Toolkit 2 Volatile Substance Abuse: Legal and Lethal

1. Toolkit 2Volatile Substance Abuse: Legal and Lethal

2. Aims Toolkit 2 completion aims To understand, in relation to Volatile Substance Abuse (VSA): Methods of use Causes of death Effects Signs Specific dangers Incident management Dependence and treatment options Assessment and intervention

3. VSA methods of use VSA methods of use* • 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

4. Causes of death Deaths by method of inhalation*

5. VSA product categories & physiological effect VSA Effects *see slide notes

6. Amyl Nitrites (Poppers) VSA Effects *see slide notes • 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.*

7. VSA Effects Psychoactive impact:the ‘buzz’ of VSA Desired effects* • euphoria • hallucinations • exhilaration • sense of invulnerability • disinhibition Negative effects* • drowsiness • headaches • nausea • diarrhoea • reckless behaviour • aggression • death *see slide notes

8. VSA Effects Long-term or chronic use* Chronic users may present with a variety of symptoms as a consequence of long-term use, including: • 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

9. VSA Signs Cues for detecting recent use* • 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

10. Dangers VSA Dangers WARNING: The following slide contains images of physical harm caused by VSA. Some viewers may find these images distressing. • 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

11. Dangers VSA Dangers Burns caused by the cold temperatures of butane gas.

12. 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

13. VSA Dangers Aggression, crime and VSA* Violent crimes committed in the UK under the influence of volatile substances, 1996-2012. *see slide notes

14. VSA myth: frozen throat or lungs VSA Dangers *see slide notes 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.*

15. VSA scenario* ACTIVITY SLIDE *see slide notes 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?

16. 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

17. 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

18. 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

19. 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

20. Patterns of VSA* VSA Dependence & Treatment Risk of Sudden Sniffing Death applies to all patterns dependent intensive purposive experimental *see slide notes

21. Dependence ICD-10 criteria* VSA Dependence & Treatment *see slide notes Applies to VSA as for any other type of substance misuse. Three or more of the following in a 12 month period: • 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.

22. Withdrawal* VSA Dependence & Treatment • sleep disturbances • tremors • irritability and depression • nausea • excessive sweating • fleeting illusions • agitation • loss of appetite • dizziness • aggressive behaviour • headaches • abdominal cramps • Withdrawal can be eased by treating the symptoms that the person is presenting with. *see slide notes There is no physiological addiction to volatile substances. The psychological addiction may manifest itself in physical withdrawal symptoms associated with anxiety, such as:

23. Pharmacotherapy VSA Dependence & Treatment *see slide notes 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: • 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)*

24. 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. VSA Assessment & Intervention *see slide notes

25. Addressing supply VSA Assessment & Intervention 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 additionalbenefit of enhancing retailer awareness in broader VSA prevention.

26. 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

27. 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

28. 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

29. 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.

30. 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

31. ? ? ? Questions? Published August 2013. Review date August 2014.