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Inhalant-Related Psychiatric DisordersLast
Updated: June 19, 2002 |
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| Synonyms and related keywords:
huffing, sniffing, bagging, volatile substance abuse, substance
abuse, drug abuse, drug-induced psychosis, inhalant abuse, inhalant
dependence, inhalant intoxication, substance intoxication delirium,
substance-induced anxiety disorder, inhalant-related disorder NOS,
inhalant-related disorder not otherwise specified, substance-induced
psychotic disorder, depression, general anxiety disorder, sudden
sniffing death syndrome |
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AUTHOR INFORMATION
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Section 1 of 10
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| Author: Guy
E Brannon, MD, Director of Adult Psychiatry Service,
Brentwood Behavior Health Company; Assistant Clinical Professor,
Department of Psychiatry, Louisiana
State University at Shreveport
Coauthor(s): Jeanie
McGee Gary, BS, Editorial Manager, Department of
Neurosurgery, Louisiana State
University Health Sciences Center in Shreveport
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| Guy E Brannon, MD, is a member of the following medical
societies: American College of
Clinical Pharmacology, American Medical Association, American Medical Women's
Association, American
Psychiatric Association, American
Society of Addiction Medicine, Louisiana State Medical Society, and
Southern Medical Association
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| Editor(s): Barry I Liskow, MD, Vice Chairman,
Program Director, Professor, Department of Psychiatry, University of
Kansas Medical School; Francisco Talavera, PharmD,
PhD, Senior Pharmacy Editor, eMedicine; Iqbal
Ahmed, MD, Program Director, General and Geriatric
Psychiatry Residency Programs, Vice Chair for Education, Professor,
Department of Psychiatry, John a Burns School of Medicine,
University of Hawaii; Harold H Harsch, MD, Program
Director of Geropsychiatry, Department of Geriatrics/Gerontology,
Associate Professor, Department of Psychiatry, Assistant Professor,
Department of Medicine, Froedtert Hospital, Medical College of
Wisconsin; and Stephen Soreff, MD, Director of
Quality Improvement, President of Education Initiatives, HMA
Behavioral Health, Inc |
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INTRODUCTION |
Section 2 of 10   |
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Background:
Inhalant-related psychiatric disorders are a heterogenous group
of illnesses that are caused by the abuse of solvents, glues, paint,
fuels, or other volatile substances, excluding anesthetic gases, which are
not included in the category.
Although huffing, as it is referred to commonly, has existed since
ancient times, it has regained popularity in recent years. The resurgence
of this newfound phenomenon is believed to be due to a number of
variables, which have made this potentially fatal activity popular among
many young people today.
Because most of the products used in huffing are legal household
products, they are easily accessible and are relatively inexpensive to
obtain. Most recent reports state that nearly 1000 such products are
available to huffers every day. Some of the most common products used for
inhaling are spray paint (containing butane, lead, or propane), permanent
markers, correction fluid (eg, Liquid Paper, Wite-Out), glue (containing
toluene or ethyl acetate), lighter fluid (containing butane or
isopropane), hairspray (containing butane or propane), propane, gasoline
(containing lead), and kerosene. Due to the increase in awareness of the
potential dangers caused by sniffing or inhaling, laws have been
established prohibiting the sale of certain products to minors; however,
enforcing these laws is difficult.
Generally, adolescents practice huffing; however, younger children and
young adults also engage in this potentially fatal act. Huffing involves
placing the volatile substance (most commonly some type of chemical, eg,
butane found in spray paint, acetone found in nail polish remover) on a
rag or in a closed container (eg, soda can, plastic bag), placing the rag
over the nose and mouth, and breathing deeply to cause mood-altering
effects.
The effects experienced by persons who use inhalants vary from
excitement and euphoria to confusion, disorientation, and hallucinations.
Most persons who abuse inhalants experience a lessening of inhibitions,
loss of coordination, and muscle relaxation. Most who abuse inhalants
continue to sniff to produce the feeling of euphoria. The effects last
from minutes to hours, depending on the chemical being inhaled; then, the
person experiences a hangover.
The inhalation of these substances can cause permanent organ damage and
death. Huffing is a problem not only in the United States, but also
abroad, and accounts for a large portion of emergency department visits.
Diagnosis of inhalant-related psychiatric disorders is based on
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) or International Classification of
Diseases, 10th Revision criteria.
Although studies have shown that inhalant abuse has been difficult to
diagnose, treatment efforts for inhalant-related psychiatric disorders may
be promising. Treatment consists of psychotherapy (eg, 12-step programs
similar to Alcoholics Anonymous, cognitive behavior therapy,
rational-emotive therapy) and pharmacotherapy. Early intervention may play
a key role because engagement in this activity may lead to the use of
other drugs.
Pathophysiology: Inhalants are CNS depressants
(similar to alcohol) and are thought to influence GABA, although the exact
mechanism has yet to be determined. No evidence associates inhalants with
the opiate system; N-methyl-D-aspartate may play a role.
Medical effects
- Brain: Most of the damage inflicted by inhalant abuse initially
affects the brain. The tissue damage that occurs results in cell death
after the chemicals in the inhalant dissolve the protective covering
that surrounds the neurons (ie, myelin sheath). The cellular death can
cause specific syndromes related to the cerebellum or peripheral nervous
system or can cause changes to take place throughout the brain that
result in memory impairment, personality changes, loss of coordination,
speech impairment, learning disabilities, and hallucinations. Tremors
and uncontrollable shaking are observed in those who abuse inhalants for
a long period. Inhalants also affect eyesight, causing double vision and
other sight disorders. Many who abuse inhalants experience seizures.
Those who abuse toluene may have significantly wider cerebellar and
cerebral sulci and larger ventricular systems.
- Lungs: Repeated use of inhalants can cause lung damage.
- Heart: Heart problems can occur, including irregular heartbeat and
sudden sniffing death syndrome, which is heart failure resulting from an
irregular heartbeat.
- Liver: Liver function can actually shut down, either temporarily or
permanently, depending on length and extent of inhalant use.
- Kidney: Kidney stones and complete loss of kidney function can
develop.
- Muscle: Long-term inhalant abuse leads to muscle weakness, muscle
wasting, and reduced muscle tone and strength.
- Bone marrow: Inhalants damage bone marrow. In addition, the chemical
benzene, which is found in gasoline, has been shown to cause leukemia.
- Peripheral nervous system: Damage from inhalants can cause temporary
numbness, permanent nerve damage, or permanent paralysis, depending on
the frequency of abuse.
- Hearing: Some who abuse inhalants have become deaf because of the
inhalation of chemicals that destroy cells that relay sound to the
brain.
- Other medical effects: Other effects of inhalant abuse include
respiratory problems, asphyxiation, aeration, and fetal damage similar
to that observed in patients with fetal alcohol syndrome.
Psychiatric effects
The psychiatric effects of inhalant abuse include impaired judgment,
confusion, fright, hyperactivity, anxiety, acute psychosis, increased
violence and aggressive behavior, depression, organic brain syndrome (ie,
coarse tremor, staggering gait, speech problems, thought disorder), abuse,
tolerance and dependence, hallucinations, decreased intelligence quotient,
intoxication, mood disorder, dementia, and withdrawal. Inhalant abuse also
affects social, educational, and economic status. In addition, those who
abuse inhalants are more likely to be involved in accidents.
Frequency:
- In the US: Of the population, 5% have tried huffing
once and 1% are current users. According to statistics gathered by the
National Inhalant Prevention Coalition, ". . . by the time a student
reaches the eighth grade, 1 in 5 will have used inhalants." Inhalants
account for 1% of substance-induced death.
- Internationally: Incidents occur worldwide, but
determining exact numbers is difficult.
Mortality/Morbidity: Inhalants work quickly by passing
through the nasal cavity and entering the lungs, bloodstream, and the
brain, all in a matter of seconds. The chemical vapors of the inhalants
are dissolved into the fatty tissues of the brain. The results of inhalant
abuse affect virtually every organ and function of the body, including the
brain, heart, lungs, kidneys, muscle, bone marrow, and peripheral and
central nervous systems, to name a few. Those who abuse inhalants for the
long-term may become disabled permanently, losing their ability to walk,
talk, and think. The possible damage depends on the chemical used, the
frequency with which it is used, and the amount used.
Race: Persons who abuse inhalants predominantly are
white; however, studies have found minority involvement in subcultures of
American and Canadian Indians and in Hispanic persons with low income
status. Inhalant use is more common in rural and suburban areas than in
urban areas.
Sex: Although long-term inhalant use is more common in
males than in females, experimental use is equally common in males and
females.
Age: Experimental use of inhalants normally occurs in
late childhood and early adolescence (age 9-13 y). Long-term use appears
during early and late adolescence (age 12-17 y). Inhalants commonly are
the first substance used before the onset of substance (eg, tobacco,
alcohol, marijuana, cocaine) abuse occurs. Inhalant abuse among younger
children and adults is less frequent, although it does occur
History: Those who abuse
inhalants commonly share characteristics that may help identify them as
users. While taking the patient's history, determine their diagnosis based
on the DSM-IV criteria for inhalant abuse, inhalant dependence,
inhalant intoxication, substance intoxication delirium, substance-induced
persistent dementia, substance-induced psychotic disorder,
substance-induced mood disorder, substance-induced anxiety disorder, and
inhalant-related disorder not otherwise specified (NOS). Pay close
attention to the signs and symptoms that are commonly associated with
persons who abuse inhalants (see below). Inquire about other drugs of
abuse and a family history of drug and alcohol abuse or addiction.
- Signs and symptoms
- Chemical smell or odor on breath or body
- Redness, sores, or spots around the lips or mouth
- Redness of eyes
- Runny or red nose
- Paint stains on clothing or body
- Nausea or loss of appetite
- Drunken or dazed appearance
- Dizziness
- Irritability, excitability, or anxiety
- Slow verbal responses in conversation
- Sudden behavior change
- Sensitivity to light
- Sore or irritated throat
- Rashes or redness on hands
- Characteristics of persons who abuse inhalants
- Delinquency
- Theft and burglary
- Poor school attendance
- Frequent suspension and expulsion from school
- Social outcasts
- Impoverished families or middle-to-upper income status
- Lack of parental control or guidance
- Attention deficit
- Poor academic performance
- Antisocial personality
- Depressive disorders
- Emotional problems (specifically anxiety, depression, and anger)
- Low self-esteem
- Peer pressure with drug influence
- Criteria for inhalant abuse, adapted from the DSM-IV
- A maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by one (or more) of
the following, occurring within a 12-month period:
- Recurrent substance use resulting in a failure to fulfill major
obligations at work, school, or home
- Recurrent substance use in situations in which it is physically
hazardous
- Recurrent substance-related legal problems
- Continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance
- Symptoms never meeting criteria for substance dependence for this
class of substance
- Criteria for inhalant dependence, adapted from the DSM-IV:
A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by 3 (or more) of the following,
occurring at any time in the same 12-month period:
- Tolerance
- A need for markedly increased amounts of the substance to
achieve intoxication or desired effects
- Markedly diminished effects with continued use of the same
amount of the substance
- Withdrawal
- Characteristic withdrawal syndrome for the substance
- Same (or a closely related) substance taken to relieve or avoid
withdrawal symptoms
- Substance often taken in larger amounts or over longer periods
than was intended
- A persistent desire or unsuccessful effort to cut down or control
substance use
- Significant time is spent in activities necessary to obtain the
substance or recover from its effects
- Important social, occupational, or recreational activities are
given up or reduced because of the substance use
- Substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by the substance
- Criteria for inhalant intoxication, adapted from the DSM-IV
- Recent intentional use or short-term high-dose exposure to
volatile inhalants
- Clinically maladaptive behavioral or psychological changes that
developed during or shortly after use of or exposure to volatile
inhalants
- Two (or more) of the following signs developing during or shortly
after inhalant use or exposure:
- Dizziness
- Nystagmus
- Incoordination
- Slurred speech
- Unsteady gait
- Lethargy
- Depressed reflexes
- Psychomotor retardation
- Tremor
- Generalized muscle weakness
- Blurred vision or diplopia
- Stupor or coma
- Euphoria
- Symptoms not due to a general medical condition and not better
accounted for by another mental disorder
- Criteria for substance intoxication delirium, adapted from the
DSM-IV
- Disturbance of consciousness with reduced ability to focus,
sustain, or shift attention
- A change in cognition or the development of perceptual disturbance
that is not accounted for by a preexisting, established, or evolving
dementia
- Disturbance occurs over a short period of time and tends to
fluctuate during the course of the day
- Evidence from the history, physical examination, or laboratory
findings of either of the following:
- Symptoms of (1) disturbance of consciousness with reduced
ability to focus, sustain, or shift attention or (2) a change in
cognition or the development of perceptual disturbance that is not
accounted for by a preexisting, established, or evolving dementia
that developed during substance intoxication
- Medication use etiologically related to the
disturbance
- Criteria for substance-induced persistent dementia, adapted from the
DSM-IV
- Development of multiple cognitive deficits manifested by both (1)
memory impairment and (2) one (or more) of the following cognitive
disturbances:
- Aphasia
- Apraxia
- Agnosia
- Disturbance in executive functioning
- Cognitive deficit in (1) memory impairment and (2) aphasia,
apraxia, agnosia, or disturbance in executive functioning each cause
significant impairment in social or occupational functioning and
represents a significant decline from a previous level of functioning
- Deficients do not occur exclusively during the course of a
delirium and persist beyond the usual duration of substance
intoxication or withdrawal
- Evidence from history, physical examination, or laboratory
findings that deficits are etiologically related to the persistent
effects of substance use
- Criteria for substance-induced psychotic disorder, adapted from the
DSM-IV
- Prominent hallucinations or delusion
- Evidence from history, physical examination, or laboratory
findings of either of the following:
- Symptoms of prominent hallucinations or delusion developing
during or within 1 month of substance intoxication or withdrawal
- Medication use etiologically related to the disturbance
- Disturbance not better accounted for by a psychotic disorder that
is not substance induced
- Disturbance does not occur exclusively during the course of a
delirium
- Criteria for substance-induced mood disorder, adapted from the
DSM-IV
- Prominent and persistent disturbance in mood predominates in the
clinical picture and is characterized by either (or both) of the
following:
- Depressed mood or markedly diminished interest or pleasure in
all, or almost all, activities
- Elevated, expansive, or irritable mood
- Evidence from history, physical examination, or laboratory
findings of substance intoxication or withdrawal and the symptoms of
(1) depressed mood or markedly diminished interest or pleasure
activities and (2) elevated, expansive, or irritable mood developing
during or within 1 month of substance intoxication or withdrawal
- Disturbance not better accounted for by mood disorder that is not
substance induced
- Disturbance does not occur exclusively during the course of a
delirium
- Disturbance causes clinically significant distress or impairment
in social, occupational, or other important area of
functioning
- Criteria for substance-induced anxiety disorder, adapted from the
DSM-IV
- Prominent anxiety, panic attacks, obsession, or compulsion
predominating in the clinical picture
- Evidence from history, physical examination, or laboratory
findings of either of the following:
- Symptoms of prominent anxiety, panic attacks, obsession, or
compulsion developing during or within 1 month of substance
intoxication or withdrawal
- Medication use etiologically related to the
disturbance
- Disturbance not better accounted for by an anxiety disorder that
is not substance induced
- Disturbance not occurring exclusively during the course of a
delirium
- Disturbance causes clinically significant distress or impairment
in social, occupational, or other important area of
functioning
- Criteria for inhalant-related disorder NOS, adapted from the
DSM-IV: The inhalant-related disorder NOS category is for
disorders associated with the use of inhalants that are not classified
as inhalant dependence, inhalant abuse, inhalant intoxication, inhalant
intoxication delirium, inhalant-induced persistent dementia,
inhalant-induced psychotic disorder, inhalant-induced mood disorder, or
inhalant-induced anxiety disorder.
Physical:
- Perform a detailed neurological evaluation to look for the
following:
- Altered levels of consciousness
- In addition, be aware of the signs and symptoms of inhalant abuse
when performing the physical examination; for example, look for the
following:
- Rashes (particularly around the hand, nose, and mouth)
- Unusual breath odors (eg, chemical smells)
- Red or irritated eyes, throat, lungs, and nose
Causes: Much speculation exists on the cause of
inhalant abuse. Its popularity appears to be based on the fact that the
substances are easily accessible to young people. The products used are
fairly easy to hide, fairly inexpensive, easily attainable, and, for the
most part, are legal. Therefore, inhalants are readily becoming the drugs
of choice. Many adolescents are becoming interested in the instant
gratification huffing offers, while others engage in huffing merely
because their friends are doing it. However, a subgroup of young people
still exists who abuse inhalants because they have seen their parents or
older siblings abuse illegal drugs, and these young people have decided
that huffing is the activity they choose to begin their drug use and
addiction.
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DIFFERENTIALS |
Section 4 of 10 |
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Anxiety Disorders
Delirium
Depression
Stimulants
Other Problems to be Considered:
Because substance-induced psychiatric disorders resemble the primary
mental disorders (ie, major depression, generalized anxiety disorder),
these should be considered in the differential diagnosis.
Other
disorders to consider include the following:
Conduct
disorder
Antisocial personality disorder
Alcohol abuse and
dependence
Cannabis abuse and dependence
Temporal lobe
epilepsy
Psychosis
Polysubstance dependence
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Lab Studies:
- Sequential multiple analysis
- Electrolyte (eg, sodium, potassium, chloride) levels
- Complete blood cell count with differential and platelets
- Rapid plasma reagin testing
- Thyroid-stimulating hormone testing
- Creatine kinase, if not included in sequential multiple
analysis
- Twenty-four–hour urine test
- Heavy metal screening test
Imaging Studies:
- Perform a chest radiograph.
- Perform a CT scan to help identify brain atrophy. Include cerebral
and cerebellar regions and the brainstem.
- Perform an MRI to help identify brain atrophy and white matter
disease or leukoencephalopathy.
- Perform a positron emission tomography (PET) scan to help identify
decreases in cerebral blood flow.
- Order a CT scan and electroencephalogram (EEG) if neurological
symptoms are present (eg, hearing loss, headaches, cerebellar signs,
paresis, motor impairment, parkinsonism, encephalopathy).
- Perform an EEG to help identify seizure activity, specifically
temporal lobe epilepsy.
- If PET scanning is not available, perform single-photon emission
computed tomography scanning to help identify nonhomogenous uptake of
radiopharmaceuticals, which may indicate hypoperfusion and
hyperperfusion foci.
Other Tests:
- Electrocardiogram (may be necessary)
- Wechsler Adult Intelligence Scale
- Wide Range Achievement Test
Procedures:
- Liver or kidney biopsy, if indicated
Histologic
Findings: Findings may include evidence of heavy metal damage to
specific organs, such as that caused by lead in gasoline and paint, and
inflammation, rhabdomyolysis, brain atrophy, and renal tubular acidosis.
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TREATMENT |
Section 6 of 10 |
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Medical Care:
- The medical care of patients with inhalant-related psychiatric
disorders encompasses many areas.
- A team of medical professionals must work in unison to ensure that
every aspect of the treatment plan is fulfilled.
- Patients will likely require hospitalization. As inpatients, they
may require the administration of medications (eg, haloperidol,
risperidone, carbamazepine) to relieve any psychosis related to the
chemicals inhaled.
- Counseling should be initiated, along with patient education to
explain the dangers of huffing. Evaluate patients for psychiatric
comorbidity.
- No controlled studies have been performed to guide the treatment of
patients who abuse inhalants and have inhalant dependence. Additionally,
no specific medications indicated by the pharmaceutical industry are
available for detoxification from inhalants.
- Programs that specifically treat inhalant abuse do exist; however,
they are rare and difficult to find. Therefore, treatment planning most
often is tailored much like that of the treatment of patients with
chemical dependence, in which the first step is to detoxify the
patient.
- Patients who are addicted to inhalants experience withdrawal
symptoms similar to those of any other patient addicted to drugs,
including tremors, chills, sweats, cramps, nausea, and hallucinations.
- Next, a peer system is established.
- Once these 2 tasks are accomplished, assess the patient for
physical, cognitive, and neurologic problems. If any problems are
noted in these areas, they must be treated immediately. Identify any
strengths the patient has and build on these strengths to increase
them and to create new additional strengths for the patient. Address
any other problems they may have. The goal is to get the patient back
into the community with a drug-free peer network and continuing or
enhanced self-support.
- Treat any conduct problems noted.
- Once the patient is detoxified, evaluate for other psychiatric
illnesses using the DSM-IV.
- The patient should participate in group therapy sessions, 12-step
programs/chemical dependency groups, rational-emotive therapy, cognitive
behavior therapy, and family therapy.
- Discuss safe sex with the patient, including partner precautions and
birth control. In addition, the family should receive education about
the disorder, secure substances that could be huffed, and become
familiar with local mental health laws regarding commitment policies.
- No medications should be used unless a treatable DSM-IV
diagnosis has been identified.
- If the patient has depression independent of the inhalant abuse,
treat with the antidepressant of choice.
- If the patient has alcohol abuse coexisting with inhalant abuse,
disulfiram (Antabuse) or naltrexone can be used to treat appropriate
patients.
- If the patient meets DSM-IV criteria for
attention-deficit/hyperactivity disorder, a psychostimulant such as
Cylert can be used to treat the patient.
- If the patient is psychotic as a result of the inhalant abuse
(inhalant-induced psychosis), the physician may use an appropriate
antipsychotic such as haloperidol or Risperdal, with or without a
benzodiazepine. This is the physician's choice.
- If the patient has an inhalant-induced mood disorder,
detoxification is recommended, without the use of any medications
unless the depression persists for longer than 2-4 weeks after
withdrawal.
- Detoxification also is recommended for patients who are
experiencing inhalant-induced anxiety; however, the use of sedatives
or antianxiety medications is contraindicated because inhalant
intoxication can worsen if the patient uses again.
- If the patient cannot maintain sobriety, the physician should
consider residential treatment options, which can last anywhere from
3-12 months.
- Most persons who abuse inhalants receive most of their medical care
in local emergency departments after they have either passed out or
become psychotic from chemical inhalation. In the emergency department,
they receive supportive care, social interventions, and appropriate
medical care.
Surgical Care:
- Patients may need liver or kidney transplantation.
Consultations:
- Chemical dependence counselor
- Attorney, if legal problems develop
Diet:
- Consultation with a dietitian may be helpful if patients have poor
nutrition (eg, liver problems, low protein).
- If no additional medical problems are present, patients can eat a
regular diet.
Activity:
- Patients who are not a danger to themselves or others, are not
gravely disabled, and are medically stable can maintain routine
activities.
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MEDICATION |
Section 7 of 10 |
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If psychosis or delirium is present, use
an antipsychotic such as risperidone or haloperidol and/or an
anticonvulsant such as carbamazepine. Avoid benzodiazepines because they
may worsen respiratory depression.
Drug Category: Antipsychotics -- Reduce
psychosis and aggressive behavior. All antipsychotics may be equally
efficacious, but their adverse affect profiles are different. The atypical
antipsychotics such as risperidone, olanzapine, quetiapine, and
ziprasidone have an advantage in the adverse effect profile, especially in
their lower risk to cause adverse extrapyramidal effects and tardive
dyskinesia.
Drug Name
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Haloperidol (Haldol) -- Used for
the management of psychosis. Also used to treat motor and vocal tics
in children and adults.
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| Adult Dose |
0.5-5 mg PO bid; 2-5 mg IM q4-8h
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| Pediatric Dose |
3-12 years (15-40 kg): 0.05-0.15
mg/kg/d PO
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| Contraindications |
Documented hypersensitivity;
narrow-angle glaucoma; bone marrow suppression; severe cardiac or
liver disease; severe hypotension; subcortical brain damage
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| Interactions |
May increase tricyclic
antidepressant serum concentrations and hypotensive action of
antihypertensive agents; phenobarbital or carbamazepine may decrease
effects; coadministration with anticholinergics may increase
intraocular pressure; encephalopathylike syndrome associated with
concurrent administration of lithium
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| Pregnancy |
C - Safety for use during pregnancy
has not been established.
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| Precautions |
Severe neurotoxicity manifesting as
rigidity or inability to walk or talk may occur in patients with
thyrotoxicosis also receiving antipsychotics; if IV/IM, watch for
hypotension; caution in diagnosed CNS depression or cardiac disease;
if history of seizures, benefits must outweigh risks; significant
increase in body temperature may indicate intolerance to
antipsychotics (discontinue if it occurs); elevates prolactin
levels |
Drug Name
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Risperidone (Risperdal) -- Binds to
dopamine D2 receptor with 20 times lower affinity than
5-HT2–receptor affinity. Improves negative symptoms of psychoses and
reduces incidence of adverse extrapyramidal effects.
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| Adult Dose |
0.25-6 mg/d PO qd/bid
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| Pediatric Dose |
Not established
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| Contraindications |
Documented hypersensitivity
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| Interactions |
Coadministration with carbamazepine
may decrease effects; may inhibit effects of levodopa; clozapine may
increase levels
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| Pregnancy |
C - Safety for use during pregnancy
has not been established.
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| Precautions |
Orthostatic hypotension, seizures,
dysphagia, hyperprolactinemia, cognitive and motor impairment,
priapism, and rare thrombotic thrombocytopenic purpura may
occur | Drug Category:
Anticonvulsants -- Usually used to treat seizures but have
been used for treatment of manic-depressive symptoms and behavioral
agitation. Other anticonvulsants such as valproic acid (Depakene) or
divalproex sodium (Depakote) may also be as effective as carbamazepine.
Drug Name
|
Carbamazepine (Tegretol) -- Used to
treat epilepsy and trigeminal neuralgia.
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| Adult Dose |
200-600 mg bid; 800-1200 mg/d
maintenance
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| Pediatric Dose |
<6 years: 10-20 mg/kg/d bid;
<35 mg/kg/d maintenance
6-12 years: 100 mg bid; 400-800
mg/d maintenance
| Contraindications |
Documented hypersensitivity;
administration of MAOIs within last 14 d; history of liver disease
and blood dyscrasias
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| Interactions |
Do not coadminister with MAOIs;
cimetidine may increase toxicity, especially if taken in first 4 wk
of therapy; grapefruit juice, danazol, isoniazid, cimetidine,
fluoxetine, erythromycin, and phenelzine increase plasma levels;
phenytoin, alprazolam, clonazepam, primidone, and phenobarbital
decrease levels
Decreases levels of imipramine,
phenothiazines, haloperidol, ritonavir, contraceptives, risperidone,
thiothixene, corticosteroids, doxycycline, trazodone, and
amitriptyline; increases plasma levels of diltiazem and verapamil;
can reduce its own level by autoinduction; coadministration with
clozapine further increases bone marrow toxicity and resulting
agranulocytosis
| Pregnancy |
D - Unsafe in pregnancy
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| Precautions |
Very small but significant risk of
causing agranulocytosis or aplastic anemia; can cause drowsiness,
dizziness, and blurred vision; caution while driving or performing
other tasks requiring alertness; caution in mixed seizure disorders
and cardiac, renal, liver, or hematological problems; report any
indications of blood dyscrasias (eg, easy bruising, sore throats,
fever, rash) | | |
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FOLLOW-UP |
Section 8 of 10 |
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Further Inpatient Care:
- Patients who represent a danger to themselves or to others, are
gravely disabled, or are medically unstable require inpatient care, even
if involuntary measures are needed.
Further Outpatient Care:
- Therapy should include interventions such as a 12-step program or
chemical dependency counseling, cognitive behavior therapy, or
rational-emotive therapy.
- Continued pharmacotherapy may be indicated.
- Patients may need to join Alcoholics Anonymous.
In/Out Patient Meds:
- Continued pharmacotherapy depends on the diagnosis and what
medications were started in the hospital.
Transfer:
- Transfer to a medical/surgical hospital may be necessary.
- If legal problems develop, transfer to prison, jail, or a juvenile
detention center may be necessary.
Deterrence/Prevention:
- Educating those who abuse inhalants, students, teachers, educators,
parents, and the community in general may help prevent further
abuse.
- Early identification of the problem may help prevent continued
abuse.
Complications:
- Social problems
- Difficulty at work
- Anxiety
- Mood disorders
- Delirium
- Confusion or impaired judgment
Prognosis:
- The prognosis is fair if inhalants are used short-term.
- The prognosis is poor if inhalants are used long-term.
Patient Education:
- Education about substance abuse
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MISCELLANEOUS |
Section 9 of 10 |
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Medical/Legal Pitfalls:
- Failure to know local and state laws is a potential pitfall; persons
who abuse inhalants may be placed in jail.
Special Concerns:
- HIV: Any person who engages in risky behavior that results in
impaired judgment (eg, use of drugs, alcohol, inhalants) should be made
aware of the risks associated with the acts, especially drug abuse that
is known to occur in a subgroup of adolescents aged 12-17 years. Whether
the impaired judgment leads to promiscuity, impaired cognitive
functioning that can affect driving, or other activities in which
accidents can be expected to occur, an awareness of the additional risk
of HIV infection must be conveyed. Even tissue damage in the nose
associated with huffing, which can cause nosebleeds, can put someone at
risk.
- Pregnancy: The use of inhalants can cause preterm labor, fetal
growth retardation, and abnormalities similar to those associated with
fetal alcohol syndrome.
- Conduct disorder: Abuse may be more frequent and extensive, thus
worsening treatment outcome.
- Antisocial personality disorder: Abuse may be more frequent and
extensive, thus worsening treatment outcome.
| |
BIBLIOGRAPHY |
Section 10 of
10 |
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| NOTE:
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