Threat of nitrous oxide use
Dr. Elizabeth OgunjimiThe Psychiatry Registrar at HSE Youth Drug and Alcohol Service highlights the risks, including death, associated with the use of laughing gas, also known as "laughing gas" or "hippie crack".
Dr. Elizabeth Ogunjimi
T.here the use of laughing gas (N) has increased2O or nitrous oxide) for poisoning purposes during the Covid-19 pandemic, in which large quantities of steel pears or whippets were found to pollute public places such as parks and green spaces. For the past two decades, the use of N.2O is increasing rapidly, especially in the dance and festival scenes. In 2019, data collected by the Health Service Executive (HSE) and Trinity College Dublin at music festivals in Ireland showed that more than a quarter of respondents had used N.2Ö.
In the UK, N.2O is the second most popular recreational drug after cannabis. From 2001 to 2016, 34 deaths were recorded in England and Wales, where N.2O was involved.
Legal substance
In Ireland, as in most countries, N.2O is a legal substance that is widely available and cheap. It is used as a combustion fuel in car races and rocket engines, as well as in the food industry as a propellant in whipped cream dispensers known as whippets. It has also been used in smaller surgeries because of its anesthetic and analgesic properties since its first use in 1844. The mechanism of action for the analgesic and anesthetic effects is not fully understood.
Poisoning purposes
When inhaled for poisoning purposes, the desired euphoric and dissociative effect is similar to that of ketamine. Users report an onslaught of awareness, breakup, excitement, deep “silly” voice, sound distortion and dizziness. These set in quickly, peak after about a minute of inhalation, and dissolve two minutes after the last inhalation. Some users report that the effects can be felt up to 30 minutes after their last inhalation. N.2O is usually used with other medicines to increase the effects or intensity. The user can suffer from psychological dependence.
On the street, N.2O is referred to as "charger", "hippie crack", etc., and its use as an inhalant is referred to as "nag" or "nag". Because of its use in medicine, the Health Products Regulatory Authority (HPRA) provides guidelines for the use of N.2Ö.
However, it can still be bought from online retailers (i.e. Amazon, eBay, Wish) and specialty stores. Although N.2O is not provided for in the Drug Abuse Act, the delivery of N.2O as a recreational drug is illegal under the Criminal Justice (Psychoactive Substances) Act (CJPSA) of 2010. Under the CJPSA 2010, the sale or supply of psychoactive substances for human consumption is considered a criminal offense.
N.2O toxicity
The 8 gram steel pears (or whippets) contain 10 ml of pressurized N2O in liquid form and cost less than € 1 per pear (or € 44 for a pack of 50). The dispenser (or cracker) costs about € 4 relatively inexpensive drug. For recreational use, the lightbulbs are usually placed in a balloon with the metal cracker. Larger professional canisters with 3-5L pressurized N.2O are also used to fill balloons.
At room temperature, laughing gas is a colorless, non-flammable gas that smells and tastes slightly sweet. Medical class N.2O and nitrous oxide in lightbulbs intended for home use are at least 99 percent pure, while N.2O, which is used in car racing, is usually contaminated with toxic hydrogen sulfide, so it should not be consumed. It has been suggested that some imported whippets contain impurities.
Occupational exposure
N.2O toxicity has been documented for both patients and professionals who are exposed to it since the 1950s. Since then, many security measures have been put in place to reduce this risk. The instant access dentists and other professionals have to N.2O Toxicity is of concern given the many reports of N2O abuse and abuse in this population. N.2O Misuse is now generally recognized in dentistry as a serious occupational risk, which is present in up to 5 percent.
Abuse or even professional N.2O exposure can disrupt lipid synthesis in neurons and cause a deficiency in vitamin B12 (cyanocobalamin) through oxidation of cobalt.
Several case studies have reported myelopathy, myeloneuropathy, and subacute combined degeneration and psychosis successfully treated with vitamin B12 in abusers of N2O. Other medical effects such as pneumomediastinum, pulmonary embolism, and pneumothorax have no clear explanation except due to their nature N.2O displaces other gases in the lungs more than 30 times faster (low blood gas distribution coefficient).
Associated Deaths
Several deaths have been linked to the use of pouches that are placed over the head to facilitate inhalation and inhalation in enclosed spaces. Death related to N.2O Inhalation from case studies and medical records includes hypoxia and asphyxiation. Although nitrous oxide does not significantly depress the respiratory center, the normal physiological response to hypoxia is blunted at concentrations above 50 percent N.2O is given.
There is evidence of cardiovascular complications or mortality from use. Frostbite can occur through prolonged contact with the nitrous oxide container.
Given the increased use of N.2O in recent years it has been important that doctors and other clinical staff keep a suspicion index and actively ask young people about their use of this substance. If use is reported, brief intervention including some psychoeducation of potential risks is required.
With persistent and problematic use, referral to a specialist addiction service may need to be considered.
More information about N.2O and updates on new trends in drug use in Ireland can be found at www.drugs.ie.
References
- A. Garakani, R. J. Jaffe, D. Savla, A. K. Welch, C. A. Protin, E. O. Bryson, and D. M. McDowell (2016). Neurological, psychiatric, and other medical manifestations of nitrous oxide abuse: a systematic review of the case literature. The American Journal on Addictions, 25 (5), 358-369.
- van Amsterdam, J., Nabben, T. and van den Brink, W. (2015). Recreational nitrous oxide use: prevalence and risks. Regulatory Toxicology and Pharmacology, 73 (3), 790-796. www.drugs.ie.
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