Volatile substance abuse—overlooked and under-serviced

The recent release of new UK data on the number of deaths caused by drug misuse highlighted the continued high levels of harm associated with substance use. Of particular concern in the ensuing media reports was the increase in fentanyl related deaths registered in England and Wales, which reached 75 in 2017—an increase of 30% from 2016. Yet absent from the ONS release, and failing to receive as much publicity on publication, was the number of deaths associated with volatile substances. 

There have been 834 deaths since 2001 related to VSA in Great Britain, and 64 recorded in 2016 alone (including 25 suicides, latest data). Despite this, people who use volatile substances are not a research, policy, or practice priority, and we know little about who uses these substances, nor the best ways to support them with their health and social care needs.

Volatile substance abuse (VSA) refers to the intentional inhalation of volatile substances for psychoactive effects. Substances include aromatic and chlorinated hydrocarbons (e.g. toluene containing glues, cleaning fluids, paint); lighter fuels (butane, propane); alkyl, butyl, and isobutyl nitrites; petrol; fluorocarbons (aerosol propellants); and acetone (nail polish remover). As volatile substances are marketed for household or industrial purposes, they are readily available.

The effects of VSA are rapid in onset and of brief duration, but they can be serious. Unfortunately, the UK has no publicly available data on hospital admissions and poisonings related to VSA. Our data collection systems for acute drug toxicity need to be improved in general, but sharing information on VSA would be a step towards a more coordinated response. We’ve already seen how the publication of data on other illicit drugs has provided an important focus for action, and improved public awareness of the potential negative impact of substance use.

Furthermore, while the clinical presentations of VSA can be serious, including delirium (which can be prolonged), seizures, respiratory depression, and coma, the number of international clinical and practice guidelines are limited, with VSA failing to appear in the NEPTUNE guidance.

Early detection is important as the chronic effects of VSA are serious and include headaches, sleep disturbances, respiratory tract symptoms, renal damage, and neuropsychiatric impairments that may not always be reversible. Yet healthcare professionals’ awareness of VSA and their associated competency is relatively low compared to other substances.

At the root of this unfamiliarity may be a lack of media attention on the harms of VSA, the rapid rise and focus on new psychoactive substances, or perhaps even because of outdated associations with 1970s punk music. There may also be the lingering perception that VSA is largely restricted to periods of adolescent experimentation; if so, that perception needs to be reframed. While school surveys in England, have estimated that 4.4% of pupils aged 11-15 report use in the previous year—making it the second most popular drug after cannabis—most adolescent use tends to be time limited.

The number of VSA deaths in young people in the UK has actually declined. While in contrast, almost three quarters of all VSA deaths are now in adults aged over 30, and the mean age of death is increasing each year. This shift in the profile of people who die after VSA suggests that while policies, such as purchasing and manufacturing restrictions, may have helped to protect younger people from the most serious harm, it has not helped adults.

Acute presentation to health services might provide a good opportunity for assessment and care planning, but the common perception of VSA as something affecting young people may mean we are missing the signs in adults. Unlike other substances, we no longer routinely collect data on adult VSA prevalence, so assessing the required health service response is made even more difficult.  

Public Health England reported that 359 individuals presenting to drug treatment services in 2016/17 declared use of “solvents.” Yet this may be an underestimate of need as VSA is often stigmatised or regarded by some as not a “real” form of substance use, and there is a lack of knowledge of effective service responses. Systematic reviews have highlighted the lack of high quality intervention research in this area, which makes recommending responses difficult. Public education on VSA, information about harm reduction strategies for those unlikely to desist, building the treatment evidence base (including updated healthcare guidance), and further development of supply reduction approaches are needed to prevent VSA and its associated harms.

There should never be a competition for resources between vulnerable groups with health and social care needs; and no group is more “deserving” than another. Nevertheless, with the drug and alcohol treatment sector in England already experiencing budget cuts of up to 30%, people who use volatile substances are unlikely to become a priority group, and it is telling that these substances are not mentioned anywhere in the 2017 Drugs Strategy. Healthcare professionals and providers should review their understanding of and responses to VSA, to ensure that services provide high quality care for these often underserved and ignored members of our communities.

Harry Sumnall is a professor in substance use at the Public Health Institute, Liverpool John Moores University. His research has included investigation of the harms of adolescent substance use, and the effectiveness of prevention programmes.

Competing interests: Harry Sumnall receives and has received funding from grant awarding bodies for drug and alcohol research. He is an unpaid member of the UK Government Advisory Council on the Misuse of Drugs (ACMD), an unpaid trustee of the drug and alcohol prevention charity Mentor UK, an unpaid board member of the European Society for Prevention Research (EUSPR), and an unpaid scientific adviser to the MIND Foundation.

Sarah MacLean is a researcher at La Trobe University, Australia. Her research has explored how people experience volatile substance abuse and what this means for the design of policy responses and treatment programmes. 

Competing interests: Sarah J MacLean receives funding from the Australian Research Council and the Victorian Responsible Gambling Foundation. She is affiliated with the Australian Greens.