Drugs such as cocaine and cannabis are seldom out of the headlines, but it is rare to read about another class of drugs - volatile substances. Volatile substances cover a range of gases and chemicals that are commonly found in legal household products. Many people will be familiar with nitrous oxide (laughing gas), but these substances also include butane, glue and alkyl nitrites (poppers).
Once inhaled, they are quickly absorbed through the lungs into the bloodstream, passing to the brain. As central nervous system depressants they produce intoxicating effects that last only a few minutes. This can range from euphoria to less welcome visual or auditory hallucinations.
A new report from the Office for National Statistics reveals that these substances are not completely benign. Between 2001 and 2020, 716 people in England and Wales died as a result of using volatile substances.
While the annual rate of death has remained stable at 36 people a year, what is striking is the rise in the average age of fatalities, from 28 years old in 2001 to 46 in 2020. The majority (78%) of these are male.
Although we don’t know why there has been a rise in the average age of death, it is possible that, as with drugs like heroin, there is an ageing cohort of users. And like those using heroin, this older group often has complicating physical health problems such as respiratory or heart-related problems that increase their risk of dying.
Although nitrous oxide was recorded in 56 deaths between 2001 and 2020, and is currently subject to government review potentially ahead of further legal controls, it is gases such as butane and propane that are the most commonly recorded on death certificates, accounting for 324 and 123 deaths respectively during the same period.
Both are found in lighter fuels and some aerosols. The most common risks from exposure to these gases is from choking or asphyxiation or from heart failure referred to as sudden sniffing death syndrome.
Misperception
A popular perception is that the use of volatile substances as drugs largely ceased in the 1980s, but surveys of population drug use suggest otherwise. Volatile substances are second only in popularity to cannabis in schoolchildren. They are also more likely to be used at much earlier ages, which is a risk factor for more problematic substance use in later adolescence.
Nearly one in ten people aged 16-24 years old reported using nitrous oxide in the year up to March 2020 – the last year that data is available because of the pandemic. This compares with one in 50 adults aged 16-59. Unfortunately, despite concerns about use in children, data on the use of other volatile substances such as glue and aerosols is not routinely reported in older age groups.
Given how widely available these volatile substances are, and their use in everything from baking equipment to DIY, restricting access to those who might misuse them is difficult. As volatile substances are marked for household or industrial purposes, they are readily available for the adult population. However, the supply for intoxicating purposes (except for alkyl nitrites) is an offence under the Psychoactive Substances Act 2016. Likewise, age-restricted sales of butane lighter fuel for any purpose is controlled under the Cigarette Lighter Refill (Safety) Regulations 1999.
But health promotion campaigns offer some hope. Analysis of an earlier UK Department of Health campaign in February 1992, which was aimed at parents warning them of the dangers of misusing volatile substances, appears to have had some effect on fatalities. At the time, there was an estimated 62% fall in deaths related to these substances following the campaign.
However, with new products on the market, and the rise in popularity of nitrous oxide, these campaigns need to be updated. Despite the clear harms, there has been little in the way of official public health activity regarding these substances.
Up-to-date campaigns are needed
The recent UK Drug Strategy makes no specific mention of these compounds, nor does the updated guidance to health professionals and others who might come into contact with people who use drugs.
Although drugs education forms part of the statutory health education delivered in English schools, there is no mention of volatile substances in the official training materials for teachers from the Department for Education. It is left to charities such as the PSHE Association and Re-Solv to provide resources and activities for schools to address these substances.
There is also a concern that not only are deaths from volatile substances under-recorded, but due to the stigma associated with using substances like glue and lighter fluid, even within people who take drugs, those that develop problems are not seeking treatment.
These substances are rarely asked about when someone does present to services, and there are workforce issues in drug services generally, with high caseloads, and training that is orientated towards drugs such as heroin and crack cocaine. This means that even if someone does decide to seek support, then workers may not have the necessary skills to support them. There is a risk that none of the recently announced increases in funding for drug services will be spent on developing activities to help people experiencing problems with volatile substances.
The most pressing need is for government, education and health agencies to recognise the problem. The average number of deaths related to volatile substances has not decreased over the last 20 years, and, without action, this trend will continue. Unlike other drugs, data on volatile substance deaths, hospitalisations, and treatment episodes are rarely reported, with this new report being something of a rarity.
A renewed public health campaign about the risks of using these substances should be accompanied by advice on how to reduce the potential risks. It may seem counter-intuitive to provide information on how to minimise harm when using these substances, but it could save lives.