Will modifying inhalants reduce volatile substance misuse? A review

Drugs: education, prevention and policy, October 2006; 13(5): 423–439

Will modifying inhalants reduce volatile substance misuse? A review SARAH MACLEAN1 & PETER H. D’ABBS2 1

Youth Research Centre, The University of Melbourne, 3010, Victoria, Australia and School of Public Health, Tropical Medicine & Rehabilitation Science, James Cook University (Cairns Campus), PO Box 6811, Cairns, 4870, Queensland, Australia 2

Abstract Recent growing concern in Australia and elsewhere about harm associated with volatile substance misuse (VSM) in both urban and remote settings has prompted an openness to new policies, laws and programs for prevention and treatment. One measure under consideration is product modification of volatile substances (VSPM). This article reviews international literature documenting instances of three kinds of product modification: (1) replacement of particularly harmful or psychoactive components; (2) addition of deterrent chemicals; and (3) package modification. Although VSPM has received considerable attention, few initiatives have been implemented and, of these, even fewer evaluated. Where VSPM has occurred, success in reducing misuse of specific products appears to have occurred in relation to type (1) modifications, many of which have been driven by environmental rather than health concerns. The ready availability of a wide range of VSM products in most urban settings means that even where interventions reduce misuse of targeted substances, other substances are likely to be substituted. We conclude that any VSPM should target substances most strongly associated with harm and be supported by an appropriate range of other strategies.

Keywords: Volatile substitution

substance,

solvent,

inhalant,

product

modification,

product

Introduction Volatile substance misuse (VSM) (also frequently termed ‘inhalant’ or ‘solvent’ misuse) is the ‘deliberate inhalation of a volatile substance in order to

Correspondence: Sarah MacLean, Youth Research Centre, The University of Melbourne, Victoria, 3010 Australia. Tel: þ61 3 8344 9633. Fax: þ61 3 8344 9632. E–mail: [email protected]. edu.au ISSN 0968–7637 print/ISSN 1465–3370 online ß 2006 Informa UK Ltd. DOI: 10.1080/09687630600762202

424 S. MacLean & P. H. d’Abbs achieve a change in mental state’ (Advisory Council on the Misuse of drugs, 1995, p. 14). Misuse of these substances may be differentiated from that of other psychoactive drugs because direct inhalation is almost always the only means of self-administration (National Institute on Drug Abuse, 2005). VSM is attractive to users for its cheapness and accessibility and for its capacity to produce an immediate and intense intoxication. This intoxication may be accompanied by vivid hallucinations, feelings of bodily power and self-confidence and (for some) becomes an important adjunct to interaction with friends (MacLean, 2005). VSM is not a new phenomenon, but in Australia in recent years an apparent increase in chronic inhalant misuse among disadvantaged youths in urban settings, together with evidence of the devastating effects of petrol sniffing among Indigenous youths in some remote communities, have prompted a search for new legislative and policy options (Parliament of Victoria Drugs and Crime Prevention Committee, 2002; South Australia Coroner’s Court, 2002, 2004). One such option under consideration is volatile substance product modification (VSPM)—that is, removing inhalants from drug users’ repertoires by either (1) replacing harmful psychoactive ingredients with other ingredients that perform the same function but are less toxic or less amenable to misuse, or (2) making the substance highly unpleasant to inhale by adding deterrent chemicals, or (3) repackaging the substance in a way that reduces the likelihood of misuse (Advisory Council on the Misuse of Drugs, 1995; World Health Organization, 1999). In this review, we report on evidence of instances and outcomes using all three mechanisms. Our review focuses on evidence relating to the impact of product modification on the use and consequences of VSM; we do not address evidence relating to the technical feasibility or otherwise of modifying particular inhalants. Around 250 household, medical and industrial products contain potentially intoxicating inhalants (Australian Drug Foundation, 2005). While various systems of classification have been proposed, a commonly accepted system distinguishes four categories of inhalants: (1) volatile solvents; (2) gases; (3) aerosols; and (4) nitrites. Table I gives examples of each of these.

Literature search strategy Literature was sourced from electronic databases including Web of Science, Ovid Bibliographic Records, Expanded Academic, Psycho Info, APAIS, Criminal Justice Abstracts, IBSS: International Bibliography of the Social Sciences, Sociological Abstracts, TOXLINE, and Highwire and the search engine Google. Two specialist libraries were also consulted; the Australian Drug Foundation and the online library for the Australian National Drug Research Institute. Searches of online databases used combinations of terms

Will modifying inhalants reduce volatile substance misuse?

425

Table I. Types of volatile substances. Category

Characteristics

Examples

1. Volatile solvents thinners and removers

Liquids that vaporize at room temperature

Paint thinners and removers Dry cleaning fluids Degreasers Petrol (gasoline) Glues Correction fluids Felt-tip marker fluids

2. Gases

Medical anaesthetics, and gases used in household and commercial products. Active chemicals include butane, isopropane, bromochlorodifluoromethaneandnitrous oxide

Medical anaesthetic gases, such as ether, chloroform, halothane, and nitrous oxide Butane cigarette lighters Whipped cream dispensers Refrigerants Bottled cylinder gas

3. Aerosols

Sprays containing propellants and solvents

Spray paint Hair and deodorant sprays Fabric protector sprays Vegetable oil cooking sprays Cyclohexyl nitrite—found in room deodorizers

4. Nitrites

Organic nitrites used primarily to enhance sexual pleasure rather than to alter moods

Illegally diverted amyl nitrite

Note: Based on National Institute on Drug Abuse, 2005.

for VSM (i.e. volatile, solvent, inhalant) with terms referring to relevant interventions (deterrence, product modification, product substitution, Bitrex, denatonium benzoate, mercaptan, oil of mustard) over all years to 2005. We found no published articles focusing specifically on VSPM. Four journal articles and a range of newspaper and magazine articles were found that deal with the matter indirectly. Given the scarcity of available information all journal articles identified were utilized. Magazine and newspaper articles were included only where they added information not otherwise available. Some of the information in review was sourced from our own knowledge of the ‘grey’ literature in this area and we have relied also on published reviews of the VSM literature (i.e. Advisory Council on the Misuse of drugs, 1995; Parliament of Victoria Drugs and crime Prevention Committee, 2002; World Health Organization, 1999). We requested additional assistance in accessing relevant literature from specialist researchers in Australia, the UK, the USA and Canada. Also, as part of this project, one of us (SM) conducted a workshop investigating instances and outcomes of VSPM at the International Conference on Solvent Addiction held in Canmore, Canada, on 15–17 March 2005.

426 S. MacLean & P. H. d’Abbs Below, we report briefly on epidemiology, health effects and interventions relating to VSM before reviewing findings on the three recognized methods of product modification: 1. Replacement of harmful or psychoactive components. 2. Addition of deterrent chemicals. 3. Package modification.

Patterns, prevalence, problems and prevention Patterns of VSM vary historically and by location in ways that appear to be a function of both availability and of fashion (see for example Ives, 1986). International literature shows VSM to be episodic in nature, and most prevalent among young people from poor and often Indigenous minority groups and street children in developing countries (World Health Organization, 1999). Within developed nations a significant minority of young people also report lifetime use (Commission on Narcotic Drugs, 1999). In 2002 around one in five Australian secondary students reported lifetime VSM (White & Hayman, 2004) with 15% having used inhalants within the past year. In 2004 9.6% of US 8th graders and 8% of English secondary students reported VSM during the previous year (Blenkinsop et al., 2004; Johnston, O’Malley, Bachman, & Schulenberg, 2005). Chronic or dependent use is unusual and often co-occurs with a range of other lifetime difficulties including poverty, mental health problems, other problematic drug use, abuse, family conflict and homelessness, poor schooling achievement and involvement with the justice and child welfare systems (see for example Best et al., 2004; Howard & Jenson, 1999; Kurtzman, Otsuka, & Wahl, 2001; Sakai, Hall, Mikulich-Gilberts, & Crowley, 2004; Worley, 2001). A study of adolescents in the UK found that only 0.4% of respondents met the DSM-IV criteria for inhalant abuse or dependence (Wu, Pilowsky, & Schlenger, 2004). Two particularly concerning consequences of VSM are described in the literature. First, the practice is linked with a syndrome named ‘sudden sniffing death’, involving heart arrhythmia resulting from the toxic effects of the drug. Further deaths result from trauma (for instance, injury or suffocation) sustained while intoxicated. In 2003, 51 UK deaths were associated with VSM, the youngest at 7 years of age and the oldest in the 45–54 age group. Between 1971 and 2003, 2103 deaths were recorded, half of them in the under-18 age group. Fuel gas misuse is implicated in a greater proportion of fatalities than any other inhalant (Field-Smith, Butland, Ramsey, & Anderson, 2005). Second, longterm inhalation of substances (in particular those containing toluene) is associated with cognitive dysfunction, dementia and wide-spread cerebellar damage (Kurtzman et al., 2001) with some potential for recovery on VSM abstinence (Cairney, Maruff, Burns, Currie, & Currie, 2005; Rosenberg, 1997). Other harms related to VSM include damage to the heart, liver and other organs, consequences of crimes committed while intoxicated, vulnerability


427

to sexual and physical assault and intensification of marginalization as a result of associated stigma (Fairbairn & Murray, 2004; MacLean, 2005; Rosenberg, 1997). In comparison with other drugs VSM is poorly understood and under researched (Beauvais, 1997; Brouette & Anton, 2001; Caputo, 1993; May & Del Vecchio, 1997; Parliament of Victoria Drugs and Crime Prevention Committee, 2002). VSM treatment literature does not give cause for optimism about likely outcomes of intervention for chronic users, seen by many workers as an intractable treatment population (Beauvais, Jumper-Thurman, Plested, & Helm, 2002). Much of the emphasis in dealing with volatile substances is therefore on preventive interventions including those that aim to restrict the availability or supply of involved products. Product modification can best be understood as one type of ‘supply reduction’ strategy as it entails altering the effective availability of a drug, but does not, in itself, do anything to address either demand for these or other psychoactive drugs, or the social contexts in which demand for drugs occurs. In a review of interventions into petrol sniffing in remote Aboriginal communities in Australia, we concluded that, as a general observation, interventions targeting the substance itself have been effective in Australia provided that they are part of a broad strategy involving interventions that concurrently address the needs of users and their social setting (d’Abbs & MacLean, 2000; MacLean & d’Abbs, 2002). Reducing supply of inhalants through targeting retailers has also been an effective strategy when introduced through a local community development process entailing retailer education (Helfgott & Rose, 1994; Mosey, 2004). The benefits of introducing legislation to restrict sales of volatile products are less clear as they are hard to enforce, alert young people to the potential misuse of products or simply encourage users to substitute other, potentially more harmful, inhalants (Ives, 1994; Parliament of Victoria Drugs and Crime Prevention Committee, 2002). This was evident in the UK when introduction of legislation and education targeting sales of glue products coincided with an increase in deaths from butane and aerosol misuse (Esmail, Anderson, Ramsey, Taylor, & Pottier, 1992; Taylor, Field-Smith, Norman, Ramsey, & Anderson, 2000). Also in the UK, regulations introduced in 1999 banned the sale of cigarette lighter refills to persons under 18 years of age. The effects of this legislation are unclear as deaths associated with lighter fuel VSM among under-18s fell in 2000 and 2003 but were at pre-legislative levels in the intervening years (Field-Smith et al., 2005). Other governments considering the efficacy of VSM product sales restrictions will no doubt be watching these trends closely. VSPM, as one ‘supply side’ strategy, appears to have attracted considerable attention from policy makers and product manufacturers internationally, although few research studies deal specifically with the issue.

428 S. MacLean & P. H. d’Abbs Evidence on replacement of harmful or psychoactive components This kind of intervention involves reformulating products either to reduce their psychoactive effect (and thus make misuse less attractive) or to replace particularly harmful chemical components with more benign alternatives. (Often the same chemical—for instance toluene, butane or propane—is implicated in producing both psychoactive and harmful effects.) The World Health Organization (WHO) (1999) sees removing the intoxicating potential of products as the most effective form of VSPM. Much product reformulation of this nature is driven by environmental concerns rather than a specific intention to reduce VSM and related harms. The Montreal Protocol on Substances that Deplete the Ozone Layer (an international agreement initially signed in 1987) has meant that some volatile substances, for instance those that include chlorofluorocarbons (CFCs) have now been reformulated. Some aerosol products are now available in aqueous pump-pack form or with carbon dioxide propellants making them unattractive for misuse (Flanagan & Ives, 1994; World Health Organization, 1999). Unfortunately not all products subject to VSM can be reformulated in this way as yet; other products have been reformulated using butane or nitrous oxide propellants without reducing their potential for misuse (Re-Solv, undated-a; Trochimowicz, 1992). A few studies shed some light on the effects of product reformulations aimed at reducing VSM. Between 1974 and 1985, 22 deaths in Australia were attributed to inhalation of two aerosols—‘Pure and Simple’, a cooking oil spray, and ‘Skefron’, a muscle relaxant spray. A Commonwealth of Australia Senate Select Committee on Volatile Substance Fumes (1985, p. 281 ff.) reported that both products had been subject to attempts by the manufacturers to modify them in order to make them non-misusable. In the case of the cooking oil spray, the CFC propellant had been removed, although the resulting product was reportedly criticized by some legitimate users as less efficient than the previous one. Attempts to modify ‘Skefron’ proved unsuccessful, largely because its function was based entirely on the action of the pressurized CFCs (Commonwealth of Australia Senate Select Committee on Volatile Substance Fumes, 1985, p. 118). Having failed to devise an alternative formulation of the product, and following a further Skefron-related fatality in July 1985, the manufacturer Smith, Kline and French Laboratories (Australia) Ltd. voluntarily withdrew the product. In the UK, the white-out or correction fluid ‘Tipp-Ex’ was reformulated as a non-sniffable aqueous formulation for use in schools and sold alongside the original formulation—which unfortunately was more effective than the aqueous solution (Ives, 1995). The manufacturing company (also called Tipp-Ex) gave the aqueous formulation a label that it thought would appeal to youth and plastered a prominent warning sign on the product that it still contained 1-1-1 trichlorethane. This intervention does not appear to have been evaluated and trichlorethane has been phased out of manufacture since 1996 in accordance with the Montreal Protocol (Advisory Council on the Misuse of Drugs, 1995).


429

Environmentally driven product reformulation appears to have impacted on patterns of substance-related harm. Since 1995 there have been no UK deaths associated with correction fluid, only one death from pain-relief spray and one associated with use of an old (unmodified) fire extinguisher (Field-Smith et al., 2005). In Australia the Victorian Parliamentary Drugs and Crime Prevention Committee (2002), heard evidence of what it considered to be one promising development in relation to VSPM. Barloworld Coatings (a paint manufacturer) reported to the Committee that, having established toluene and xylene as the chemicals most strongly implicated in misuse of aerosol paints, the company had successfully tested a modified paint formulation based on a Solvesso 100/acetone blend to replace these components (2002, p. 477 ff.). This new formulation is now retailed but no research has been undertaken to assess whether it is subject to misuse. One documented instance of successful substitution of a non-inhalable product for a volatile substance is the so-called Comgas scheme—an arrangement under which a number of remote Aboriginal communities in central Australia replaced unleaded petrol with aviation fuel (known as Avgas) in the 1990s. Although Avgas contained high lead levels, its low volatility made it effectively unsniffable. The idea of using Avgas was initiated in an Arnhem Land community in 1992. At the time, however, the use of aviation fuel for purposes other than fuelling aircraft attracted a high excise levy. In 1998 a number of central Australian communities asked the Commonwealth Government to waive the excise and—in effect— subsidize the use of Avgas as an alternative to unleaded petrol in their communities. The government agreed and this became the ‘Comgas Scheme’ (Shaw et al., 2004). The effect on petrol sniffing prevalence in communities was rapid and sustained. An evaluation of the Comgas scheme reported that, although petrol continued to be smuggled into communities where Avgas was used, the presence of Avgas clearly functioned to make petrol much harder to get. In communities where Avgas was used on a sustained basis, sniffing became episodic rather than chronic (Roper & Shaw, 1996; Shaw et al., 2004). Where older and more chronic users continued to access petrol, they would often have less in their cans and fewer young people commenced use. A recent evaluation (Shaw et al., 2004) indicates that the reduced prevalence of petrol sniffing that occurred after communities elected to replace petrol with Avgas was accompanied by clear drops in medical clinic presentations for sniffing-related morbidity. The scheme also enjoyed high levels of community support. While finding clear evidence of successful outcomes, including evidence of communities experience a respite from petrol sniffing, the evaluators point out that the Comgas scheme did not begin to address the factors that led to petrol sniffing, and for that reason other programs were required (Shaw et al., 2004). Further, the scheme’s success was found to be dependent upon the isolated nature of the communities in question; the scheme was least effective where other sources of petrol were close at hand (Shaw et al., 2004). In urban centres,

430 S. MacLean & P. H. d’Abbs where the range of readily available volatile substances is extensive, the Comgas scheme could not be regarded as a viable model for reducing VSM. In any event, the Comgas scheme in its initial form was unsustainable on account of the environmental consequences of the high lead levels present in Avgas. It was in response to these levels that BP in 2003 commenced work on producing a new aviation fuel that would have lower lead levels but also, as a consequence, higher levels of aromatic hydrocarbons than the previous Avgas. The new Avgas would no longer be unsniffable. In response to the desire of communities to continue to have access to an affordable, non-sniffable fuel, in 2004 BP Australia Ltd. also developed a ‘boutique’ motor vehicle fuel, known as Opal, which contains extremely low levels of both volatile hydrocarbons and lead, and was therefore far less amenable to VSM than regular petrol. The Commonwealth Government has also agreed to subsidize the use of Opal in those communities that have hitherto used Avgas. Following representations from other remote Aboriginal communities in Queensland, the Northern Territory and Western Australia, the Commonwealth has also agreed to extend the new scheme beyond the boundaries of the original Comgas scheme. The first phase of the Opal scheme will be evaluated in 2005–2006. Leaded petrol is particularly neurotoxic and causes more severe and irreversible damage to users’ brains than unleaded petrol (Cairney et al., 2005). Replacement of leaded with unleaded petrol for motor vehicles (now mandatory for environmental reasons) has resulted in decreases in petrolsniffing morbidity and mortality (Burns, Currie, & Powers, 1995). This is one instance where substitution of a less-harmful inhalant for a more-harmful one has reduced inhalant-related harms, without necessarily reducing overall use of inhalants.

Evidence on adding chemical deterrents The second strategy identified—adding deterrent chemicals to inhalants—may be an option in relation to products that cannot be reformulated to remove psychoactive components or harms associated with misuse. Chemical additives mooted for inclusion in volatile substances have included volatile oil of mustard (allyl isothiocyanate) and mercaptan compounds (which smell noxious due to their composition including sulphur), and Bitrex (denatonium benzoate), which is odourless but has an extremely bitter taste. Precedents for this kind of intervention can be found elsewhere. For example Bitrex has been used to deter deliberate consumption of methylated spirits and ethylene glycol—a primary component in engine coolants ( Jackson & Payne, 1995; Jones, Lund, & Andersson, 1989; Rich, 1993). Although adding Bitrex to ethanol products is generally considered an effective strategy it does not deter all misuse. Particularly in places where alcohol is expensive some dependent users of ethanol products will put up with the altered taste ( Jones et al., 1989).


431

Patents have also been lodged to add capsaicin irritants (found in chilli peppers) to tablet form opioid medications to deter diversion and misuse. The irritant would cause pain when tablets were crushed and snorted or injected but not when swallowed whole as prescribed (Woolf & Hashmi, 2004). Adding deterrent chemicals is viable as an option only where the modification does not adversely affect legitimate users. In the past this has frequently led to the abandonment of such strategies in relation to VSPM (Akerman, 1982; Kerner, 1988; Sharp, Beauvais, & Spense, 1992). The UK Advisory Council on the Misuse of Drugs (1995) has suggested that manufacturers are less averse to adding components that are detected via taste than smell, as these are unlikely to be detected by legitimate users of products. A meeting of experts held in the UK to consider means of controlling VSM concluded that adding bittering agents would be the most effective means of addressing the problem (Ross, 2004). However, as Sarah Ross (2004) of the British Aerosol Manufacturers’ Association observed, subsequent consultations with users and workers suggested that this would deter only first-time or experimental users. In Australia the 1985 Senate Select Committee on Volatile Substance Abuse reported that considerable research had been conducted internationally into the use of deterrent chemicals for inhalants, with ‘mixed success’. The Committee concluded that ‘the approach may be useful in some instances, but not in the majority of cases’ (1985, p. 114). On the basis of evidence presented, the Committee identified a number of dangers associated with adding deterrents, including possible adverse effects on legitimate users, the risk of reducing product effectiveness and the danger of the added chemical breaking down, possibly into toxic compounds. The Committee found that the most extensively researched compound was volatile oil of mustard, which had been added experimentally to a number of glues and correction fluids. Its addition to adhesives had been unsuccessful for several reasons: first, it caused medical problems; second, it degraded over a period often shorter than the shelf life of the product, and therefore lost its deterrent effect; third, it reduced the bond strength of adhesives; and, fourth, if heated it released highly toxic cyanide fumes. Other evidence points to more positive outcomes. In 1968 Testor Corporation, an American company, added oil of mustard to model aeroplane glues, then an inhalant popular with teenagers. The company reported that this resulted in dramatic reductions in both glue misuse and complaints to the company from police and doctors, but that product sales also fell (Bauerlein, 1993; Jeffrey, 1995). Some determined sniffers continued to use Testor’s glues, despite the presence of the additive (Bauerlein, 1993). From August 1985, Gillette Corporation, manufacturers of ‘Liquid Paper’ correction fluid and thinners, introduced volatile oil of mustard to these products. The deterrent was said to act as a nasal irritant when inhaled, but not to affect the product or the user when being used as designed. (Commonwealth of Australia Senate Select Committee on Volatile Substance Misuse, 1985; Parliament of Victoria Drugs and Crime Prevention Committee, 2002; Troutman, 1988).

432 S. MacLean & P. H. d’Abbs In Australia the Parliament of Victoria Drugs and Crime Prevention Committee (2002) reported a submission by Drug Arm Victoria to the Inquiry claiming that the addition of mustard oil to Liquid Paper in Australia in the 1980s dramatically reduced a current fad of correction fluid sniffing. Nonetheless, one of the few published articles mentioning this intervention documents one young man’s death in the USA from the direct effects of inhaling Liquid Paper despite the presence of a mustard oil additive (Troutman, 1988). Troutman suggests that interventions including product modification with odorants are ‘important initial steps in combating TFC abuse’, but adds that such interventions will never deter all users and also that there is no data to support conclusions on whether this intervention has been broadly successful in reducing the misuse of affected substances (1988, p. 132). Manufacturers of Tipp-Ex decided not to add odorants to their products due to revenue loss reported by companies that had trialled the intervention (Ives, 1995). In many countries camping fuels such as propane cylinders already have stenching agents added (as does natural gas) to alert consumers of leakage and to deter misuse (Re-Solv, undated-b). Despite this, anecdotal evidence suggests that these products are subject to misuse in Australia, indicating that the level of additive currently included in propane is insufficient to deter all VSM. Other attempts to add deterrent chemicals have been undermined by political, technological or health objections. Glue sniffing is an entrenched form of drug use for young homeless people in Latin American countries. For many years the product of choice for these young people has been a solvent-based shoe glue called Resistol, manufactured by the American-based multinational corporation H. B. Fuller (Malamud, 1996). In the mid-1980s activists associated with the charity organization Casa Alianza in Honduras lobbied H. B. Fuller to add mustard oil to Resistol. Sales of these glues in Latin America were, however, very profitable to H. B. Fuller (World Health Organization, 1999). The company responded to new legislation in Honduras with a campaign claiming that mustard oil would endanger the health of people engaged in the manufacture of shoes. Whether in fact those with occupational exposure would be thus affected has been disputed (Jeffrey, 1995). However, in the face of this campaign the Honduran Government rescinded a decision to force companies to include mustard oil in glue products (Jeffrey, 1995). The company has since replaced the toluene in its glue with the slightly less toxic cyclohexane and restricted some sales, but their products continued to be used as inhalants in the mid-1990s (Henriques, 1995). Legislation has been passed in the US state of New Jersey requiring deterrent agents to be added to aerosols (subject to resolution of technical and commercial issues). Companies, however, have found these issues insurmountable and no such modification has occurred (Parliament of Victoria Drugs and Crime Prevention Committee, 2002). The 1985 Senate Select Committee on Volatile Substance Abuse (1985, pp. 114–115) also reported that New York State had passed a law requiring the addition of oil of mustard to solvent-based adhesives


433

but, in the light of the problems encountered, had subsequently rescinded the law. Consideration has also been given to adding stenching agents to fire extinguishers. These plans were abandoned due to concerns that additives would reduce the effectiveness of the product and make legitimate use difficult (Re-Solv, undated-c). A further documented strategy of using aversive additives as a deterrent concerns the addition of ethyl mercaptan (also known as ‘skunk juice’) to petrol supplies in a number of remote Australian Indigenous communities The Senate Select Committee of Inquiry into Volatile Substance Abuse (1985) concluded that in none of the four communities where this had occurred had the addition of ethyl mercaptan proved a viable means of reducing petrol sniffing. Due to its strong smell it was very unpopular with people in contact with petrol within communities where it was trialled (see also Shaw et al., 2004). A resident medical officer at one community concluded that the effects of the additive were no less harmful than those of petrol sniffing, particularly for chronic sniffers who were undeterred. Shaw et al. report that some young people were made so sick by ethyl mercaptan added to petrol in the late-1980s that they needed to be sent to Darwin for treatment (Shaw et al., 2004). Parents became distressed at the sight of their children vomiting after sniffing petrol containing the additive and in at least one community it was felt that the intervention foundered through lack of genuine community support. The intervention, however, proved a failure for other reasons. It did not take long for petrol sniffers to work out that ethyl mercaptan has a higher relative volatility than petrol and may be removed simply by leaving petrol in the sun. Other serious concerns have been raised in relation to the irritant effects of oil of mustard. Akerman (1982) summarizes the effects for people in ongoing contact with oil of mustard as including vesication (blistering) and slow healing ulcers, asthma, watery eyes, sneezing and contact dermatitis. It would appear that some individuals are more able than others to habituate to unpleasant odours (Smeets & Dalton, 2005). The Senate Select Committee (1985) also pointed out that some chronic inhalant misusers, having already severely damaged their nasal tissues, might be unable to detect deterrents or develop a tolerance to them. Individuals who, for whatever reason, are not averse to the smell of chemical additives would be at particular risk of cumulative toxic effects (Akerman, 1982). A final deterrent option to have been considered is addition of Bitrex to butanecontaining cigarette lighter fuels. Bitrex is a non-toxic (when not consumed chronically) odourless salt and thus is not generally detected by users of products in which it is dissolved (Berning, Griffith, & Wild, 1982; Payne, 1998). For some years Shell in the UK has been investigating the addition of Bitrex to cigarette lighter fuels to deter VSM. However, the resulting product has not been marketed in the UK and, according to one UK-based expert, research has shown that, with care, gas can be extracted from lighters without the Bitrex additive (Dr John Ramsey, St George’s Hospital, London, personal communication, 29 June 2005).

434 S. MacLean & P. H. d’Abbs Bitrex has a low level of solubility in hydrocarbon solvents, as a result of which it cannot be incorporated into most VSM products.

Evidence on modifying packaging The third method of VSPM—modifying packaging so as to deter misuse (while not interfering with legitimate use) appears on the evidence to hold little promise. WHO (1999) proposes modification of the delivery system of aerosol products to prevent the gaseous propellant being extracted from the container separately from the product. However, as spray-paint misusers in Australia are used to inhaling a certain amount of paint it is difficult to see how this would be effective. Interviews conducted by one of us (SM) with young people who inhale aerosol paints suggest that they are already used to inhaling a certain amount of paint, and might therefore not be deterred by such a measure. Modification to aerosol can nozzles was trialled in the UK. Determined inhalers of these products managed to puncture cans or remove nozzles to access the contents, a practice that may in itself be hazardous (Parliament of Victoria Drugs and Crime Prevention Committee, 2002). Tipp-Ex correction fluids have been produced as pens and sticks and cassettes so as to be less easily misused, although the impact of these interventions has not been evaluated (Ives, 1995).

Conclusions VSPM has generally occurred in relation to environmental concerns rather than with any strategic goal of reducing overall VSM and related harm. Where VSPM has been attempted with the intention of deterring misuse this has occurred most often in relation to specific products and at the instigation of manufacturers, rather than as part of a broader harm-minimization strategy. Three types of VSPM have been identified: (1) replacement of harmful or psychoactive components; (2) addition of deterrent chemicals; and (3) package modification. Of these the optimal form of VSPM appears to be development of formulations that are less amenable to misuse or are associated with less harm, and even here the range of successful applications is limited. Data from the UK suggest that environmentally-driven reformulations of correction fluids, painrelief sprays and fire extinguishers may have reduced fatalities associated with misuse of these products. The Australian Comgas Scheme, under which nonsniffable aviation fuel was substituted for petrol in several remote Indigenous communities, is one of the few instances of VSPM where evaluation has demonstrated a reduction in VSM and associated harm, although even here the success of the scheme was a function of the isolated nature of the communities concerned, making it easier to control access to fuel sources. Attempts to add chemical deterrents to VSM products have met with less success. Where reduction of misuse of affected products appears to have occurred (in relation to model aeroplane glue and Liquid Paper) only


435

anecdotal evidence is available. This kind of intervention may also be undermined by commercial considerations. In considering suitable additives for this form of intervention it would be critical to investigate the health consequences likely to ensue for this group as well as for legitimate consumers of affected products. The limited evidence available indicates that modifying packaging in order to prevent VSM is not generally effective, although some aerosols have been reformulated and delivered by alternative mechanisms, such as pump action, making them unsniffable. Any form of VSPM carries risks of at least two kinds of unintended consequences: 1. Some users continue to inhale the modified product, either because of their strong desire for the inhalant, or because sensory damage has left them insensitive to the modification; in these instances, the presence of a deterrent in the product may aggravate rather than reduce harm to the user. 2. Users abandon the modified product, but switch instead either to other (possibly more harmful) volatile substances, or to other, possibly more harmful drugs. (Many household and industrial products may be subject to VSM, not all of which can feasibly be modified. If certain inhalants become unpalatable as a result of VSPM, users will in many instances have the option of turning to other cheaply available inhalants.) In the few instances where product modification appears to have reduced use of a particular inhalant, there is no evidence to indicate to what extent the modification may simply have caused users to substitute alternative inhalants. The published literature does not provide answers to the likelihood of either the desired or unintended sequelae occurring, or the circumstances under which they do so, other than suggesting that VSPM is more likely to deter experimental and early users rather than chronic users (Commonwealth of Australia Senate Select Committee on Volatile Substance Misuse, 1985; Ross, 2004; Shaw et al., 2004). The extent to which findings reported in one set of circumstances may or may not hold in other settings will be shaped by a range of factors that lie beyond the scope of our review. These include the nature of local regulatory and law-enforcement regimes, availability of possible substitute drugs, and the accessibility of social and economic opportunities to overcome the disadvantages to which VSM is so often a short-term response. VSPM will be effective as harm reduction only if users shift from misuse of relatively harmful substances to reduced use or abstinence or if they substitute misuse of less-harmful substances. VSPM should therefore target substances that are considered particularly dangerous. While inhalants that are liquid at room temperature (such as glue) appear to pose less risk of sudden death due to drug toxicity than do gaseous products, misuse of products containing toluene is particularly associated with brain injury, leading to serious impairment for chronic users. This makes determining ‘safer’ VSM products extremely problematic (Advisory Council on the Misuse of Drugs, 1995). However it is clear that use of gas fuel inhalants is strongly associated with mortality and any

436 S. MacLean & P. H. d’Abbs intervention that inadvertently encouraged their misuse through reducing the attractiveness of other products would be highly inadvisable. The strongest case (where technologically feasible) for VSPM may thus be made in relation to gas fuels. VSPM can only, at best, be a small component in a broader strategy to reduce related harm. As we have elaborated elsewhere (d’Abbs & MacLean, 2000; MacLean & d’Abbs, 2002) such strategies should include demand-reduction measures (e.g. education, counselling and, in some instances, treatment and rehabilitation services), additional supply-reduction measures (e.g. agreements with retailers to restrict availability of inhalants), and programs to reduce social and economic disadvantages, and create opportunities, in affected communities and regions. Because of the severely harmful effects of VSM to some of those who become involved in it (death; neurological damage; aggravating social marginality) the limited potential of VSPM should be exploited where it provides a means of intervening in particularly harmful patterns.

Acknowledgements This paper is drawn from a report commissioned by the State of Victoria (acting through the Department of Human Services) and the Australian Government (acting through the Department of Health and Ageing). The views represented within this report are those of the authors and do not necessarily represent the position of the State of Victoria and the Australian Government. Sarah MacLean receives scholarship support from The Victorian Health Promotion Foundation and the Alcohol, Education and Rehabilitation Foundation. We acknowledge advice and/or assistance in accessing research articles from: Mark Aspinal, GlaxoSmithKline; Kay Carter, Re-Solv; Jack Dempsey; Biosecurity and Disease Control Branch of the Australian Commonwealth Department of Health; Richard Ives, educari; Anne Mosey, the Northern Territory Department of Health and Community Services; John Ramsey and Mary Field-Smith, St George’s, University of London; and Irene Tomaszewski and Kerryn Riseley, Department of Human Services. James Mardel from the Australian Commonwealth Scientific and Industrial Research Organisation provided comments on a draft of the paper. We are grateful also the suggestions made by two anonymous reviewers.

References Advisory Council on the Misuse of Drugs. (1995). Volatile substance abuse: A report. London: HMSO. Akerman, H. E. (1982). The constitution of adhesives, and its relationship to solvent abuse. Human Toxicology, 1, 223–230. Australian Drug Foundation. (2005). Dealing with inhalant use: A guide for parents. Melbourne, Australia: Drug Info Clearinghouse, Australian Drug Foundation.


437

Bauerlein, M. (1993, August 11). The sweet smell of success. Citypages. (http://www.pangaea.org/ street_children/latin/citypg1.htm). Beauvais, F. (1997). Research topics for the problem of volatile solvent abuse. In F. Beauvais & J. E. Trimble (Eds.), Sociocultural perspectives on volatile solvent abuse (pp. 103–107). New York: Harrington Park Press. Beauvais, F., Jumper-Thurman, P., Plested, B., & Helm, H. (2002). A survey of attitudes among drug user treatment providers towards the treatment of inhalant users. Substance Use & Misuse, 37(11), 1391–1410. Berning, C. K., Griffith, J. F., & Wild, J. E. (1982). Research on the effectiveness of denatonium benzoate as a deterrent to liquid detergent ingestion by children. Fundamental and Applied Toxicology, 2, 44–48. Best, D., Manning, V., Gossop, M., Witton, J., Floyd, K., Rawaf, S. et al. (2004). Adolescent psychological health problems and delinquency among volatile substance users in a school sample in South London. Drugs: Education, Prevention and Policy, 11(6), 473–482. Blenkinsop, S., Boreham, R., Hewton, J., Kothari, G., McGee, A., Moody, A. et al. (2004). Drug use, smoking and drinking among young people in England in 2003. Norwich, UK: The Stationery Office. Brouette, T., & Anton, R. (2001). Clinical review of inhalants. The American Journal on Addictions, 19, 79–94. Burns, C. B., Currie, B. J., & Powers, J. R. (1995). Unleaded petrol: A useful harm-reduction strategy for petrol sniffers? In M. Brady & P. Torzillo (Eds.), Workshop on lead and hydrocarbon toxicity from chronic petrol inhalation (p. 21). Canberra, ACT: Australian Government Publishing Service. Cairney, S., Maruff, P., Burns, C. B., Currie, J., & Currie, B. J. (2005). Neurological and cognitive recovery following abstinence from petrol sniffing. Neuropsychopharmacology, 30, 1019–1027. Caputo, R. A. (1993). Volatile substance misuse in children and youth: A consideration of theories. The International Journal of Addictions, 28(10), 1015–1032. Commission on Narcotic Drugs. (1999). Youth and drugs: A global overview (No. E/CN.7/1999/8). Vienna: United Nations Economic and Social Council. Commonwealth of Australia Senate Select Committee on Volatile Substance Fumes. (1985). Volatile substance abuse in Australia. Canberra, ACT: Australian Government Publishing Service. d’Abbs, P., & MacLean, S. (2000). Petrol sniffing in Aboriginal communities: A review of interventions. Darwin, Northern Territory: Co-operative Research Centre for Aboriginal and Tropical Health. (http://www.crcah.org.au/index.cfm?attributes.fuseaction ¼ docSearch&search ¼ y). Esmail, A., Anderson, H. R., Ramsey, J., Taylor, J. C., & Pottier, A. (1992). Controlling deaths from volatile substance abuse in the under-18s: The effect of legislation. British Medical Journal, 305, 692. Fairbairn, R., & Murray, D. (2004). Duty of care, harm reduction and young people in care. Youth Studies Australia, 23(2), 17–21. Field-Smith, M. E., Butland, B. K., Ramsey, J. D., & Anderson, H. R. (2005). Trends in deaths associated with abuse of volatile substances 1971–2003. London: Department of Community Health Sciences, St George’s Hospital Medical School. Flanagan, R. J., & Ives, R. J. (1994). Volatile substance abuse. Bulletin on Narcotics, 46(2), 49–78. Helfgott, S., & Rose, J. (1994). Maximum prevention with minimum intervention: Intervention with a retail hardware store. Pro-Ed, 1(1), 19–20. Henriques, D. B. (1995, November 26). Black mark for a ‘good citizen’: Critics say H. B. Fuller isn’t doing enough to curb glue sniffing. New York Times, p. 1. Howard, M. O., & Jenson, J. M. (1999). Inhalant misuse among antisocial youth: Prevalence and correlates. Addictive Behaviors, 24(1), 59–74. Ives, R. (1986). The rise and fall of the solvents panic. Druglink, November/December, 10–12. Ives, R. (1994). Stopping sniffing in the States: Approaches to solvent misuse prevention in the USA. Drugs: Education, Prevention and Policy, 1(1), 37–48.

438 S. MacLean & P. H. d’Abbs Ives, R. (1995). Problems with solutions: A manual for working with solvent sniffers and other young drug users. London: Institute for the Study of Drug Dependence. Jackson, M. H., & Payne, H. A. S. (1995). Bittering agents: Their potential in reducing ingestions of engine coolants and windshield wash. Veterinary and Human Toxicology, 37(4), 232–236. Jeffrey, P. (1995). Firm resists tighter control on toxic glue. National Catholic Reporter, 31(22), 10–11. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2005). Monitoring the future national results on adolescent drug use: Overview of key findings, 2004. Bethesda, MD: National Institute on Drug Abuse. Jones, A. W., Lund, M., & Andersson, E. (1989). Drinking drivers in Sweden who consume denatured alcohol preparations: An analytical-toxicological study. Journal of Analytic Toxicology, 13(4), 199–203. Kerner, K. (1988). Current topics in inhalant abuse. In R. A. Crider & B. A. Rouse (Eds.), Epidemiology of inhalant abuse: An update (pp. 8–29). Rockville, MD: National Institute on Drug Abuse. Kurtzman, T. L., Otsuka, K. N., & Wahl, R. A. (2001). Inhalant abuse by adolescents. Journal of Adolescent Health, 28, 170–180. MacLean, S. (2005). ‘It might be a scummy-arsed drug but it’s a sick buzz’: Chroming and pleasure. Contemporary Drug Problems, 32(Summer), 295–318. MacLean, S., & d’Abbs, P. (2002). Petrol sniffing in Aboriginal communities: A review of interventions. Drug and Alcohol Review, 21, 65–72. Malamud, S. (1996). H. B. Fuller: A different record home and abroad. Business and Society Review, 96, 51–52. May, P. A., & Del Vecchio, A. M. (1997). The three common behavioral patterns of inhalant/ solvent abuse: Selected findings and research issues. Drugs and Society, 10(1/2), 3–37. Mosey, A. (2004). Retailers responsible sale of solvents and voluntary code of conduct products (Funded by the Commonwealth Department of Health and Ageing to Tangentyere Council and supported by Alice Springs Town Council and NT Chamber of Commerce). Alice Springs: Central Australian Youth Link-up Service and Tangentyere Council. National Institute on Drug Abuse. (2005). Research report series—Inhalant abuse. Bethesda, MD: National Institute on Drug Abuse, National Institutes of Health. Parliament of Victoria Drugs and Crime Prevention Committee. (2002). Inquiry into the inhalation of volatile substances. Melbourne, Australia: Parliament of Victoria. (http:// www.parliament.vic.gov.au/dcpc/Reports%20in%20PDF/VSA%20Report_www.pdf). Payne, H. A. S. (1998, November 28). Bitrex—A bitter solution to safety. Chemistry and Industry, 721–723. Re-Solv. (undated-a). Factsheet: Aerosols. (http://www.re-solv.org/aerosols.asp [Retrieved 24 June, 2005]). Re-Solv. (undated-b). Factsheet: Gas fuels. (http://www.re-solv.org/gas_fuels.asp [Retrieved 25 June, 2005]). Re-Solv. (undated-c). Factsheet: Fire extinguishers. (http://www.re-solv.org/fire_extinguishers.asp [Retrieved 24 June, 2005]). Rich, V. (1993). Poland: curbing ethylene glycol abuse. The Lancet, 341, 8838. Roper, S., & Shaw, G., (1996). Moving on: A report on petrol sniffing and the introduction of Avgas on the Anangu Pitjantjatjara lands. Canberra: Department of Human Services and Health. Rosenberg, N. L. (1997). Solvent toxicity: A neurological focus. Substance Use and Msisuse, 32(12–13), 1859–1864. Ross, S. (2004, July). The industry’s efforts to tackle VSA. VS Focus Scotland, p. 2. Sakai, J. T., Hall, S. K., Mikulich-Gilberts, S. K., & Crowley, T. J. (2004). Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems. Journal of American Academic Child and Adolescent Psychiatry, 43(9), 1080–1088.


439

Sharp, C. W., Beauvais, F., & Spense, R. (Eds.). (1992). Inhalant abuse: A volatile research agenda. Rockville, MD: National Institute of Drug Abuse. Shaw, G., Biven, A., Gray, D., Mosey, A., Stearne, A., & Perry, J. (2004). An evaluation of the Comgas scheme. Canberra, ACT: Australian Government, Department of Health and Ageing. Smeets, M. A. M., & Dalton, P. H. (2005). Evaluating the human response to chemicals: Odor, irritation and non-sensory factors. Environmental Toxicology and Pharmacology, 19, 581–588. South Australia Coroner’s Court. (2002). Finding of inquest at Umuwa, South Australia, Wayne Chivell, Coroner, in May, June and September 2002 into three deaths. Adelaide, Australia: South Australian Coroner’s Office. South Australia Coroner’s Court. (2004). Finding of inquest before Wayne Cromwell Chivell concerning the deaths of Kunmanara Ward, Kunmanara Ken, Kunmanara Ryan and Kunmanara Cooper. Adelaide, Australia: South Australia Coroner’s Office. Taylor, J. C., Field-Smith, M. E., Norman, C. L., Ramsey, J. D., & Anderson, H. R. (2000). Trends in deaths associated with abuse of volatile substances 1971–1998 (No. 13). London: Department of Public Health Sciences and the Toxicology Unit, Department of Cardiological Services, St George’s Hospital Medical School. Trochimowicz, H. J. (1992). Development of alternative fluorocarbons. In C. W. Sharp, F. Beauvais & R. Spense (Eds.), Inhalant abuse: A volatile research agenda (pp. 287–299). Rockville, MD: National Institute on Drug Abuse. Troutman, W. G. (1988). Additional deaths associated with the intentional inhalation of typewriter correction fluid. Veterinary and Human Toxicology, 30(2), 130–132. White, V., & Hayman, J. (2004). Australian secondary students use of over-the-counter and illicit substances in 2002. Canberra, ACT: Australian Government Department of Health and Ageing. Woolf, C. J., & Hashmi, M. (2004). Use and abuse of opioid analgesics: Potential methods to prevent and deter non-medical consumption of prescription opioids. Current Opinion in Investigational Drugs, 5(1), 61–66. World Health Organization. (1999). Volatile solvents abuse: A global overview. Geneva, Switzerland: World Health Organization. Worley, C. (2001). ‘Buzzing, sniffing, tooting’. Volatile substance abuse and looked after young people: Towards a review of existing literature. Staffordshire, UK: Staffordshire University Institute of Social Work and Applied Social Studies. Wu, L., Pilowsky, D., & Schlenger, W. (2004). Inhalant abuse and dependence among adolescents in the United States. Journal of American Academic Child and Adolescent Psychiatry, 43(10), 1206–1214.