# Presentation: 706364

## Inhalant Use in the United States: Correlates and Consequences

**Li-Tzy Wu, ScD**
**Duke University School of Medicine**
**Department of Psychiatry and Behavioral Sciences**
**Duke Clinical Research Institute**
**Durham, North Carolina**
**Inhalant Abuse Among Children and Adolescents: **
**Building an International Research Agenda Conference, November 7–9, 2005. **

## Focuses

- I. 	Inhalant use and disorders
- II. 	Inhalant use and other 	substance use disorders
- III. 	Inhalant use and psychiatric 		disorders

## I.Inhalant Use and Disordersamong American Adolescents Aged 12-17 

- 	Wu LT, Pilowsky DJ, Schlenger WE. Inhalant abuse and dependence among adolescents in the United States. J Am Acad Child Adolesc Psychiatry. 2004 Oct;43(10):1206-14.

## Study Sample

**2000-2001 ****National Household Surveys on Drug Abuse**** (NHSDA), renamed as ****National Survey on Drug Use and Health**** (NSDUH) in 2002.**
**Approximately ****70,000**** non-institutionalized household residents aged 12 or older participated in the annual, independent survey**
**Interview response rates: 74% in 2000, 73% in 2001**
**Adolescents aged 12-17 (N = 36,859)  **

## Designs of NHSDA-NSDUH 

- Annual, national survey of  the use of a variety of licit and illicit substances by Americans aged 12 or older (civilian, non-institutionalized populations)
- Multistage area probability sampling methods
- Face-to-face personal interview conducted at the respondent’s home or place of residence -- Interviewers requested the respondents to identify a private area away from other household members to conduct the interview.

## Designs of NHSDA-NSDUH 

- Use of a combination of computer-assisted personal interviewing (CAPI) and audio computer-assisted self-interviewing (ACASI) methodologies.
- Use of ACASI interviewing for questions of a sensitive nature, e.g., substance use questions -- Respondents either read the questions on the computer screen, or the questions were read to them through headphones. In either case, they entered their responses directly into the computer.

## Prevalence of inhalant use among adolescents aged 12-17 in 2000-01

**Lifetime use: ****8.8% ****(10.7% in 2003; 11.0% in 2004)**
**   ****Male: 8.7%****	****	****Female: 8.8%**
**   ****White:  9.5%****	****	****African American:  5.3%**
**   ****Hispanic:  9.0%  ****	****Native American:  13.2%**
**   ****Asian:  6.5%****	****         ****More than one race:** ** 11.2%**
**Past year use: ****3.5% ****(4.5% in 2003; 4.6% in 2004)**
**	****Male: 3.5%****	****	****Female: 3.4% **

## Prevalence of weekly use and disorders among past-year adolescent inhalant users

**Weekly inhalant use:  ****19.8%**** **
**     ****Male:     19.8% ****	****      Female:  19.8% **
**DSM-IV Inhalant use disorder:  ****10.9%**
**	**** ****Abuse:    6.3%****	****      Dependence:   4.3%**
**	**** **
**	**** ****Male:      5.9%                                    4.4%**
**     ****Female:  6.8%                                    4.2%**
**Sub-threshold condition:  ****14.0%**
**     ****Male:     11.4% ****	****       Female:  16.9%**
**  **

## Type of inhalants used among lifetime inhalant users

| Type of Inhalants Used | Overall | Male | Female | 2 test |
| --- | --- | --- | --- | --- |
| Glue, shoe polish, toluene  | 42.7%  | 38.7%  | 46.9 % | P < .001 |
| Gasoline, lighter fluid  | 36.0  | 38.1  | 33.9  | P = .044 |
| Spray paints  | 23.4  | 20.5  | 26.4  | P < .001 |
| Correction fluid, degreaser  | 21.7  | 18.0  | 25.5  | P < .001 |
| Nitrous oxide, whippets  | 21.7  | 24.2  | 19.0  | P = .004 |
| Aerosol sprays  | 18.8  | 16.4  | 21.2  | P = .004 |
| Amyl nitrite, poppers, rush  | 17.6  | 16.1  | 19.1  | NS |
| Paint solvents, lacquer thinner  | 16.7  | 16.8 | 16.6  | NS |
| Lighter gases, butane, propane  | 10.6  | 11.4  | 9.7  | NS |

## Type of inhalants used and age of onset among lifetime inhalant users

| Type of Inhalants Used | Overall | Male | Female | 2 test |
| --- | --- | --- | --- | --- |
| Ether, halothane, anesthetic  | 5.1% | 5.6 % | 4.7 % | NS
 |
| Number of different types of inhalants used   
   1   
   2   
   ≥ 3 | 

49.1
20.7
30.2 | 

51.3
20.8
27.9 | 

46.9
20.6
32.6 | 

NS |
| Recency of inhalant use
   Past year use
   Prior to past year use  | 
39.7
60.3 | 
40.5
59.5 | 
38.9
61.1 | 
NS |
| Age of first inhalant use  
   < 13   
   13-14   
   15-17 | 
46.4
34.2
19.5 | 
47.5
32.4
20.1 | 
45.3
36.0
18.8 | 
NS |

## Adjusted odds ratios (AOR) of past-year inhalant use disorder among past-year inhalant users aged 12-17 (N = 1,313)

| Independent variables | Abuse
AOR (95% CI) P-value | Dependence
AOR (95% CI) P-value |
| --- | --- | --- |
| Age group | NS | NS |
| Gender | NS | NS |
| Racial/ethnic groups | NS | NS |
| Level of family income  | NS | NS |
| Population density
Large metro vs. nonmetro Small metro vs. nonmetro | 
2.4 (1.1-5.2)   p≤.5
NS | 
NS
NS |

## Adjusted odds ratios (AOR) of past-year inhalant use disorder among past-year inhalant users aged 12-17 (N = 1,313)

| Independent variables | Abuse
AOR (95% CI) P-value | Dependence
AOR (95% CI) P-value |
| --- | --- | --- |
| Use of mental health services Yes vs. no | 
1.9 (1.0-3.7) p≤.05 | 
2.4 (1.2-4.7) p≤.01 |
| History of incarceration 
Yes vs. no | 
NS | 
NS |
| History of foster care placement Yes vs. no | 
NS | 
4.9 (1.9-13.1) p≤.001 |
| Number of delinquent behaviors 
1-2 vs. none 
≥ 3 vs. none | 

NS
2.9 (1.1-7.6) p≤.05 | 

NS
NS |

## Adjusted odds ratios (AOR) of past-year inhalant use disorder among past-year inhalant users aged 12-17 (N = 1,313)

| Independent variables | Abuse
AOR (95% CI) P-value | Dependence
AOR (95% CI) P-value |
| --- | --- | --- |
| Alcohol use disorder
 Yes vs. no | 
NS | 
NS |
| Other drug use disorder 
1 drug vs. no 
2 drugs vs. no 
≥ 3 drugs vs. no | 
NS
3.7 (1.4-9.9) p≤.01
8.4 (3.6-19.7) p≤.001 | 
NS
8.9 (2.8-28.3) p≤.001
11.8 (3.3-42.4) p≤.001 |
| Use of inhalants weekly Yes vs. no | 
NS | 
2.6 (1.1-5.8) p≤.05 |
| Age of first inhalant use
< 13 vs. 15-17
13-14 vs. 15-17 | 
NS
NS | 
5.1 (1.4-18.0) p≤.01
6.0 (1.7-21.3) p≤.01 |

## Adjusted odds ratios (AOR) of past-year inhalant use disorder among past-year inhalant users aged 12-17 (N = 1,313)

| Independent variables | Abuse
AOR (95% CI) P-value | Dependence
AOR (95% CI) P-value |
| --- | --- | --- |
| Number of different types of inhalants used
2 vs. 1 
≥ 3 vs. 1  | 

4.2 (1.5-11.4) p≤.01
3.7 (1.4-9.3) p≤.01 | 

NS
NS |
| Survey year
2000 vs. 2001 | 
NS | 
NS |

## Conclusion

- Among adolescents who used inhalants in the past year, 11% met the criteria for abuse or dependence in that year.
- A high proportion (60%) of past-year inhalant users reported using multiple types of inhalants.
- Using inhalants weekly or more (20%), and for more than one year (35%), was not uncommon.
- Inhalant use disorder was associated with early first inhalant use and repeated use.
- There also was a significant association between other drug abuse or dependence and progression to inhalant abuse or dependence.

## Implications

- Adolescents who met criteria for inhalant abuse or dependence reported coexisting delinquent behaviors, multiple drug abuse and dependence, and utilizing mental health services for other emotional problems.
- Inhalant use prevention should start early.

## Limitations 

- Self-reported data -- recall and reporting biases (under-reporting?)
- Cross-sectional design – association, not causality
- Exclusion of a small but high-risk group (incarcerated, homeless, and transient adolescents) in the survey

## II.Inhalant Use and Other Substance Use Disorders

- 	Wu LT, Pilowsky DJ, Schlenger WE. High prevalence of substance use disorders among adolescents who use marijuana and inhalants. Drug Alcohol Depend. 2005 Apr 4;78(1):23-32.

## Background

- Marijuana use has been conceptualized as a gateway to other illicit drug use, and inhalant use has been found to be associated with multiple drug use.
- Studies of either marijuana or inhalants typically do not consider that many adolescents use both drugs.

## Aims

- To examine the likelihood of progression to substance use disorders among **adolescents who used both marijuana and inhalants** compared with those who used either drugs, i.e., **marijuana users who did not use inhalants**, **inhalant users who did not use marijuana**, and with **adolescents who used other drugs but no marijuana and inhalants**.

## Samples

**Lifetime adolescent drug users aged 12-17 who participated in 2000-01 NHSDA (N = 10,180)**
**Users of both marijuana and inhalants**
**Marijuana users who did not use inhalants**
**Inhalant users who did not use marijuana**
**Other drugs users who had never used marijuana and inhalants**

## Lifetime prevalence of inhalant and marijuana use among adolescents

| Drug Use | Inhalants without marijuana  | Marijuana without inhalants  | Inhalants and marijuana | Other
Drugs
 |
| --- | --- | --- | --- | --- |
| Overall | 4.4% | 14.6% | 4.4% | 4.2% |
| Age
 12
 13
 14
 15
 16
 17  | 
4.1%
5.9
6.2
4.7
3.2
1.9  | 
1.4%
3.9
9.0
17.8
24.6
30.9  | 
0.8%
1.7
3.5
5.8
6.7
7.8  | 
3.1%
3.9
4.2
4.9
4.7
4.5  |

## Substance use characteristics among adolescent drug users (N = 10,180)

| Drug 
Use | Inhalant without marijuana  | Marijuana without inhalant  | Inhalant and marijuana | Other
Drugs
 | 
T test |
| --- | --- | --- | --- | --- | --- |
| Mean age of first inhalant use | 11.8 years
(0.07)  | 
............ | 13.2 years
(0.07)  | 
............
 | 
<.001 |
| Mean age of first 
marijuana use | 
............
 | 13.8  
(0.03) | 13.0 
(0.06)  | 
............
 | 
<.001 |
| Mean # of drugs ever used | 1.4
(0.02)  | 1.7 
(0.02) | 3.9
(0.05)  | 1.2 (0.01) | <.001 |

## Lifetime prevalence of substance use among lifetime adolescent drug users (N = 10,180)

| Lifetime prevalence of use, % | Inhalant without marijuana  | Marijuana without inhalant  | Inhalant and marijuana | Other
Drugs
 | 2 test |
| --- | --- | --- | --- | --- | --- |
| Alcohol | 60.2% | 91.2% | 96.6% | 55.4% | <.001 |
| Cocaine  | 0.6 | 7.4 | 26.5  | 1.4 | <.001  |
| Heroin  | 0.1 | 0.7 | 5.3 | 0.2 | <.001  |
| Hallucinogen  | 5.0 | 20.6 | 48.6 | 9.8 | <.001  |
| Pain reliever  | 18.3 | 18.7 | 48.1 | 76.6  | <.001  |
| Sedative  | 2.8 | 1.0 | 7.7 | 3.8 | <.001  |
| Stimulant | 8.4 | 9.6 | 32.9 | 15.6  | <.001  |
| Tranquilizer | 4.1 | 6.6  | 24.9 | 7.9  | <.001  |

## Prevalence of past-year DSM-IV substance use disorders among lifetime adolescent drug users (N = 10,180)

| Prevalence of disorder, % | Inhalant without marijuana  | Marijuana without inhalant  | Inhalant and marijuana | Other
Drugs
 |
| --- | --- | --- | --- | --- |
| Inhalant
use disorder | 3.2%  | .......... | 5.3% | ..........
 |
| Marijuana
use disorder | ..........
 | 14.4 | 31.7 | ..........
 |
| Any drug
use disorder | 6.0  | 16.0  | 38.9  | 7.0  |
| Alcohol
use disorder | 6.0  | 16.8  | 35.0  | 6.2  |

## Adjusted odds ratios (AOR) of Past-year drug use disorder among adolescent drug users aged 12-17 (N = 10,180 )

| Independent variables | Drug use disorder
AOR      P-value |
| --- | --- |
| Lifetime drug Use
Marijuana vs. inhalants
Marijuana and inhalants vs. inhalants
Other drugs vs. inhalants | 
2.5         p≤ .001
3.0         p≤ .001 
1.5         p≤ .05 |
| Age in years 
14-15 vs. 12-13 
16-17 vs. 12-13 | 
1.3         p≤ .01 
1.3         p≤ .01 |
| Gender | NS |
| Level of family income
 | NS |

## Adjusted odds ratios (AOR) of Past-year drug use disorder among adolescent drug users aged 12-17 (N = 10,180 )

| Independent variables | Drug use disorder
AOR      P-value |
| --- | --- |
| Race/ethnicity
White vs. African American
Hispanic vs. African American
Native American vs. African American
Asian vs. African American
More than one race vs. African American | 
0.9         NS
1.0         NS 
1.2         NS
1.7         p≤ .05 
0.8         NS |
| Population density | NS |
| Use of mental health service in the past year 
Yes vs. No | 
2.1         p≤ .001 |
| History of incarceration 
Yes vs. No | 
2.9         p≤ .001 |

## Adjusted odds ratios (AOR) of past-year drug use disorder among adolescent drug users aged 12-17 (N = 10,180 )

| Independent variables | Drug use disorder
AOR      P-value |
| --- | --- |
| # of delinquent behaviors in the past year 
1-2 vs. None
≥ 3 vs. None | 
2.3         p≤ .001 
6.1         p≤ .001 |
| # of drugs used in the lifetime
3 vs. 1-2 
≥ 4 vs. 1-2 | 
4.1         p≤ .001 
9.4         p≤ .001 |
| Age of first alcohol use  | NS |
| Age of first inhalant use | NS |
| Age of first marijuana use
Before 13 vs. ≥ 13 years/no use  | 
1.4         p≤ .001 |

## Adjusted odds ratios (AOR) of past-year alcohol use disorder among adolescent drug users aged 12-17 (N = 10,180 )

| Independent variables | Alcohol use disorder
AOR      P-value |
| --- | --- |
| Lifetime drug Use
Marijuana vs. inhalants
Marijuana and inhalants vs. inhalants
Other drugs vs. inhalants | 
2.3         p≤ .001
3.0         p≤ .001 
NS |
| Age in years 
14-15 vs. 12-13 
16-17 vs. 12-13 | 
2.0         p≤ .01 
2.7         p≤ .01 |
| Gender
Male vs. Female | 
0.8         p≤ .001 |
| Level of family income
$0-$19,999 vs. 75K+
$20K-$39,999 vs. 75K+
$40k-$74,999 vs. 75K+ | 
0.7         p≤ .01
0.7         p≤ .001
NS |

## Adjusted odds ratios (AOR) of past-year alcohol use disorder among adolescent drug users aged 12-17 (N = 10,180 )

| Independent variables | Alcohol use disorder
AOR      P-value |
| --- | --- |
| Race/ethnicity
White vs. African American
Hispanic vs. African American
Native American vs. African American
Asian vs. African American
More than one race vs. African American | 
1.6         p≤ .001
1.6         p≤ .01 
2.5         p≤ .01 
1.9         NS
1.2         NS |
| Population density
Large metro vs. Non-metro
Small metro vs. Non-metro | 
0.8         p≤ .01
0.7         p≤ .001 |
| Use of mental health service in the past year 
Yes vs. No | 
1.2         p≤ .05 |
| History of incarceration 
Yes vs. No | 
1.3         p≤ .05 |

## Adjusted odds ratios (AOR) of past-year alcohol use disorder among adolescent drug users aged 12-17 (N = 10,180 )

| Independent variables | Alcohol use disorder
AOR      P-value |
| --- | --- |
| # of delinquent behaviors in the past year 
1-2 vs. None
≥ 3 vs. None | 
1.9         p≤ .001 
3.6         p≤ .001 |
| # of drugs used in the lifetime
3 vs. 1-2 
≥ 4 vs. 1-2 | 
1.7         p≤ .001 
2.5         p≤ .001 |
| Age of first alcohol use 
Before 13 vs. ≥ 13 years/no use | 
1.6         p≤ .001 |
| Age of first inhalant use | NS |
| Age of first marijuana use | NS |

## Conclusion

**	**
**	**There is a very high prevalence of alcohol and drug use disorders (35% and 39%, respectively) among adolescent drug users who reported using both marijuana and inhalants in their lifetime as compared with those who reported using either inhalants (6% and 6%) or marijuana (17% and 16%) and those who reported using other drugs (6% and 7%).

## Conclusion

**	**
**	**Adolescent drug users who reported *never *having used marijuana, inhalants, or both may be different from those with a lifetime history of using one or both drugs.
- 	Prescription-type drugs are their main drugs of choices, and they are least likely to use multiple drugs.**  **

## Implications

- 	Adolescents who reported a lifetime history of using both inhalants and marijuana may well be a high-risk group and deserve more attention from investigators and clinicians.

## III.Inhalant Use and Psychiatric Disorders

- Preliminary Findings

## Study Sample

- 2000-2001 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Dawson et al., 2005; Grant et al., 2004)
- A total of 43,093 non-institutionalized household residents aged 18 or older participated in the survey: persons living in households, the military living off base, and persons living in group quarters (boarding houses, rooming houses, non-transient hotels or motels, shelters, facilities for housing workers, college quarters, and group homes )
- Overall survey response rate: 81%

## Designs of NESARC 

- National survey of substance use disorders and psychiatric disorders among Americans aged 18 or older
- Multistage area probability sampling methods
- Face-to-face personal interview conducted at the respondent’s home or place of residence

## Designs of NESARC

**Substance use disorders, personality disorders, mood disorders, and anxiety disorders were assessed by the ****NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV)**** -- a state-of-the-art structured diagnostic interview designed for use by lay interviewers who are not clinicians.**

## Inhalant use and disorders among adults aged 18 or older in NESARC (N=43,093)

**0.11%**

**1.74%**

**0.02%**

**0.00%**

**0.30%**

**0.04%**

## Selected characteristics of lifetime inhalant users in NESARC (N=664)

|  | Men | Women | X2 (df) |
| --- | --- | --- | --- |
| Age group |  |  |  |
|    18-29 | 35.79 | 39.29 |  |
|    30-44 | 37.19 | 44.24 | 7.42(2) |
|    45 or older | 27.01 | 16.47 | p <.05 |
| Race/Ethnicity   |  |  |  |
|     White, Non-Hispanic  | 83.0 | 80.07 |  |
|    Black, Non-Hispanic  | 3.99 | 3.27 |  |
|    Other | 6.87 | 7.09 | NS |
|    Hispanic | 6.14 | 9.58 |  |
| Educational level |  |  |  |
|    Less than high school | 15.04 | 10.27 |  |
|    High school | 27.22 | 26.94 | NS |
|    College or more | 57.74 | 62.78 | NS |

## Prevalence (%) of lifetime mood disorders among adult lifetime inhalant users, by gender

**P=.05**

## Prevalence (%) of lifetime anxiety disorders among adult lifetime inhalant users, by gender

**    ****P<.01**

**  ****P<.01**

## Prevalence (%) of lifetime personality disorders among adult lifetime inhalant users, by gender

**    ****P<.01**

## Prevalence (%) of past-year psychiatric disorders among adult lifetime inhalant users, by gender

**Mood disorders**

**Anxiety disorders**

**P<.05**

**P<.05**

## Prevalence (%) of lifetime personality disorders among adult lifetime inhalant users, by age of onset of first inhalant use

*                   ***P=.05**

*               ***P<.05**

**    ****P<.001**

## Prevalence (%) of past-year psychiatric disorders among adult lifetime inhalant users, by age of onset of first inhalant use

**Mood disorders**

**Anxiety disorders**

## Number of lifetime psychiatric disorders among adult lifetime inhalant users, by gender 

## Number of past-year psychiatric disorders among adult lifetime inhalant users, by gender 

## Number of lifetime psychiatric disorders among adult lifetime inhalant users, by age of onset 

## Number of past-year psychiatric disorders among adult lifetime inhalant users, by age of onset 

## Limitations 

- Self-reported data -- recall and reporting biases (forgetting, under-reporting?)
- Cross-sectional design – association, not causality
- Exclusion of a small but high-risk group in the survey (e.g., incarcerated, homeless, and institutionalized adults)

## Acknowledgments

- National Institute on Drug Abuse (R21DA015938), National Institute of Health.
- Office of Applied Studies, Substance Abuse and Mental Health Services Administration
- Substance Abuse and Mental Health Data Archive
- Dan Pilowsky, Columbia University
- Bill Schlenger, RTI International
- Chris Ringwalt, Chapel Hill Center, Pacific Institute for Research and Evaluation