Psychiatric Nursing

Introduction

Inhalant drugs (also called inhalants or volatile substances) are volatile hydrocarbons such as toluene, trichloroethylene, trichloroethane, dichloromethane, gasoline and butane. These chemicals are sold in four commercial classes:

• 1. Solvents for glues and adhesives.
• 2. Propellants for aerosol paint sprays, hairsprays, frying pan sprays, and shaving cream
• 3. Thinners( paint products)
• 4. Fuels

At room temperature these compounds volatilize to gaseous fumes that can be inhaled through the nose or mouth, entering the blood stream by transpulmonary route.

Epidemiology

Inhalant substances are easily available, legal and inexpensive. These three factors contribute to the high use of inhalants among poor persons and young persons. According to DSM IV- TR about 6% of persons in the United States had used inhalants at least once, and about 1% of persons are current users. In one study of high school seniors, 18% reported having used inhalants at least once, and 2.7% reported of having used inhalants within the preceding month.

Patterns of use/ abuse

• Methods of use include huffing"- a procedure in which a rag soaked with the substance is applied to the mouth and nose and the vapours breathed in.
• Another common method is called "bagging" in which the substance is placed in a paper or plastic bag and inhaled from the bag by the user. They may also be inhaled directly from the container or sprayed in the mouth or nose.
• Children with inhalant disorder may use inhalants several times a week, often weekends and after school. Adults with inhalant dependence may use the substance at varying times during each day, or they may binge on the substance during a period of several days.

Neuropharmacology

• Inhalants usually act as a central nervous system depressant.
• Tolerance for inhalants can develop, although withdrawal symptoms are usually fairly mild and are not classified as disorders in DSM-IV-TR. Inhalants are rapidly absorbed through the lungs and rapidly delivered to the brain.
• The effects appear within 5 minutes and can last for 30 minutes to several hours, depending on the inhalant substance and the dose. The concentration of the many inhalant substances is increased when used in combination with alcohol.
• Inhalants are detectable in the blood for 4-10 hours after use, and blood samples should be taken in the emergency room when inhalant use is suspected.

Inhalant dependence and inhalant use:

Most persons use inhalants for a short time without developing a pattern of long term use resulting in dependence and abuse.

Inhalant intoxication:

• The DSM IV -TR diagnostic criteria for inhalant intoxication specify the presence of maladaptive behavioural changes and at least two physical symptoms.
• The intoxicated state is often characterized by apathy; diminished social and occupational functioning, impaired judgement, and impulsive or aggressive behaviour and it can be accompanied by nausea, anorexia, Nystagmus, depressed reflexes and diplopia. With high doses and long exposures, a user's neurological status can progress to stupor and unconsciousness, and a person may later be amnestic for the period of intoxication.
• Clinicians can sometimes identify a recent user of inhalants by rashes around the patient's nose and mouth, unusual breath odours, the residue of the inhalant substances on the patient's face, hands or clothing and irritation of the patient's eyes, throat, lungs and nose.

DSM -IV diagnostic criteria for inhalant intoxication:

• a) Recent intentional use or short term , high dose exposure to volatile inhalants(excluding anaesthetic gases and short acting vasodilators)
• b) Clinically significant maladaptive behavioural or psychological changes ( eg: belligerence, assaultiveness, apathy, impaired judgement, impaired social or occupational functioning) that developed during, or shortly after, use of or exposure to volatile inhalants.
• c) Two( or more) of the following signs, developing during, or shortly after, inhalant use or exposure:

• d) The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Inhalant intoxication delirium

Delirium can be induced by the effects of the inhalants themselves, by pharmacodynamic interactions with other substances, and by hypoxia, that may be associated with either the inhalant or its method of inhalation.

If the delirium results in severe behavioural disturbances, short term treatment with a dopamine receptor antagonist, such as haloperidol may be necessary.

Benzodiazepines should be avoided because of the possibility of increasing the patient's respiratory depression.

Inhalant induced persisting dementia

Inhalant induced persisting dementia as with delirium, may result from the neurotoxic effects of the inhalants themselves; the neurotoxic effects of metals commonly used as inhalants, or the effects of frequent and prolonged periods of hypoxia. The dementia caused by inhalants is likely to be irreversible in all but the mildest cases.

Inhalant induced psychotic disorder

Clinicians can specify hallucinations or delusions as the predominant symptoms. Paranoid states are probably the most common psychotic syndromes during inhalant intoxication.

Inhalant induced mood disorder and inhalant induced anxiety disorder

Inhalant induced mood disorder and inhalant induced anxiety disorder are DSM IV TR diagnoses that allow the classification of inhalant related disorders characterized by prominent mood and anxiety symptoms. Depressive disorders are the most common mood disorders associated with inhalant use, and panic disorders and generalized anxiety disorder are the most common anxiety disorders.

DSM- IV Diagnostic criteria for inhalant disorder not otherwise specified.

This category is for disorders associated with the use of inhalants and is not classifiable as inhalant dependence, inhalant abuse, inhalant intoxication, Inhalant abuse, Inhalant intoxication, Inhalant intoxication delirium, Inhalant induced persisting dementia, Inhalant induced psychotic disorder, with delusions, Inhalant induced psychotic disorder, with hallucinations, Inhalant induced mood disorder, and Inhalant induced anxiety disorder.

 Clinical features:

• In small initial doses, inhalants can be disinhibiting and produce feelings of euphoria and excitement and pleasant floating sensations, the effects for which persons presumably use the drugs.
• High doses of inhalants can cause psychological symptoms of fearfulness, sensory illusions, auditory and visual hallucinations, and distortions of body size. The neurological symptoms can include slurred speech, decreased speed of talking, and ataxia.
• Long term can be associated with irritability, emotional lablity and impaired memory.
• Tolerance for inhalants does develop; although not recognized by DSM-IV TR , a withdrawal syndrome can accompany the cessation of inhalant use.
• The withdrawal syndrome does not occur frequently; when it does it can be characterized by sleep disturbances, irritability, jitteriness, sweating, nausea, vomiting, tachycardia, and delusions and hallucinations.

Effects on the body

Inhalants are absorbed the lungs and reach the CNS very rapidly. Inhalants generally act as a CNS depressant. The effects are relatively brief, lasting from several minutes to a few hours, depending on the specific substance and amount consumed.

a)      Central nervous system:

• Inhalants can cause both central nervous system and peripheral nervous system damage, which may be permanent. Neurological deficits, such as generalized weakness and peripheral neuropathies, may be evident.
• Other CNS effects that have been reported with heavy inhalant use include cerebral atrophy, cerebellar degeneration, and white matter lesions resulting in cranial nerve or pyramidal tract signs.

b)     Respiratory effects:

• Upper or lower airway irritation, including increased airway resistance, pulmonary hypertension, acute respiratory distress, coughing, sinus discharge, dyspnoea, rales, or rhonchi
• Rarely cyanosis may result from pneumonitis or asphyxia.
• Death may occur from respiratory or cardiovascular depression.

c)      Gastrointestinal effects:

• Abdominal pain, nausea and vomiting
• Rashes around the individual's nose or mouth
• Unusual breath odours

d)     Renal system effects:

• Chronic renal failure, hepatorenal syndrome, and proximal renal tubular acidosis

Treatment:

• Inhalant intoxication, as with alcohol intoxication, usually requires no medical attention and resolves spontaneously. Effects of the intoxication, such as coma, bronchospasm, laryngospasm, cardiac arrhythmias, trauma, or burns, need treatment, however.
• Otherwise care primarily involves reassurance, quiet support and attention to vital signs and level of consciousness.
• Sedative drugs including benzodiazepines are contraindicated because they worsen inhalant intoxication.
• Street outreach and extensive social service support have been offered to severely deteriorated, inhalant dependent and homeless adults. Patients may require extensive support within their families or in foster or domiciliary care.
• Confusion, panic, and psychosis mandate special attention to patient's safety. Severe agitation may require cautious control with haloperidol( 5 mg I M per 70 kg body weight)
• Inhalant induced anxiety and mood disorders may precipitate suicidal ideation, and patients should be carefully evaluated for that possibility.

Day treatment and residential programs: This has been used successfully, especially for adolescent abusers with combined substance dependence and other psychiatric disorders. Treatment address the co morbid state which, in most cases, is conduct disorder or in other instances, may be ADHD, major depressive disorder, dysthymic disorder and PTSD.

Both group and individual therapy are used that are behaviourally oriented, with immediate rewards for progress towards objectively defined goals in the treatment and punishments for lapses to previous behaviours.

Patient's families are often given a family therapy, which has good empirical support. Participation in 12 step program is needed. Treatment interventions are coordinated with interventions by the community social worker and probation officers.

Progress is monitored with urine and breath samples analyzed for alcohol and other drugs at intake and frequently during treatment. Treatment usually lasts 3 to 12 months. Termination is considered successful if the youth has practiced a plan to stay abstinent; is showing fewer antisocial behaviours.    

Nursing diagnosis:

Common nursing diagnosis can be:

1.      Ineffective denial related to knowledge deficit regarding negative effects of substance abuse or dependency.

 2.      Disabled family coping related to domestic violence/ abuse.

 3.      Risk for injury related to effects of drugs on body systems and functions, including mental status.

 4.      Risk for self directed violence/ other directed violence related to drug or substance use.

 Conclusion

Hallucinogens and inhalants are two substances of abuse. It is important for a nurse to first examine his or her own feelings personal substance use and the substance use by others. Only the nurse who can be accepting and non-judgemental of substance abuse behaviours will be effective in working with these clients. 

 JOURNAL REFERENCES 

1. Relation between social drug use/abuse and dental disease in California, U.S.A.

This study has explored the social drug use/abuse patterns associated with dental disease. Seventy-seven subjects from the Berkeley Free Clinic were given questionnaires on their drug-use habits and then were examined for OHI-S scores. Ninety-seven percent of the subjects indicated that they used one or more of the eight drugs being surveyed. The study indicated that persons who used barbiturates, miscellaneous hallucinogens and heroin have poorer oral hygiene than those in other categories. An unexpected finding was that subjects who used four or five of the surveyed drugs had lower OHI-S scores than those who used a lesser or a greater number of these drugs. The significance of these findings for an individual's oral health is not yet clear, but it is interesting that the oral hygiene index did not increase with the increasing number of drugs used, although the specific use of barbiturates, miscellaneous hallucinogens and heroin were related to higher OHI-S scores. The lower OHI scores probably can be explained by the frequency of tooth brushing. Ninety-five percent of the 4-5 drug-use groups brushed one or more times per day.

 2.  Epidemiology of inhalant use:

The aim of this article was to review recent research on the prevalence and correlates of inhalant use. During the review period more prevalence studies have been conducted in the developing world, adding information to the ongoing studies that are periodically undertaken in the more developed countries. These studies suggest that inhalant use is more among children and adolescents and is increasing among females in the developing and developed world. Not all surveys report inhalants as a separate group from other illegal substances; data by type of inhalants are even rarer, and few studies address abuse or dependence. New evidence suggests lower reliability rates for the diagnostic criteria of dependence as compared to other substances suggesting the need for a review including the evidence of withdrawal. Studies conducted in the period identify vulnerable groups and suggest an increased risk of injecting drug use, HIV, suicidality and psychiatric problems among inhalant users.

References:

1. Townsend M C Psychiatric mental health nursing- concepts of care. (5 ^th edn). Philadelphia: F.A Dais company; 2005
2. Kaplan. Comprehensive textbook of psychiatry (9 th edn). Philadelphia: Williams 7Wlkins; 2007.
3. Gelder M G, Lopez-Ibor J J$ Andereasen N. New oxford textbook of psychiatry. (Ist edn) Oxford university press. 2000.
4. Kaplan &Sadock's. Synopsis of psychiatry. Behavioural sciences clinical psychiatry (10 ^th edn). Lippincott. Williams &Wilkins. New Delhi: 2007.
5. Steven J. S. Relation between social drug use/abuse and dental disease in California, U.S.A. Community Dentistry and Oral Epidemiology. 2006 vol 1: 89-93.
6. Elena E, Mora M & Real T. Epidemiology of inhalant use: current opinion in psychiatry 2008, 21: 247-251.