Toolkit 2
Volatile Substance Abuse:
Legal and Lethal
Aims
Toolkit 2 completion aims
To understand, in relation to Volatile Substance Abuse (VSA):
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Methods of use
Causes of death
Effects
Signs
Specific dangers
Incident management
Dependence and treatment options
Assessment and intervention
VSA methods of use
VSA methods of use*
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Spraying straight from can into mouth
Sniffing directly from a container
Using towels/cloths/clothing etc. as a filter
Spraying into bag and placing over head
Sniffing from a cloth
Sniffing from bags
Inhaling from masks and balloons
*see slide notes
Causes of death
Deaths by method of inhalation*
15%
directly into mouth
sniffed from container
4%
sniffed from cloth
sniffed from bag
11%
50%
bag over head
mask or padding
5%
not known
2%
13%
*see slide notes
VSA Effects
VSA product categories &
physiological effect
Product
Physiological effect
Solvents
Central Nervous Sytem (CNS)
depressants
Gases/Aerosols
CNS depressants
Nitrites (Poppers)
Muscle relaxant, blood vessel dilator
Nitrous Oxide
Dissociative*
*see slide notes
VSA Effects
Amyl Nitrites (Poppers)
• Nitrites differ pharmacologically from other inhalants. Instead of directly
affecting the central nervous system, they primarily cause vasodilation
(the widening of blood vessels) and smooth muscle relaxation.
• Nitrites are inhaled primarily to enhance sexual feelings and to intensify
sexual experience.
• Evidence suggests that, in some cases, the inhalation of poppers has been
responsible for causing permanent eye damage.*
*see slide notes
VSA Effects
Psychoactive impact:
the ‘buzz’ of VSA
Desired effects*
Negative effects*
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euphoria
hallucinations
exhilaration
sense of
invulnerability
• disinhibition
drowsiness
headaches
nausea
diarrhoea
reckless behaviour
aggression
death
*see slide notes
VSA Effects
Long-term or chronic use*
Chronic users may present with a variety of symptoms as a
consequence of long-term use, including:
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chronic headaches
sinusitis, nosebleeds, runny nose
diminished cognitive function
uncoordinated muscle movements
chronic coughing
chest pain or angina
tinnitus
extreme tiredness, weakness, dizziness
depression / anxiety
shortness of breath
indigestion
stomach ulcers
*see slide notes
VSA Signs
Cues for detecting recent use*
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red, watery eyes
sneezing and coughing
constant sniffing
excessive sweating
chemical smell on breath
staining on clothing, fingers, nose, or mouth
unusual spots, marks, rashes and sores around nose and mouth
apparent intoxication / altered behaviour / risk taking
incoherence, confusion
poor coordination
*see slide notes
VSA Dangers
Dangers
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Sudden Sniffing Death
suffocation from plastic bags
fires/burns/explosion through heat/piercing/smoking
harm from inhalation of other chemicals in product (e.g.
perfume in deodorants)
frost or freeze burns from spraying directly from the can
Central Nervous System(CNS) depression to unconsciousness
choking on vomit while unconscious
erratic behaviour and accidents
WARNING: The following slide contains images of
physical harm caused by VSA. Some viewers may
find these images distressing.
VSA Dangers
Dangers
Burns caused by the cold temperatures
of butane gas.
VSA Dangers
The greatest risk:
Sudden Sniffing Death*
Gases, aerosols, and solvents can make the heart oversensitive to the effect of
adrenaline. A burst of activity leads to more adrenaline, leading to an even
greater risk.
This oversensitivity can remain for several hours following recovery from the
psychoactive phase.
A heart that stops beating as a result of VSA can be very difficult to resuscitate.
Defibrillation needs to be administered within 10 minutes.
Other substances can increase the risk of Sudden Sniffing Death. Stimulants and
depressants can both cause harmful interactions.
*see slide notes
VSA Dangers
Aggression, crime and VSA*
Violent crimes committed in the UK under the influence of
volatile substances, 1996-2012.
Murder
Occurrence between
1996-2012
37
Rape / serious sexual assault
39
Assault / serious threat of
assault
198
Arson
27
Crime reported
*see slide notes
VSA Dangers
VSA myth: frozen throat or lungs
The throat and/or lungs or do not ‘freeze’.
What may occur is Vagal Inhibition
When butane is sprayed directly into the throat, the jet of fluid can cool
rapidly to −20⁰C which may stimulate the nerves of the larynx. This
causes a reflex with nerve impulses passing up to the brain via one set of
nerves, then connecting in the brain and relaying impulses down to the
heart via the vagus nerves, resulting in cardiac arrest.*
*see slide notes
ACTIVITY SLIDE
VSA scenario*
You enter a person’s room, either their own home or
supported accommodation, and witness that they are
actively inhaling a deodorant aerosol. They are under the
influence and incoherent.
Given the risk of Sudden Sniffing Death, what
actions do you take immediately and post incident?
*see slide notes
VSA Incident
Management
VSA incident: assess the situation*
• Are you (and any others present) safe in the environment?
• Is the person acting aggressively or likely to become
aggressive?
• Is the room ventilated?
• Have you made sure there are no lit cigarettes or open
flames in the room?
(continued)
*see slide notes
VSA Incident
Management
VSA incident: if someone is ‘high’ on VSA*
• Stay calm and stay with them – so long as it’s safe – until
the effects have worn off.
• Ensure adequate ventilation – open windows and loosen
tight clothing, etc.
• Keep the person calm and still. There is a risk of sudden
death if exertion follows inhalation. Don’t chase or excite
someone who is ‘high’.
• Remove the solvents from them if you can do so calmly
and without using force.
(continued)
*see slide notes
VSA Incident
Management
VSA incident: if the person is unconscious*
• Keep calm – assess the situation, in particular, the risks to
yourself.
• See if the person responds by gentle shaking or loud talking.
• Check their Airway, Breathing and Circulation and apply first
aid if you know how.
• Place them on their side in the recovery position.
• Call an ambulance or, if possible, send someone to do it.
• Stay with the person if you can and keep them warm and still.
*see slide notes
VSA Dependence &
Treatment
Tolerance and dependence*
• Some users self report using 20 + cans per day
to maintain the intense initial phase.
• Psychological dependence can occur just as it
can for any substance.
*see slide notes
VSA Dependence &
Treatment
Patterns of VSA*
Risk of Sudden
Sniffing Death applies
to all patterns
dependent
intensive
purposive
experimental
*see slide notes
VSA Dependence &
Treatment
Dependence ICD-10 criteria*
Applies to VSA as for any other type of substance misuse.
Three or more of the following in a 12 month period:
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Strong desire or sense of compulsion to take the substance.
Difficulties in controlling substance-taking in terms of onset,
termination or levels of use.
A physiological withdrawal state.*
Evidence of tolerance.
Progressive neglect of alternative pleasures or interests.
Persisting with substance use despite clear evidence of overtly
harmful consequences.
*see slide notes
VSA Dependence &
Treatment
Withdrawal*
• There is no physiological addiction to volatile substances.
The psychological addiction may manifest itself in physical
withdrawal symptoms associated with anxiety, such as:
• sleep disturbances
• agitation
• tremors
• loss of appetite
• irritability and depression • dizziness
• nausea
• aggressive behaviour
• excessive sweating
• headaches
• fleeting illusions
• abdominal cramps
• Withdrawal can be eased by treating the symptoms that the
person is presenting with.
*see slide notes
VSA Dependence &
Treatment
Pharmacotherapy
There is no proven pharmacological treatment for VSA
One case report and one preclinical study have reported positive but very
preliminary evidence of potentially effective therapies for VSA:
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Lee, Shiffer and Dewey (2004) reported preclinical evidence suggesting that Vigabatrin, a
selective GABA transaminase inhibitor could be an effective treatment.*
Shen (2007) 100mg of lamotrigine daily reduced cravings in 21yr old user of 4 years,
achieving 6 months of abstinence.*
The use of short acting benzodiazepine (i.e. Lorazepam or Oxazepam) to
reduce anxiety has also been suggested. Cited by Howard et al (2011)*
*see slide notes
VSA Assessment &
Intervention
Assessment*
• GPs and Drug Services are required to submit a completed SMR25a/b
form for all patients/clients who receive a comprehensive assessment of
their care/treatment needs in relation to their substance misuse.
• Although the SMR25 specifies only illegal substance use is to be recorded,
Volatile Substances are included and specified throughout the SMR25.
• Clear and unambiguous inclusion of questions about volatile substance
use at assessment and in advising/promoting of service strands offered
will help to better engage VS users and aid disclosure of VSA.
*see slide notes
VSA Assessment &
Intervention
Addressing supply
Partnering with the local Trading Standards authority is
recommended following disclosure of VSA at assessment.
Trading Standards respond to intelligence reports received from any
stakeholder.
Addressing the source of supply can be a key factor in supporting
VSA recovery and relapse prevention. It has the additional benefit
of enhancing retailer awareness in broader VSA prevention.
VSA Assessment &
Intervention
Interventions*
• Brief Interventions can be very effective for
experimental/recreational VSA in younger users.
• Family support both for the benefit of the family and the
user, whether the user is engaged in services or not, is
recommended. Even basic knowledge about VSA can
help to identify it and help the family to cope.
• Multidisciplinary joint working as required for chronic
cases, which may present or be assessed as dual
diagnosis.
*see slide notes
VSA Assessment &
Intervention
Psychosocial interventions
• Early intervention is recommended due to risk of death.
• All psychosocial interventions are applicable. Short session
Motivational Interviewing can help determine/promote
change readiness and bridge the gap from assessment to
treatment.
• Shorter sessions and/or breaks within the session in the
early stages can help.
*see slide notes
VSA Prevention
Proactive prevention activity is vital
Every stakeholder with a responsibility to prevent VSA should be able
to evidence that they have tried, to the best of their ability, to inform
about this dangerous type of substance misuse.
Education is effective for VSA.
The use of volatile substances, as with use of other psychoactive drugs,
impacts not only personal health but also:*
• families
• workplace safety
• communities
• society
*see slide notes
How Re-Solv can help
• Family and user support at Community for Recovery:
www.communityforrecovery.org.
• Recent research findings: www.re-solv.org.
• Free workforce training via direct delivery, resource cascade and online
facility: http://training.re-solv.org.
• Capacity-building partnership work with other organisations.
• Development of resources for partners.
• Information literature.
• Consultation and guidance for stakeholders on policy, law and
governance.
• International partnership support and guidance.
Contact details
Scotland: Marina Clayton
Development Manager Scotland
07505 000024
scotland@re-solv.org
Re-Solv UK Head Office
01785 817885
information@re-solv.org
Questions?
Published August 2013. Review date August 2014.