Emese Kroon
- Neuroscience of Addiction (NofA) Lab, Center for Substance use and Addiction Research (CESAR), Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Karis Colyer-Patel
- Neuroscience of Addiction (NofA) Lab, Center for Substance use and Addiction Research (CESAR), Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Janna Cousijn
- Neuroscience of Addiction (NofA) Lab, Center for Substance use and Addiction Research (CESAR), Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Cruz ES, Fortanier E, Hilezian F, Maarouf A, Boutière C, Demortière S, Rico A, Delmont E, Pelletier J, Attarian S, Audoin B. Factors affecting the topography of nitrous oxide-induced neurological complications. Eur J Neurol 2024:e16291. [PMID: 38532638 DOI: 10.1111/ene.16291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/04/2024] [Accepted: 03/15/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND The factors underlying the topography of nitrous oxide (N2O)-induced neurological complications are unknown. METHODS We included all consecutive patients admitted to the university hospital of Marseille for N2O-induced neurological complications in a prospective observational study. Patients underwent neurological examination, spinal cord magnetic resonance imaging, and nerve conduction studies within the first 4 weeks after admission. RESULTS In total, 61 patients were included: 45% with myeloneuropathy, 34% with isolated myelopathy, and 21% with isolated neuropathy. On multivariable analysis, the odds of myelopathy were associated with the amount of weekly N2O consumption (~600 g cylinder per week, odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.001-1.24). The extent of the myelopathy (number of vertebral segments) was correlated with the number of ~600-g cylinders consumed weekly (ρ = 0.40, p < 0.005). The odds of neuropathy were associated with the duration of consumption (per month; OR = 1.29, 95% CI = 1.05-1.58). Mean lower-limb motor nerve amplitude was correlated with the duration of consumption (in months; ρ = -0.34, p < 0.05). CONCLUSIONS The odds of myelopathy increased with the amount of N2O consumption, and the odds of neuropathy increased with the duration of N2O exposure, which suggests distinct pathophysiological mechanisms underlying these two neurological complications.
Collapse
Affiliation(s)
- Eva Sole Cruz
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, APHM, Marseille, France
| | - Etienne Fortanier
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, APHM, Marseille, France
| | - Frederic Hilezian
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
| | - Adil Maarouf
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
- Aix-Marseille University, CRMBM UMR 7339, CNRS, Marseille, France
| | - Clémence Boutière
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
| | - Sarah Demortière
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
| | - Audrey Rico
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
- Aix-Marseille University, CRMBM UMR 7339, CNRS, Marseille, France
| | - Emilien Delmont
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, APHM, Marseille, France
| | - Jean Pelletier
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
- Aix-Marseille University, CRMBM UMR 7339, CNRS, Marseille, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, APHM, Marseille, France
- Aix-Marseille University, INSERM, GMGF, Marseille, France
| | - Bertrand Audoin
- APHM, Department of Neurology, La Timone University Hospital, APHM, Marseille, France
- Aix-Marseille University, CRMBM UMR 7339, CNRS, Marseille, France
| |
Collapse
|
5
|
Sutherland R, Man N, Brown J, Cairns R, Raubenheimer J, Grigg J, Dawson A, Jamshidi N, Peacock A. Has there been an increase in nitrous oxide use and associated harms in Australia? An analysis of triangulated data sources, 2003-2020. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 121:104178. [PMID: 37776604 DOI: 10.1016/j.drugpo.2023.104178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND There is growing concern, globally, regarding use of nitrous oxide (N2O) for intoxication purposes. This paper aims to examine trends in: (i) past six month N2O use among a sample of people who use regularly use ecstasy and/or other illicit stimulants (2003-2020); (ii) volume of N2O-related Google searches and social media posts (2009-2020); and (iii) N2O-related calls to Poisons Information Centres (PIC) (2004-2020). METHODS Data were obtained from annual interviews with sentinel samples of Australians aged ≥16 years who used ecstasy and/or other illicit stimulants ≥monthly and resided in a capital city (∼800 each year); Google search activity; social media posts; and exposure calls to four PIC. RESULTS Among samples of people who regularly use ecstasy and/or other illicit stimulants, past six-month N2O use increased 10% each year from 2009 to 2020, with the sharpest increase observed between 2015 and 2018 (25.4% p/year; 95% CI: 14.6-37.1). Frequency and quantity of N2O use remained stable and low. Google search probabilities increased by 1.8% each month from January 2009 and December 2019 (95% CI: 1.5-2.2), with the sharpest increase observed between July 2016 to December 2017 (6.0% p/month; 95% CI: 4.4-7.5). Social media posts increased 2.0% per month from January 2009 and December 2019 (95% CI: 1.1-3.0), with the sharpest increase observed between March and October 2017 (19.2% p/month; 95% CI: 1.7-39.7). The number of N2O-related calls to Australian PIC increased sixfold between 2016 (16) and 2020 (111). CONCLUSIONS Triangulation of various data sources indicate significant shifts in N2O use and harms in Australia. This includes increases in use, Google searches and social media posts, although these have plateaued in recent years, coupled with increased rates of harm. These findings correspond with evidence of a global increase in N2O use and harm, highlighting the need for education of both people who use N2O and health professionals.
Collapse
Affiliation(s)
- Rachel Sutherland
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
| | - Nicola Man
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Jared Brown
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Australia; New South Wales Poisons Information Centre, Sydney Children Hospital Network, Australia
| | - Rose Cairns
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Australia; New South Wales Poisons Information Centre, Sydney Children Hospital Network, Australia
| | - Jacques Raubenheimer
- The University of Sydney, Sydney, Australia; New South Wales Poisons Information Centre, Sydney Children Hospital Network, Australia
| | - Jodie Grigg
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | - Andrew Dawson
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Australia; Drug Health Services, Sydney Local Health District, Sydney, Australia; New South Wales Poisons Information Centre, Sydney Children Hospital Network, Australia
| | - Nazila Jamshidi
- The University of Sydney, Sydney, Australia; Drug Health Services, Sydney Local Health District, Sydney, Australia; New South Wales Poisons Information Centre, Sydney Children Hospital Network, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; School of Psychological Sciences, University of Tasmania, Hobart, Australia
| |
Collapse
|
6
|
Mechanisms Involved in the Neurotoxicity and Abuse Liability of Nitrous Oxide: A Narrative Review. Int J Mol Sci 2022; 23:ijms232314747. [PMID: 36499072 PMCID: PMC9738214 DOI: 10.3390/ijms232314747] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The recreational use of nitrous oxide (N2O) has increased over the years. At the same time, more N2O intoxications are presented to hospitals. The incidental use of N2O is relatively harmless, but heavy, frequent and chronic use comes with considerable health risks. Most importantly, N2O can inactivate the co-factor cobalamin, which, in turn, leads to paresthesia's, partial paralysis and generalized demyelinating polyneuropathy. In some patients, these disorders are irreversible. Several metabolic cascades have been identified by which N2O can cause harmful effects. Because these effects mostly occur after prolonged use, it raises the question of whether N2O has addictive properties, explaining its prolonged and frequent use at high dose. Several lines of evidence for N2O's dependence liability can be found in the literature, but the underlying mechanism of action remains controversial. N2O interacts with the opioid system, but N2O also acts as an N-methyl-D-aspartate (NMDA) receptor antagonist, by which it can cause dopamine disinhibition. In this narrative review, we provide a detailed description of animal and human evidence for N2O-induced abuse/dependence and for N2O-induced neurotoxicity.
Collapse
|
7
|
van Amsterdam JG, Nabben T, van den Brink W. Increasing recreational nitrous oxide use: Should we worry? A narrative review. J Psychopharmacol 2022; 36:943-950. [PMID: 35678512 DOI: 10.1177/02698811221082442] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Since 2000, the prevalence of recreational nitrous oxide (N2O) use has increased in the Western world. Although N2O is a relatively safe drug, the overall increase in the use of N2O has concomitantly also initiated a modest but important increase in the number of young excessive users. The recent introduction of large 2 kg N2O tanks, allowing high and prolonged dosing, has facilitated this excessive use. This is of concern, because repeated exposure to high doses of N2O for a prolonged time is known to induce neurological damage, such as (irreversible) neuropathy and paralysis due to N2O-induced vitamin B12 deficiency. The increasing trend of recreational users with N2O-induced neurological damage at emergency departments confirms the urgency of this development. OBJECTIVE/METHODS This narrative review describes recent trends in N2O use and misuse, the adverse health effects associated with excessive use and the risk factors of excessive use. RESULTS Considering the rising trend in N2O use, particularly among young and other vulnerable people, we propose to take legislative action to limit the availability of N2O, and also advocate for better and timely education of non-users, users and medical professionals about the serious side-effects associated with excessive N2O use. CONCLUSION It is concluded that the increase in excessive N2O use is of serious concern.
Collapse
Affiliation(s)
- Jan Gc van Amsterdam
- Department of Psychiatry, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ton Nabben
- Urban Governance and Social Innovation, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Marsden P, Sharma AA, Rotella JA. Review article: Clinical manifestations and outcomes of chronic nitrous oxide misuse: A systematic review. Emerg Med Australas 2022; 34:492-503. [PMID: 35695047 DOI: 10.1111/1742-6723.13997] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
Recreational nitrous oxide (N2 O) use is widespread, and complications associated with its use are increasingly common. We sought to identify risk factors, clinical features and outcomes in individuals presenting with effects of chronic N2 O abuse to develop an approach to clinical assessment and management. A systemic literature review was completed with searches conducted across EMBASE, MEDLINE, PSYCINFO and Cochrane databases. Our search strategy identified 612 studies, 105 met inclusion criteria, and 10 were added via hand search. Subjects from 24 case series and 91 case reports were typically in their 20s, using over 100 bulbs daily for several months. Neurological presentations, including sensory change, gait disturbance or weakness, were characteristic. Serum Vitamin B12 was normal or raised in 133 out of 243 case series subjects and 37 out of 84 reports. Serum homocysteine and methylmalonic acid were usually raised. Macrocytosis and anaemia were not commonly seen. MRI findings were abnormal with dorsal column change where specified, typically involving the cervical spine. Nerve conduction studies mostly reported a sensorimotor polyneuropathy. B12 replacement was the treatment of choice and partial recovery was most reported. This review highlights the dose-dependent nature of chronic N2 O toxicity and recognises functional B12 deficiency as the cause. As B12 is often normal, homocysteine and methylmalonic acid are important biomarkers of disease. An approach to diagnosis is offered but requires validation in prospective studies. Research exploring B12 and methionine therapy is required to refine management.
Collapse
Affiliation(s)
- Pierce Marsden
- Department of Medicine, Northern Health, Melbourne, Victoria, Australia
| | - Aakriti A Sharma
- Department of Medicine, Northern Health, Melbourne, Victoria, Australia
| | - Joe-Anthony Rotella
- Department of Emergency Medicine, Northern Health, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Largeau B, Karam A, Potey C, Caous AS, Tard C, Carton L, Kuchcinski G, Gautier S, Deheul S, Bordet R. Myeloneuropathy induced by recreational nitrous oxide use with variable exposure levels. Eur J Neurol 2022; 29:2173-2180. [PMID: 35460312 DOI: 10.1111/ene.15370] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although several case series have described nitrous oxide-associated neurological disorders, a comprehensive assessment of exposure characteristics (e.g., time to onset, level of exposure) in substance abusers has not been performed. The aim of this study was to describe the onset patterns of recreational use of nitrous oxide-induced neurological disorders. METHODS All cases of neurological disorders related to nitrous oxide recreational use reported to the Hauts-de-France addictovigilance center between January 2019 and August 2020 were selected. Only cases requiring hospitalization with informative data to perform the nitrous oxide causality assessment were included. RESULTS A total of 20 cases from 5 hospitals were included. The male-to-female ratio was 6:1 and the median age was 19 years (range 16-34). The neurological presentation [myeloneuropathy 64% (7/11), sensorimotor neuropathy 36% (4/11)] included for all patients gait disorders due to proprioceptive ataxia and limb hypoesthesia. The median dose used per occasion was 100 cartridges (range 5-960; n=19). The median time from the start of nitrous oxide use to the onset of neurological symptoms was 6 months (range 0.7-54; n=16). The cumulative dose was significantly higher in patients with damage to all four limbs than in patients with lower limbs symptoms only (p=0.042). CONCLUSIONS A low intermittent exposure may be sufficient to cause neurological damage in some subjects, suggesting that, at the population level, there is no safe exposure to nitrous oxide in recreational settings. The severity of neurological impairment could increase once used at high doses and for prolonged durations of nitrous oxide.
Collapse
Affiliation(s)
- Bérenger Largeau
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Arnaud Karam
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Centre de Référence des Maladies Neuromusculaires Nord-Est-Ile de France, F-59000, Lille, France
| | - Camille Potey
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| | - Anne-Sylvie Caous
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Céline Tard
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Centre de Référence des Maladies Neuromusculaires Nord-Est-Ile de France, F-59000, Lille, France
| | - Louise Carton
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Grégory Kuchcinski
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Neuroradiology Department, F-59000, Lille, France
| | - Sophie Gautier
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| | - Sylvie Deheul
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Poison Control Center, F-59000, Lille, France
| | - Régis Bordet
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| |
Collapse
|
10
|
The Clinical Presentations of Nitrous Oxide Users in an Emergency Department. TOXICS 2022; 10:toxics10030112. [PMID: 35324737 PMCID: PMC8950993 DOI: 10.3390/toxics10030112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023]
Abstract
Today, the concomitant abuse of nitrous oxide (N2O) and illicit drugs is evident and problematic. However, there are few reports regarding the clinical manifestations of N2O users when they present to the emergency department (ED). The purpose of this study was to describe the clinical presentations, the associated illicit substances used in combination, and the outcomes in N2O users visiting the ED. This was a retrospective observational cohort study. All N2O adult users admitted to the ED at Linkou Chang Gung Memorial Hospital between 2012 and 2020 were included. Demographic variables, clinical symptoms, and examination results were collected from medical records. Univariate comparisons were conducted between pure N2O users and combined illicit drug users. A total of 40 patients were included, 24 of which were pure N2O users. Limb weakness and numbness accounted for the majority of chief complaints. Neurologic symptoms were the most common clinical manifestations (90%). A more severe ED triage level, faster heart rate, greater agitation, and cardiovascular symptoms were significantly noted in combined illicit drug users. In ED, limb numbness/weakness should arouse physicians’ awareness of patients using N2O. Combined use of N2O and illicit drugs can cause great harm to health.
Collapse
|
11
|
van Amsterdam J, Brunt TM, Nabben T, van den Brink W. Recreational N 2 O use: just laughing or really bad news? Addiction 2022; 117:268-269. [PMID: 34545980 DOI: 10.1111/add.15652] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Jan van Amsterdam
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tibor M Brunt
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ton Nabben
- Urban Governance and Social Innovation, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
12
|
[Acute and chronic toxicities associated with the use and misuse of nitrous oxide: An update]. Rev Med Interne 2021; 43:170-177. [PMID: 34903366 DOI: 10.1016/j.revmed.2021.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/07/2021] [Accepted: 10/09/2021] [Indexed: 11/22/2022]
Abstract
Nitrous oxide (N2O) is used since the eighteenth century as an anesthetic and analgesic but also for recreational use. If the labelled uses of N2O and their modalities are nowadays perfectly framed, the misuse of N2O takes very alarming proportions among teenagers and young adults. This misuse is the cause of acute (hypoxia, barotrauma, burns, neuropsychiatric disorders) and chronic complications if repeated (myeloneuropathy, anemia, thrombosis, inhalant use disorder). The main mechanism of the latter is mainly related to a functional deficit in vitamin B12 induced by N2O. The management of acute complications is symptomatic. The management of chronic complications is based on vitamin B12 supplementation. The best biomarker of chronic N2O exposure is the elevation of the plasmatic level of methylmalonic acid. In all cases of recreational misuses, addiction treatment is necessary to prevent complications or their worsening by providing information in order to stop consumption.
Collapse
|
13
|
Jiang J, Shang X, Wang X, Chen H, Li W, Wang Y, Xu J. Nitrous oxide-related neurological disorders: Clinical, laboratory, neuroimaging, and electrophysiological findings. Brain Behav 2021; 11:e2402. [PMID: 34758196 PMCID: PMC8671776 DOI: 10.1002/brb3.2402] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/04/2021] [Accepted: 10/09/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Recreational N2 O abuse is an important etiology of neurological impairment in young patients, which may easily be ignored clinically. Few current studies have investigated the characteristics or the effects experienced by its users. We aimed to explore any correlation between the clinical severity and biomarkers and spinal magnetic resonance imaging (MRI) abnormalities, identify independent factors associated with spinal MRI abnormalities, and ascertain factors affecting depression/anxiety in patients with N2 O-related neurological disorders. METHODS Patients with N2 O-related neurological disorders were enrolled retrospectively between February 2017 and July 2020. Their demographic, clinical, laboratory, neuroimaging, electrophysiological, and neuropsychological findings were analyzed. Correlation analyses were conducted using Spearman's or Pearson's correlation and linear regression analysis. Independent factors associated with spinal MRI abnormalities were identified using univariate and multivariate analyses. RESULTS The principal clinical manifestations of N2 O-related neurological disorders (n = 63; 38 men, 25 women; mean age ± SD: 22.60 ± 4.46 years) were sensory disturbance, followed by gait disturbance and pyramidal tract damage. A significant negative correlation existed between serum vitamin B12 levels and clinical severity (r = -0.309, p = .014), which disappeared after linear regression. An interval of less than 6 months between initial N2 O abuse and hospitalization was independently associated with spinal MRI abnormalities (39.47% vs. 72.00%, respectively; χ2 = 6.40, p = .01). Thirty-eight (60.32%) and 40 (63.49%) patients experienced anxiety and depression, respectively. Moreover, the higher the clinical scores/serum homocysteine levels, the greater the severity of anxiety/depression (r = 0.442, p < .01; r = 0.346, p < .01; r = 0.477, p < .01; r = 0.324, p < .01). CONCLUSIONS The significant inverse correlation between initial vitamin B12 levels and clinical severity could aid prognosis prediction in patients with N2 O-related neurological disorders. Spinal MRI abnormalities were not related to clinical severity but depended on the time interval between initial N2 O abuse and hospitalization. Anxiety and depression were common comorbidity in these patients, and their severity increased with the intensity of clinical impairment and/or serum homocysteine levels.
Collapse
Affiliation(s)
- Jiwei Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiuli Shang
- Department of Neurology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Xiaoting Wang
- Department of Neurology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Hanze Chen
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wenyi Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanli Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
14
|
Redmond J, Cruse B, Kiers L. Nitrous Oxide-Induced Neurological Disorders - an increasing public health concern. Intern Med J 2021; 52:740-744. [PMID: 34569693 DOI: 10.1111/imj.15544] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neurologic presentations resulting from nitrous oxide (N2 O) abuse are increasing in Australia and worldwide. Despite known neuropsychiatric sequelae nitrous oxide canisters remain readily available and its use unregulated. AIMS To examine the demographics, clinical and electrophysiological findings of patients presenting with neurological complications of N2 O abuse, and thus inform clinicians and public health decision makers of the significant public health concerns of this increasing practice. METHODS Consecutive patients presenting to a tertiary referral, metropolitan hospital were included in this series. Patients were identified by a search of discharge summaries of patients admitted with acute or subacute neuropathy or myelopathy and a history of N2 O abuse, and from the electrophysiology database. RESULTS Thirteen patients were identified, most presenting with subacute paraesthesia, sensory ataxia and lower limb weakness. Eleven had low serum vitamin B12 . Spinal magnetic resonance imaging was consistent with subacute combined degeneration (SACD) in 8. Nerve conduction studies revealed a motor or sensorimotor axonal neuropathy (3 with motor predominance). There was a bimodal demographic distribution consisting of socially isolated, international university students and local residents with a history of mental illness and polydrug abuse. CONCLUSIONS Recreational N2 O use is an emerging health problem in Australia. International university students and patients with pre-existing mental illness or polydrug use appear to be at increased risk. A severe motor neuropathy may emerge following Vitamin B12 replacement. Public health measures are required to limit the availability of N2 O and to educate adolescents and young adults about the potential for significant harm. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Jessica Redmond
- Department of Neurology, Royal Melbourne Hospital, Parkville, Vic, Australia
| | - Belinda Cruse
- Department of Neurology, Royal Melbourne Hospital, Parkville, Vic, Australia.,Department of Medicine (RMH), Faculty of Medicine, Health and Dentistry, The University of Melbourne
| | - Lynette Kiers
- Department of Neurology, Royal Melbourne Hospital, Parkville, Vic, Australia.,Department of Medicine (RMH), Faculty of Medicine, Health and Dentistry, The University of Melbourne
| |
Collapse
|
15
|
Swart G, Blair C, Lu Z, Yogendran S, Offord J, Sutherland E, Barnes S, Palavra N, Cremer P, Bolitho S, Michael Halmagyi G. Nitrous oxide-induced myeloneuropathy. Eur J Neurol 2021; 28:3938-3944. [PMID: 34427020 DOI: 10.1111/ene.15077] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/25/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Nitrous oxide misuse is a recognized issue worldwide. Prolonged misuse inactivates vitamin B12, causing a myeloneuropathy. METHODS Twenty patients presenting between 2016 and 2020 to tertiary hospitals in Sydney with myeloneuropathy due to nitrous oxide misuse were reviewed. RESULTS The average age was 24 years, and mean canister consumption was 148 per day for 9 months. At presentation, paresthesias and gait unsteadiness were common, and seven patients were bedbound. Mean serum B12 was normal (258 pmol/L, normal range [NR] = 140-750) as was active B12 (87 pmol/L, normal > 35). In contrast, mean serum homocysteine was high (51 μmol/L, NR = 5-15). Spinal magnetic resonance imaging (MRI) showed characteristic dorsal column T2 hyperintensities in all 20 patients. Nerve conduction studies showed a predominantly axonal sensorimotor neuropathy (n = 5). Patients were treated with intramuscular vitamin B12, with variable functional recovery. Three of the seven patients who were bedbound at presentation were able to walk again with an aid at discharge. Of eight patients with follow-up data, most had persistent paresthesias and/or sensory ataxia. Mobility scores at admission and discharge were not significantly correlated with the serum total and active B12 levels or cumulative nitrous oxide use. There were no significant trends between serum active B12 level and cumulative nitrous oxide use (Spearman rho = -0.331, p = 0.195). CONCLUSIONS Nitrous oxide misuse can cause a severe but potentially reversible subacute myeloneuropathy. Serum and active B12 can be normal, while elevated homocysteine and dorsal column high T2 signal on MRI strongly suggest the diagnosis. Neurological deficits can improve with abstinence and B12 supplementation, even in the most severely affected patients.
Collapse
Affiliation(s)
- Grace Swart
- Department of Neurology, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher Blair
- Department of Neurology & Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Zhong Lu
- Department of Chemical Pathology, Monash Health Pathology, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Solomon Yogendran
- Department of Anaesthesia, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Joanna Offord
- Department of Neurology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Emily Sutherland
- Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Stephanie Barnes
- Department of Neurology, Concord Repatriation Hospital, Sydney, New South Wales, Australia
| | - Natalie Palavra
- Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Phillip Cremer
- Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Samuel Bolitho
- Department of Neurology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Gabor Michael Halmagyi
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
16
|
Mosalski S, Tanner A, Shiner CT. Recreational nitrous oxide misuse is resulting in serious neurological impairment and persistent disability among users. Med J Aust 2021; 215:237-237.e1. [PMID: 34350603 DOI: 10.5694/mja2.51201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Simon Mosalski
- St Vincent's Hospital Sydney, Sydney, NSW.,University of New South Wales, Sydney, NSW
| | | | - Christine T Shiner
- St Vincent's Hospital Sydney, Sydney, NSW.,University of New South Wales, Sydney, NSW
| |
Collapse
|