Title : Substance Abuse Treatment Advisory - Inhalents

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ADVISORY
Substance Abuse Treatment

March 2003
Volume 3
ssue 1
Breaking News for the Treatment Field

Inhalants
What are inhalants?
Inhalants are breathable chemical vapors or gases
that produce psychoactive (mind-altering) effects
when abused or misused. These include volatile
organic solvents, fuel gases, nitrites, and anesthetic
gases. They do not include inhaled medicinal drugs
that are taken as prescribed. Once commonly
referred to as glue sniffing, inhalant abuse now
includes a broad range of volatile solvents and gas
products (e.g., model airplane glue, paint thinner,
gasoline, and nail polish remover), aerosols (e.g.,
nonstick cooking spray and hair spray), anesthetics
(e.g., nitrous oxide or laughing gas and ether), and
nitrites (e.g., amyl, butyl, and isobutyl nitrites, often
marketed as poppers or room odorizers). (Other
powdered drugs, such as heroin, cocaine, and
methamphetamine, can be inhaled but are not con-
sidered inhalants.) Although the chemicals involved
and their effects vary, the route of administration is
the common factor.
is to paint the fingernails with a product such as cor
rection fluid and inhale the substance from the nails.
Sometimes an aerosol substance is sprayed directly
into the mouth. Substances also can be placed into
alternative containers (e.g., balloon filled with nitrous
oxide) or heated and then inhaled (Synergies 2002).

What are the most common
modes of administration?

Inhalants are abused either by sniffing through the
nose or inhaling fumes through the open mouth
(huffing) much like a smoker inhales cigarette
smoke. Usually the open tube of glue, nail polish, or
marker is placed close to the nose and the fumes are
inhaled. People who abuse inhalants may also spray
the substance into a plastic or paper bag and huff that
way (bagging) or even place the bag over the entire
head. Often a product will be poured or sprayed on a
piece of cloth, a rag, a towel, or a shirt sleeve or into a
soda can and inhaled in that manner. Another method
Who is likely to abuse
inhalants?

Contrary to popular perception, people who abuse
inhalants are found throughout the population and no
one group can be categorized as inhalant abusers. In
2001, more than 18.2 million Americans reported ever
having used an inhalant, and 141,000 were estimated
to need treatment because they were dependent on or
abused inhalants. According to the 2001 National
Household Survey on Drug Abuse (SAMHSA
2002d), 8.6 percent of youth between 12 and 17 had
used inhalants some time in their lives. The
Household Survey reported that 13.4 percent of young
adults ages 1825 had used inhalants and 7.1 percent
of persons 26 and older. Lifetime prevalence by gen
der and race/ethnicity was 8.9% for white males,
9.8% for white females, 8.3% for Hispanic males,
7.4% for Hispanic females, 5.0% for black males, and
6.8% for black females (SAMHSA 2002a).
The categories of inhalants most frequently reported
by youth were glue or toluene (3.6%) and gasoline
or lighter fluid (3.0%). Among young adults, the
most popular was nitrous oxide or whippets
(9.3%) and for adults it was nitrous oxide or whip-
pets (3.4%) and amyl nitrite, poppers, Locker
Room Odorizers, or Rush (3.4%) (SAMHSA
2002a).

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Very few people who abuse inhalants are treated in facili
ties that receive funds from State alcohol and drug agen-
cies. In 2000, only 1,251 persons (0.1% of all admissions)
entered treatment with a primary diagnosis of inhalant
dependency. Of these inhalant clients, 72.4% were male,
65.9% were white, 16.6% were Hispanic, and 10.3% were
American Indian or Alaska Native; 44% were under age
18. Some 28% reported daily use of inhalants, 26% had
used inhalants by age 12, and another 30% had used by
age 14; 61% had used other drugs as well as inhalants
(SAMHSA 2002e).
People who abuse inhalants also seek care in emergency
rooms, according to the Drug Abuse Warning Network
(DAWN), which is a national sample of hospitals with 24-
hour emergency departments. In 2001, 676 individuals
who mentioned inhalants as a drug of abuse were seen in
the DAWN sample, but in the first half of 2002 alone, 559
had been seen. Of the 2001 inhalant patients, 10% were 17
or younger, 33% were 1825, 10% were 2634, and 47%
were 35 or older (SAMHSA 2002b). 
Use of inhalants can result in death. Bowen et al. (1999)
reported on 39 deaths in Virginia between 1987 and 1996
from acute voluntary exposure to inhalants. Median age
was 19 years; 46% of the cases involved butane or
propane. Maxwell (2001) reported 144 deaths in Texas
between 1988 and 1998 in which use or abuse of inhalants
was mentioned on the death certificates. Median age was
24, and 35% of the cases involved chlorofluorocarbons or
Freon. Mortality data reported to DAWN show deaths
that were due to or involved inhalants: Birmingham (1),
Chicago (6), Dallas (1), Louisville (1), Milwaukee (2),
New Orleans (1), Oklahoma City (7), Philadelphia (2), and
San Diego (2) (SAMHSA 2002c).
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What Types of Products 
Can Be Abused?

General Suppliescements and glues; correction fluid;
magic markers; solvent-based dry erase markers
Cleaning Suppliesany product in an aerosol can;
aerosol air fresheners and deodorizers; computer 
air duster
Wood Shoppaints; varnishes; stains; paint thinner;
contact cement
Art Suppliesrubber cement; printing inks; spray
paints and clear finishes
Autodegreasers; spray lubricants; Fix-a-Flat type
products; solvents; Freon; brake fluid; gasoline; 
lacquers; thinners
Health and Beautynail polish and nail polish
remover; hair spray; deodorants
Cooking Suppliescooking spray; whipping cream in
aerosol cans; whipping cream cartridges (whippets) n
Source: Synergies 2002, Bureau of Substance Abuse
Services, Massachusetts Department of Public Health

markers, correction fluid) found in homes, offices, and
schools, it is difficult to prevent access to them. Further,
because abusable products are so common, many youth do
not perceive them as harmful and do not understand the
consequences of using them (Johnston et al. 2002).

Why are inhalants popular?
Most inhalants are readily available, inexpensive or free,
and usually legal to purchase and possess. The high is
achieved instantly and lasts only about 515 minutes.
(Pandina and Hendren 1999). Because products are easy to
conceal and are useful everyday products (e.g., permanent
What do inhalants do?
Inhalants provide an instant rush and, like alcohol, cause
euphoria followed by central nervous system depression
(Pandina and Hendren 1999). Deep breathing of the toxic
vapors may result in losing touch with ones surroundings,
a loss of self-control, violent behavior, nausea, uncon
sciousness, giddiness, loss of inhibition, loss of appetite,
and, at higher dosages, hallucinations (Kurtzman et al.

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ADVISORY
Substance Abuse Treatment

2001; Pandina and Hendren 1999). Inhalants can cause loss
of motor skills, slurred speech, heart palpitations, seizures,
nausea, vomiting, diarrhea, and abdominal pain, among
other things (Kurtzman et al. 2001). Signs of inhalant
abuse include huffers rash or drying and redness around
the mouth and nose; spots or sores around the mouth; red
or runny eyes or nose; paint or stains on body or clothing;
chemical breath odor; drunk, dazed, or dizzy appearance;
sneezing, coughing, wheezing, and excess salivation; an
unexplained collection of abusable products; nausea and
loss of appetite; and anxiety, excitability, and irritability
(Synergies 2002).
The debilitating and lethal effects of inhalants can occur
even with first use. Sudden sniffing death syndrome usual-
ly is caused by the irregular heart rate induced by
inhalants; other cardiac effects are hypotension (low blood
pressure), tachycardia (rapid heart beat), and bradycardia
(slow heart beat). Other significant effects may include
coma, seizures, brain damage, and lead poisoning
(Kurtzman et al. 2001).
Additional inhalant dangers are suffocation (e.g., from bag-
ging), fire-related injuries from inhalant combustion (especial
ly if the inhalant is heated or a cigarette is lit in a closed area
where the inhalant is being abused), and accidents related to
impaired judgment, lack of motor skills, or high-risk behavior.
and poor learning skills) to severe dementia (National
Institute on Drug Abuse 2000). However, studies often have
not been able to answer whether or to what extent neurolog
ical dysfunction existed before inhalant abuse (Pandina and
Hendren 1999). It is not clear whether the neurological
effects of inhalant abuse are permanent or transitory
(Jumper-Thurman and Beauvais 1992; Ron 1986).
Emotional problems, including violent behavior, and mental
disorders, particularly antisocial personality disorders and
depression, have been associated with inhalant abuse, but
there is no plausible evidence at this time that inhalant
abuse actuallycauses psychiatric conditions in any direct
way (Compton et al. 1994).

Are inhalants addictive? Do they
lead to further drug abuse?

Studies have reported that people who abuse inhalants can
build up tolerance (Ron 1986), which requires them to
increase their dosages to achieve the intoxication effect.
They also can develop cravings for inhalants (Keriotis and
Upadhyaya 2000). Withdrawal symptomssleep distur-
bance, nausea, tremors, and irritability, all lasting several
dayshave been described (Brouette and Anton 2001).
Early abuse of inhalants has been related to later use of
illicit drugs, particularly heroin (Bennett et al. 2000;
Johnson et al. 1995; Schutz et al. 1994). It is not clear,
however, that inhalants are a gateway drug; rather,
inhalant abuse may be a marker for risk of other drug use
(Compton et al. 1994; Dinwiddie 1994).
What are the long-term effects of
inhalant abuse?

Solvents are easily absorbed from the blood into lipid-rich
tissues (i.e., fatty tissues) (Kurtzman et al. 2001). Chronic
inhalant abuse significantly damages the heart, lungs, kid
ney, liver, and peripheral nerves (Pandina and Hendren
1999); it can cause heart failure and complete hepatic and
renal failure (Kurtzman et al. 2001). 
Continued, chronic inhalant abuse has been associated with
neurological damage (Rosenberg et al. 1988a, 1988b).
People who abuse inhalants chronically have demonstrated
a range of mental dysfunction, from mild cognitive impair-
ment (e.g., lack of concentration or attention, poor memory,
How can people who abuse
inhalants be treated?

As a group, people who abuse inhalants differ from people
who abuse other drugs. They often have multiple problems,
such as polydrug abuse, a chaotic family life, low self-
esteem, poor academic records, personality disorders, and
poor cognitive function, and they may present with neuro-
logical deficiencies. Thus, treatment is more complicated
and requires more resources than for people who abuse other

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drugs. Many drug and alcohol abuse treatment programs do
not accept people who abuse inhalants, and those that do
consider treatment ineffective for such clients (Dinwiddie
1994; Malesevich and Jadin 1995). There are few references
to evidence-based treatment protocols in the literature
(National Inhalants Prevention Coalition 1997; Reidel et al.
1995). However, the Substance Abuse and Mental Health
Services Administration (SAMHSA), through its Center for
Substance Abuse Treatment (CSAT) and Center for
Substance Abuse Prevention (CSAP), has funded an
Inhalant Resource Center that will provide resource guides
and make recommendations for additional materials con
cerning the treatment of people who abuse inhalants.
Taking into account problems unique to people who abuse
inhalants, a number of treatment approaches have been
suggested. Because people who abuse inhalants typically
consume a variety of inhalants, a detailed history and thor
ough physical examination is especially important to iden-
tify specific substances abused and their physical effects,
followed by medical treatment of physical conditions.
Inhalants can stay in the body for weeks; therefore detoxi
fication periods could extend for a month (Jumper-
Thurman et al. 1995). Abusers often are not ready to begin
therapy until detoxification is complete, and they often
require therapy for a long duration (possibly as long as 2
years) (Jumper-Thurman and Beauvais 1992). Because
people who abuse inhalants tend to have a short attention
span and difficulty with complex thinking, initial therapy
sessions should be short (e.g., 1520 minutes) (Jumper-
Thurman and Beauvais 1992). 
Treatment programs are encouraged to scan their premises
for products that clients could inhale to get high while in
treatment. A nonsolvent, nonaerosol-based product should
be substituted when possible; if there is no substitute, use
of these products should be closely monitored by staff.
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Family involvement in treatment is especially important
for young people. Intervention to improve parenting or
bonding skills or treatment of parental substance abuse
may be needed (Jumper-Thurman and Beauvais 1992;
Brouette and Anton 2001). Because inhalant abuse is often
a group activity, especially among youth, abusers need to
become part of new peer groups that do not abuse
inhalants or other drugs (Jumper-Thurman and Beauvais
1992). However, people who abuse inhalants are looked
down on by people who abuse other drugs, so group thera
py should be introduced into treatment gradually
(Malesevich and Jadin 1995). 
Treatment plans should take into account that relapse is
common among people who abuse inhalants (Reidel et al.
1995). It may be helpful to introduce abusers to safe and
healthy forms of recreation. Aftercare and followup are par
ticularly important for this group of abusers (Jumper-
Thurman and Beauvais 1992; Texas Commission on
Alcohol and Drug Abuse 1997) and may involve multiple
community resources (schools, faith-based organizations,
recreation programs, community centers, etc.). Finally, peo-
ple who abuse inhalants often need help developing basic
life skills (e.g., in hygiene, nutrition, school attendance, and
job skills) (Jumper-Thurman and Beauvais 1992).
Education about the effects and dangers of inhalants may
help people abstain from abusing inhalants. Education is a
key to primary prevention of inhalant abuse. A study that
found abuse among Native Americans decreasing since the
mid-1990s attributed the change to targeted prevention
efforts in that population (Beauvais et al. 2002). Because
inhalant abuse starts early, early education (e.g., in elemen
tary school) is needed (Dinwiddie 1994; Kurtzman et al.
2001). However, raising awareness by describing all the
potential inhalants that are subject to abuse may have the
unintended effect of increasing abuse among adolescents
(Beauvais et al. 2002).  n

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ADVISORY
Substance Abuse Treatment

What Constitutes Effective Treatment of People Who Abuse Inhalants?
People who abuse inhalants are thought to be an easily
overlooked and undertreated population. In many ways,
they are like other people who are chemically dependent,
but they also have unique treatment needs. Currently,
treatment protocols are based on limited experience and
research, primarily with disadvantaged Native American
and Hispanic populations in Southwestern and
Midwestern United States. 
The checklist below includes questions you should
consider as you review treatment protocols or guide
program development.
q Do you provide information about inhalant abuse to
referral sources? Do referral sources understand the
dangers of inhalant abuse and the need for
intervention? People who abuse inhalants are a hidden
population. They rarely seek treatment, and inhalant
abuse is often undetected because it is not on the
radar screen. 
q Do you rigorously assess for inhalant abuse? Do you
know what inhalants are abused and how they are
abused? Do you know patterns of abuse so that you
can converse with clients who may be reluctant and
embarrassed to discuss their abuse? Do you ask clients
why they are attracted to inhalants (very quick acting,
short duration, free or low cost, easy availability, not
prosecutable, hard to test for, like the high, often
overlooked as a drug)?
q Does your program allow for adequate detoxification?
Depending on type of product abused and length of
abuse, detoxification from the acute effects of solvents
and gases may last for 2 to 6 weeks. During this time,
the program may need to make adjustments.
q Do you thoroughly assess for cognitive functioning,
neurological damage, and physical effects? Levels of
physical and cognitive dysfunction vary greatly, but
some people who abuse inhalants show high levels 
of deterioration. Physical damage needs to be assessed
early, but cognitive and neurological evaluations are 
often postponed until after detoxification. In some
treatment populations, a high percentage of people
who abuse inhalants have experienced physical and
sexual abuse.
q Does treatment include specific inhalant-focused
components? Do you provide inhalant abuse
prevention education? Many people in treatment are
not aware of the toxicity and lethality of inhalants;
they are, after all, toxins, poisons, pollutants, and fire
hazards. Do you address life-skills issues? Some
people start abusing inhalants as early as elementary
school; along with the neurological damage, early
abuse can result in poorly developed life and academic
skills. Do you take into account cognitive deficits by
using brief (20-minute) and concrete interventions?
q Does family involvement include attending education
sessions about inhalants, removing inhalants from the
home, and providing extra support and supervision
that clients may need? Treatment programs need to
thoroughly assess the stability, structure, and dynamics
of the family. If family support is limited, programs
should consider alternatives such as foster care.
q Are inhalants accessible in your treatment program?
Do you have a policy to secure dry erase markers, nail
polish and remover, correction fluid, solvent-based
glues, and aerosol products (such as deodorants, hair
spray, shaving cream, cleaning products, and canned
whipped cream) in your program? 
q Are staff members knowledgeable about inhalant
abuse? Do they have realistic expectations for
recovery? To effectively treat inhalant abuse,
counselors need to understand the unique aspects of
the problem, including the slow rate of recovery.
q Does your aftercare planning take into account the
special problems of inhalant abuse? These include easy
availability of inhalants, residual cognitive impairment,
and poor social functioning. Has a school-based
advocate or counselor been included in the plan? n
Sources: Jumper-Thurman and Beauvais 1992; Jumper-Thurman et
al. 1995; Texas Commission on Alcohol and Drug Abuse, 1997. The
checklist was developed by Howard C. Wolfe, CASPAR Youth
Services, 661 Massachusetts Avenue, Suite 14, Arlington, MA 02476;
hwolfe@wolfe411.org; 781-643-7272. For more information, visit the
Massachusetts Inhalant Abuse Task Force Web site at
www.state.ma.us/dph/inhalant.

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Bennett, M.E.; Walters, S.T.; Miller, J.H.; and Woodall,
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Bowen, E.E.; Daniel, J.; and Balster, R.L. Deaths
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Brouette, T., and Anton, R. Clinical Review of Inhalants.
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Compton, W.M., III; Cottler, L.B.; Dinwiddie, S.H.;
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Dinwiddie, S.H. Abuse of Inhalants: A Review.
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Association Between Sniffing Inhalants and Injecting
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[accessed February 2003].

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Resources for Additional
Information

Substance Abuse and Mental Health Services 
 Administration
5600 Fishers Lane
Rockville, MD  20857
Web: www.samhsa.gov
Phone: 301-443-8956
National Inhalant Prevention Coalition
Web: www.inhalants.org
Phone: 800-269-4237
E-mail: nipc@io.com
National Institute on Drug Abuse
National Institutes of Health
6001 Executive Boulevard, Room 5213
Bethesda, MD  20892-9561
Web: www.drugabuse.gov
Phone: 301-443-1124
Office of National Drug Control Policy
Drug Policy Information Clearinghouse
P.O. Box 6000
Rockville, MD  20849-6000
Web: www.whitehousedrugpolicy.gov
Phone: 800-666-3332
E-mail: ondcp@nchrs.org

National Clearinghouse for Alcohol and Drug Information
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
7079 Oakland Mills Road
Columbia, MD  21046
Substance Abuse Treatment Advisory 
Substance Abuse Treatment Advisorypublished on an 
as-needed basis for treatment providerswas produced by
Johnson, Bassin & Shaw, Inc., under contract 270-99-7072,
for the Center for Substance Abuse Treatment (CSAT), of the
Substance Abuse and Mental Health Services Administration
(SAMHSA), U.S. Department of Health and Human Services
(HHS). Edwin M. Craft, Dr.P.H., LCPC, is the CSAT point 
of contact for the publication. The content of this publication
does not necessarily reflect the views or policies of SAMHSA
or HHS. For further information or to request information
about Substance Abuse Treatment Advisory, please contact 
Dr. Craft at ecraft@samhsa.gov.
Public Domain Notice: All material appearing in this report
is in the public domain and may be reproduced or copied
without permission; citation of the source is appreciated.
However, this publication may not be reproduced or
distributed for a fee without the specific, written authorization
of the Office of Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication: This
publication can be accessed electronically through the Internet
at www.csat.samhsa.gov. Additional free print copies can be
ordered from SAMHSAs National Clearinghouse for Alcohol
and Drug Information at 1-800-729-6686.
Recommended Citation: Center for Substance Abuse
Treatment. Inhalants. Substance Abuse Treatment Advisory.
Volume 3, Issue 1, March 2003.

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DHHS Publication No. (SMA) 03-3788
NCADI Publication No. MS922
Printed 2003