http://informahealthcare.com/ada ISSN: 0095-2990 (print), 1097-9891 (electronic) Am J Drug Alcohol Abuse, 2015; 41(1): 30–34 ! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/00952990.2014.956110

ORIGINAL ARTICLE

Volatile substance misuse deaths in Washington State, 2003–2012 Eric M. Ossiander, PhD

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Washington State Department of Health, Olympia, WA, USA

Abstract

Keywords

Background: Volatile substance misuse (VSM – also known as huffing or sniffing) causes some deaths, but because there are no specific cause-of-death codes for VSM, these deaths are rarely tabulated. Objectives: Count and describe VSM deaths occurring in Washington State during 2003–2012. Methods: We used the textual cause-of-death information on death certificates to count VSM-associated deaths that occurred in Washington State during 2003–2012. We extracted records that contained words suggesting either a method of inhalation or a substance commonly used for VSM, and reviewed those records to identify deaths on which the inhalation of a volatile substance was mentioned. We conducted a descriptive analysis of those deaths. Results: Fifty-six deaths involving VSM occurred in Washington State during 2003–2012. VSM deaths occurred primarily among adults age 20 and over (91%), males (88%), and whites (93%). Twelve different chemicals were associated with deaths, but 1 of them, difluoroethane, was named on 30 death certificates (54%), and its involvement increased during the study period. Gas duster products were named as the source of difluoroethane for 12 deaths; no source was named for the other 18 difluoroethane deaths. Conclusions: Most VSM deaths occurred among white male adults, and gas duster products containing difluoroethane were the primary source of inhalants. Approaches to deter VSM, such as the addition of bitterants to gas dusters, should be explored.

Difluoroethane, drug poisoning, huffing, volatile substance misuse

Introduction Volatile substance misuse (VSM), also known as ‘‘huffing’’ or ‘‘sniffing,’’ is usually defined as the inhalation of vapors from volatile substances with the intent of getting high, but not including the inhalation of illicit drugs such as cocaine or marijuana (1). VSM is common among young people in the US, with an estimated 12–15% of 8th graders having used an inhalant at least once (2–4), and is also a common drug use problem in other countries (5–7). Unusual among drug use problems, the definition of VSM refers to the route of administration, rather than the substances that are used. A wide variety of substances are used – a study of Poison Center reports in the US found 3400 different products used in VSM cases between 1993 and 2008 (8). VSM deaths cannot be easily identified in death records. The International Classification of Disease (ICD) codes which are used for coding cause of death have codes for many of the substances used in VSM, but not for the method by which the substance was administered (9). For example, ICD codes would not distinguish an incident in which a factory worker was accidentally exposed to toluene vapors at

Address correspondence to Dr Eric M. Ossiander, PhD, Washington State Department of Health, PO Box 47890, Olympia, WA, 98504-7890, USA. Tel: +1 360 236 4252. E-mail: [email protected]

History Received 11 July 2014 Revised 6 August 2014 Accepted 13 August 2014 Published online 17 November 2014

work from a VSM incident in which a person inhaled toluene to get high. For this reason, there are few estimates of the number of deaths associated with VSM. Three studies have used either medical examiner files (10,11) or a manual review of death certificates (12) to count VSM deaths in individual states. The National Poison Data System tabulates VSM deaths each year, but Poison Center reporting is voluntary, and is not thought to provide a good count of deaths (8). The SuperMICAR computer system has been used for coding cause-of-death in the US since about 2000 (the system was not implemented at the same time in all states; Washington State, from which we drew data for this study, began using it in 2003). With the SuperMICAR system, vital records staff key in the literal cause-of-death entry as it appears on the death certificate, and the computer system assigns ICD codes to describe the death (13). The text of the cause-of-death portion of the certificate is stored in a computer file with the ICD codes, and can be used for analysis (14). In the present study, we used the textual causeof-death entries to search for deaths in which there were words that suggested VSM deaths. Then we manually reviewed the entire text of those certificates to classify the deaths as being associated with VSM or not. The purpose of the present study was to count the number of deaths associated with VSM in Washington State between 2003 and 2012, and to describe the characteristics of those

VSM deaths in Washington State

DOI: 10.3109/00952990.2014.956110

deaths, including the substances used, the assigned cause of death, and the demographic characteristics of the decedents.

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Methods We obtained death certificate data, including the cause-ofdeath text, for all deaths occurring in Washington State between 2003 and 2012 from the vital statistics office of the Washington State Department of Health. Because the inhalation of volatile substances may sometimes contribute to deaths that are coded to other underlying causes (15), we used the entire set of deaths, except for suicides, and did not restrict our analysis to those classified as poisoning deaths. Methods for using the textual cause-of-death data are more completely described elsewhere (14). Briefly, these data include the text of the entries on the cause-of-death portion of the death certificate, including the immediate and underlying causes of death, other conditions contributing to the death, and the description of how the injury occurred, for deaths in which there was an injury. We combined these entries, then parsed them into separate words or phrases. We searched the entries for words that could suggest the inhalation of a volatile substance, by searching for the words and word roots listed in Table 1. We listed the death certificates identified in the search, manually reviewed their entire cause-of-death information, and classified them as involving VSM or not involving VSM. We did not consider a death to be VSMinvolved if a plausible non-VSM reason for the inhalation was mentioned. For example, if the decedents were said to have inhaled paint fumes while ‘‘painting a lawnmower in an enclosed space,’’ or to have been ‘‘self-testing a scientific premise’’ while inhaling helium, we classified the death as a non-VSM death. After identifying the deaths that were associated with VSM, we conducted a descriptive analysis of them. We

Table 1. List of words, phrases, and word roots that were used to search for VSM deaths. Aerosol Amyl nitrate Bag Butane Canned air Chloroethane Clean Compressed air Compressed nitrogen Difluoroethane Difluoromethane Duster Ethyl chloride Gasoline Gasoline vapors Glue Huff Inert gas Inhal Nitrous oxide Popp Sniff Toluene Volatile Whipped

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tabulated the inhalation method, the substances that were inhaled, the age, sex, and race of the decedents, the intent (unintentional or undetermined), and the presence of other medical conditions or drugs as either the main cause or contributors to the death. The computer code we used to process and analyze the data are available on the author’s GitHub account (https:// github.com/eossiander/vsm). This research used records from non-living subjects only, and was determined to be exempt from human subjects review.

Results A total of 476,002 deaths occurred in Washington State during 2003–2012. We found 56 deaths that were either certainly or probably associated with VSM (Table 2). Decedents were mostly male (87.5%), white (92.9%), and age 20 or older (91.1%) (Table 3). The median age for VSM deaths was 36 years (95% CI 33–43 years). Nearly all decedents (93.2%) had at least a high school education, and more than half (53.3%) had at least some college. Most of the deaths (73.2%) were to urban residents. In 40 of the 56 VSM-associated deaths, the inhalation of a volatile substance and the sequelae of its use, such as cardiac arrhythmia or asphyxia, were the only causes of death mentioned (Table 2). The other 16 deaths included mention of a disease condition, trauma following VSM, or VSM with other drugs or alcohol. Three of the deaths were certified as being due to heart disease, two to drug dependence (a disease category), 45 to unintentional poisoning, four to some other unintentional injury (one motor vehicle crash, one fall, one suffocation, and one ‘‘unspecified breathing threat’’). One person drowned after inhaling difluoroethane, but her death was coded as being due to poisoning. Two deaths were coded as poisoning of undetermined intent. Among the deaths coded as being due to unintentional poisoning, a variety of specific codes were used. Deaths involving difluoroethane by itself were variously coded as poisoning by drugs, ‘‘other gases,’’ ‘‘organic solvents,’’ ‘‘other substance,’’ or ‘‘pesticides,’’ demonstrating that the cause-of-death ICD codes cannot be used to identify these deaths. Difluoroethane was named on 30 (54%) of the 56 death certificates. The second most frequently named substance was chloroethane (also called ethyl chloride), which was named on six certificates (Table 4). Difluoroethane was named alone, without other drugs or alcohol, on 24 certificates (three of these involved a traumatic death after difluoroethane use). On 14 death certificates, the decedents were said to have used a dust cleaner product, variously described as Dust-Off, gas duster, dust destroyer, dust remover, computer keyboard cleaner, canned air, or compressed air. Twelve of these certificates named difluoroethane (one named dichloromethane, and one did not name a chemical). None of the 18 other certificates that named difluoroethane named a source for it, and it is possible that many of those decedents also used a dust cleaner product. The frequency of VSM-associated deaths increased during the study period. There were 25 deaths during 2003–2009 (3.6/year), and 31 deaths during 2010–2012 (10.3/year). Difluoroethane was mentioned on eight of 25 certificates

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E. M. Ossiander

Am J Drug Alcohol Abuse, 2015; 41(1): 30–34

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Table 2. List of all VSM-associated deaths that occurred in Washington State, 2003–2012. Year

Age

Sex

Official underlying cause

2003 2004

41 56

M M

X44 F19.1

drug poisoning drug use

2004 2004

26 44

M M

X47 Y20

poisoning, other gases suffocation

2004 2004 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 2008 2008 2008 2008 2008 2008

51 20 28 33 29 43 15 18 33 16 56 22 34 50 36 36 42 41

M M M M M M M M M F M M M M M M M M

I25.1 X49 X44 X44 F10.1 I25.0 X47 X47 X46 X46 X46 X46 X46 X46 X44 W83 X44 I49.9

heart disease poisoning, other substance drug poisoning drug poisoning alcohol use heart disease poisoning, other gases poisoning, other gases poisoning, organic solvents poisoning, organic solvents poisoning, organic solvents poisoning, organic solvents poisoning, organic solvents poisoning, organic solvents drug poisoning unspecified breathing threat drug poisoning heart disease

2009 2009 2009 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2011 2011 2011 2011 2011

50 15 45 23 21 46 36 51 44 34 34 39 35 29 13 46 51 29 23 46 43 45 22

M F M M M M F M M M M F F M M M M M M F M M M

X44 W80 X44 X46 X47 X48 X48 Y19 X43 X47 X41 X48 X46 X44 X48 X49 X44 X49 X44 X47 X47 W18 X44

drug poisoning inhalation foreign object drug poisoning poisoning, organic solvents poisoning, other gases poisoning, pesticides poisoning, pesticides poisoning, other drug poisoning poisoning, other gases drug poisoning poisoning, pesticides poisoning, organic solvents drug poisoning poisoning, pesticides poisoning, other substance drug poisoning poisoning, other substance drug poisoning poisoning, other gases poisoning, other gases fall drug poisoning

2011 2012 2012 2012 2012

45 29 40 55 33

M M M M M

X47 X47 X44 X47 V47.5

poisoning, other gases poisoning, other gases drug poisoning poisoning, other gases motor vehicle accident

2012 2012 2012 2012

44 49 35 25

F M M M

X47 X44 X47 X44

poisoning, other gases drug poisoning poisoning, other gases drug poisoning

2012 2012

63 24

M M

X49 X47

poisoning, other substance poisoning, other gases

Certifier’s description (summarized) asphyxia due to nitrous oxide inhalation pulmonary fibrosis/interstitial pneumonitis due to illicit inhaled substance abuse asphyxia due to inhalation of difluoroethane asphyxia/plastic bag over head/combined effects of methamphetamine, difluoroethane, and ethyl chloride atherosclerotic heart disease; heavy dose of inhaled hydrocarbons inhalation of difluoroethane; Dust-Off nitrous oxide and morphine, valium, and sertraline asphyxia from recreational inhalation of ethyl chloride acute alcohol and difluoroethane (Dust-Off) intoxication atherosclerotic coronary disease and butane vapor toxicity huffing of gasoline vapor inhaled butane huffing difluoroethene inhaled difluoroethane (Dust-Off) and drowned in hot tub asphyxia due to inhalation of volatile solvents including toluene ethanol and difluoromethane intoxication ethanol and difluoroethane intoxication difluoroethane poisoning/inhalation of propellant from canned air combined chloroethane and ethanol intoxication asphyxia/plastic bag over head/inhalation of nitrous oxide asphyxia/ethyl chloride with gas mask over head cardiac dysrhythmia associated with amyl nitrate inhalation abuse/ethanol intoxication inhalant abuse of ethyl chloride-containing solvent asphyxia/huffing from aerosol can oxycodone and difluoroethane intoxication/inhalant abuse positional asphyxia/1,1-difluoroethane (dynex compressed gas duster) asphyxia/propane inhalation and plastic bag over head cardiac dysrhythmia/inhalation of difluoroethane/dust destroyer difluoroethane poisoning/huffing dust remover asphyxia from inhaling fumes from aerosol cans (whipped cream) asphyxia due to inhalation of difluoroethane acute difluoroethane intoxication chlordiazepoxide and nordiazepam/huffing canned air (dichloromethane) asphyxia/inhalation of difluoroethane/aerosol dust remover inhaled chemicals containing toluene difluoroethane intoxication/inhalant abuse cardiotoxicity/aerosol inhalant abuse (difluoroethane)/huffing canned air asphyxia/huffing aerosol from compressed air can tramadol and possible inhalant intoxication cardiac dysrhythmia/difluoroethane/huffing computer keyboard cleaner asphyxiation/plastic bag over head, connected to helium tank difluoroethane poisoning/huffed inhalant difluoroethane intoxication/inhalant abuse acute subdural hematoma/head injury/fell while huffing difluoroethane combined effects of difluoroethane, doxylamine, diphenhydramine, trazodone, citalopram, hydrocodone, and ethanol difluoroethane intoxication/inhalant abuse difluoroethane poisoning/inhalation of compressed air duster cardiac arrhythmia/inhalant abuse of difluoroethane/Dust-Off inhaled difluoroethane multiple blunt force injuries/huffing difluoroethane/driver, single vehicle accident difluoroethane intoxication/inhalant abuse chloroethane intoxication/inhalant abuse difluoroethane intoxication/huffing combined effects of ethanol, difluoroethane, diazepam, oxazepam, temazepam cardiac arrhythmia/inhalation of aerosol fumes difluoroethane intoxication/inhalant abuse with plastic bag over head

VSM deaths in Washington State

DOI: 10.3109/00952990.2014.956110

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Table 3. Deaths associated with volatile substance misuse, Washington State, 2003–2012. Characteristic

n

Total Sex Male Female Age 10–19 20–29 30–39 40–49 50–59 60+ Race White All other Education (among decedents age 25 and older) 9th–12th grade, no diploma High school graduate or GED Some college Bachelor’s degree Postgraduate degree Unknown Rural/urban county Rural Urban Out-of-state Underlying cause-of-death Drug use/dependence Other disease Unintentional poisoning Other unintentional injury Undetermined intent

56

Percent

49 7

87.5 12.5

5 14 12 16 8 1

8.9 25.0 21.4 28.6 14.3 1.8

52 4

92.9 7.1

3 18 11 5 4 3

6.8 40.9 25.0 11.4 9.1 6.8

13 41 2

23.2 73.2 3.6

2 3 45 4 2

3.6 5.4 80.4 7.1 3.6

Table 4. Chemicals named on VSM-associated death certificatesy. Chemical

Count

Difluoroethane Chloroethane (ethyl chloride) Aerosol fumes/canned air, not otherwise specified Nitrous oxide Butane Toluene Inhalant abuse or use, no chemical mentioned Amyl nitrate Dichloromethane Difluoroethane Difluoromethane Gasoline Helium Propane hydrocarbons, not otherwise specified

30 6 4 3 2 2 2 1 1 1 1 1 1 1 1

yOne certificate mentioned both difluoroethane and chloroethane.

(32%) during 2003–2008, compared to 22 of 31 certificates (71%) during 2010–2012.

Discussion We found that VSM was associated with 56 deaths in Washington State between 2003 and 2012. Since the ICD does not have a code for VSM as a cause-of-death we could not tabulate the number of deaths for which VSM was named as the underlying cause, however, in most of these deaths no

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other cause than VSM was mentioned on the death certificate. Most of the deaths were among adult white males. Fourteen of the certificates mentioned the use of a gas duster product, and 12 of these named difluoroethane on the certificate. These products are often colloquially called ‘‘canned air’’ or ‘‘compressed air,’’ which gives the false impression that they are harmless. In fact, because air is difficult to compress into a liquid, they normally contain other gases. Difluoroethane is used in many gas dusters, but other gases may also be used. The use of gas dusters for VSM has been widely known, and, according to their advertising claims, many manufacturers add a bitterant to the product to discourage VSM. Only four of the death certificates in the present study identified the gas duster product that was used, and both of the named products claim to contain a bitterant. Ten other certificates that named difluoroethane mentioned the use of a gas duster, but did not name the brand. The other 16 certificates on which difluoroethane was named did not name the source (difluoroethane is also used as a refrigerant). Therefore, we cannot tell whether decedents used gas dusters despite the presence of bitterants, or if they were able to find difluoroethane that did not contain bitterants. There have been three previous state-wide studies of VSM deaths, in Virginia (10), Texas (12), and North Carolina (11). In the Virginia study, which included 39 deaths occurring between 1987 and 1996, difluoroethane was not named as being involved in any of the deaths. The Texas report, which included 144 VSM deaths occurring between 1988 and 1998, did not mention difluoroethane, but it is possible that it was involved in some of the 51 deaths in which Freon was named (difluoroethane is also known as Freon 152a). In the North Carolina study, which included 30 VSM deaths occurring between 2000 and 2008, difluoroethane was named on six deaths. In the Washington State deaths we report, the prevalence of difluoroethane involvement increased during the study period, from eight of 25 deaths during 2003–2008, to 22 of 31 deaths during 2010–2012. Together, these four studies suggest that difluoroethane involvement in VSM deaths is increasing. An analysis of reports to Poison Control Centers showed that among reports involving inhalants, the proportion in which the substance inhaled was a propellant increased from about 6% in 2000 to about 31% in 2008, while the proportions for all the other five leading categories (gasoline, paint, other hydrocarbons, and asphyxiants) decreased during that period (8). Other reports have also raised the concern that the use of gas dusters for VSM is increasing (2). Four statewide studies also suggest a secular increase in the age of the decedents. In Virginia (years 1987–1996) the median age of decedents was 19 years (10), in Texas (years 1988–1998) the median age was 26 years (12), in North Carolina (years 2000–2008), it was 28 years (11), and in the present study (years 2003–2012), it was 36 years. All of the studies reported that VSM deaths occurred predominantly among white males. Most studies of VSM focus on adolescents because, according to surveys, VSM use is much higher among adolescents than among adults (1,3,8). In the 2011 National Survey on Drug Use and Health the reported use of inhalants during the past 30 days was 0.9% among youth age 12–17,

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0.4% among young adults age 18–25, and 0.1% among adults age 26 and over (16). In the Monitoring the Future survey, the reported past 30 day use was higher among youths (2.1% among grades 8/10/12 combined in 2011), but similar in the older age groups (17). In both surveys, the reported past 30 day use of inhalants decreased between 2003 and 2011 in all age groups. These findings, together with the patterns among VSM deaths, suggest that although more adolescents than adults engage in VSM, there may be a small group of adults who are heavy users, and who are at high risk of death from their use of inhalants. Reports to Poison Control Centers show that many different substances are used for VSM. In an analysis of reports received between 2000 and 2008, more than 200 ‘‘inhalant product categories,’’ which included more than 3410 different inhalant products, were reported. This has implications for prevention, because if one product or substance is altered to become unpalatable for VSM, users may simply adopt the use of a different substance. Marketing information for gas dusters shows that most brands claim to contain a bitterant, but a review of internet blogs and comments shows that even some people not involved in VSM actively look for gas dusters that do not contain bitterants, either because they think the bitterants leave a residue on electronic components, or because, during normal use, some bitterant may end up in the mouth and leave an undesirable taste. This raises the possibility that manufacturers who add bitterant or increase the strength of bitterant in their product may lose customers. Our study has several limitations. There is no ICD coding for VSM, and no formal way to attribute the underlying causeof-death to VSM. Therefore, we counted every death for which VSM was mentioned on the death certificate as a VSMassociated death, and did not attempt to ascertain in which deaths VSM was only a contributory cause. For a few deaths it was not clear from the death certificate wording whether the decedent inhaled a volatile substance to get high, or whether the inhalation was incidental to another activity (such as using spray paint in an enclosed space), and we had to make a judgment whether to count the death as VSM-associated or not. Some inhalants, particularly difluoroethane, may cause a cardiac arrest that occurs several minutes to a few hours after inhalant use has stopped (18,19). In some of those cases, the cause-of-death certifier may not have been aware of the inhalant use, and thus not noted it on the death certificate. Because of the limited information that certifiers entered on death certificates, for most of the deaths we could not describe the source or product used for the inhalant.

Conclusion The number of VSM deaths, and the number and proportion of VSM deaths that involved difluoroethane increased in Washington State during 2003–2012. In contrast to surveys, which show higher VSM use among teens, most VSM deaths in Washington occurred among adults. Our data, together with results from other states, suggest that the age of

Am J Drug Alcohol Abuse, 2015; 41(1): 30–34

VSM-associated deaths has increased, and that the contribution of gas duster products, particularly those containing difluoroethane, has increased.

Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of this paper.

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Volatile substance misuse deaths in Washington State, 2003-2012.

Volatile substance misuse (VSM - also known as huffing or sniffing) causes some deaths, but because there are no specific cause-of-death codes for VSM...
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