Inhalant Use in the United States Correlates and

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					Inhalant Use in the United
  States: Correlates and
     Consequences
                        Li-Tzy Wu, ScD
               Duke University School of Medicine
        Department of Psychiatry and Behavioral Sciences
                Duke Clinical Research Institute
                    Durham, North Carolina



                 Inhalant Abuse Among Children and Adolescents:
   Building an International Research Agenda Conference, November 7–9, 2005.
              Focuses
I.    Inhalant use and disorders

II.   Inhalant use and other
      substance use disorders

III. Inhalant use and psychiatric
     disorders
                            I.
 Inhalant Use and Disorders
among American Adolescents
         Aged 12-17
Wu LT, Pilowsky DJ, Schlenger WE. Inhalant abuse and dependence
among adolescents in the United States. J Am Acad Child Adolesc
Psychiatry. 2004 Oct;43(10):1206-14.
           Study Sample
• 2000-2001 National Household Surveys on Drug
  Abuse (NHSDA), renamed as National Survey on Drug
  Use and Health (NSDUH) in 2002.

• Approximately 70,000 non-institutionalized household
  residents aged 12 or older participated in the annual,
  independent survey

• Interview response rates: 74% in 2000, 73% in 2001

• Adolescents aged 12-17 (N = 36,859)
  Designs of NHSDA-NSDUH
• Annual, national survey of the use of a variety of
  licit and illicit substances by Americans aged 12 or
  older (civilian, non-institutionalized populations)

• Multistage area probability sampling methods

• Face-to-face personal interview conducted at the
  respondent’s home or place of residence --
  Interviewers requested the respondents to identify
  a private area away from other household
  members to conduct the interview.
   Designs of NHSDA-NSDUH
• Use of a combination of computer-assisted
  personal interviewing (CAPI) and audio computer-
  assisted self-interviewing (ACASI) methodologies.

• Use of ACASI interviewing for questions of a
  sensitive nature, e.g., substance use questions --
  Respondents either read the questions on the
  computer screen, or the questions were read to
  them through headphones. In either case, they
  entered their responses directly into the computer.
  Prevalence of inhalant use among
  adolescents aged 12-17 in 2000-01
• Lifetime use: 8.8% (10.7% in 2003; 11.0% in 2004)
  Male: 8.7%          Female: 8.8%

 White: 9.5%         African American: 5.3%
 Hispanic: 9.0%      Native American: 13.2%
 Asian: 6.5%         More than one race: 11.2%

• Past year use: 3.5% (4.5% in 2003; 4.6% in 2004)
  Male: 3.5%         Female: 3.4%
Prevalence of weekly use and disorders
among past-year adolescent inhalant
users

• Weekly inhalant use: 19.8%
  Male: 19.8%        Female: 19.8%

• DSM-IV Inhalant use disorder: 10.9%
  Abuse: 6.3%        Dependence: 4.3%

  Male:   5.9%                   4.4%
  Female: 6.8%                   4.2%

• Sub-threshold condition: 14.0%
  Male: 11.4%        Female: 16.9%
  Type of inhalants used among lifetime
  inhalant users
Type of Inhalants Used       Overall   Male    Female   2 test
Glue, shoe polish, toluene   42.7%     38.7%   46.9 %   P < .001

Gasoline, lighter fluid      36.0      38.1    33.9     P = .044
Spray paints                 23.4      20.5    26.4     P < .001
Correction fluid, degreaser 21.7       18.0    25.5     P < .001

Nitrous oxide, whippets      21.7      24.2    19.0     P = .004
Aerosol sprays               18.8      16.4    21.2     P = .004
Amyl nitrite, poppers, rush 17.6       16.1    19.1     NS

Paint solvents, lacquer      16.7      16.8    16.6     NS
thinner
Lighter gases, butane,       10.6      11.4    9.7      NS
propane
   Type of inhalants used and age of onset
   among lifetime inhalant users
Type of Inhalants Used      Overall   Male    Female   2 test
Ether, halothane,           5.1%      5.6 %   4.7 %    NS
anesthetic
Number of different types
of inhalants used
  1                       49.1        51.3    46.9     NS
  2                       20.7        20.8    20.6
  ≥3                      30.2        27.9    32.6
Recency of inhalant use
 Past year use              39.7      40.5    38.9     NS
 Prior to past year use     60.3      59.5    61.1
Age of first inhalant use
 < 13                       46.4      47.5    45.3     NS
 13-14                      34.2      32.4    36.0
 15-17                      19.5      20.1    18.8
  Adjusted odds ratios (AOR) of past-year
  inhalant use disorder among past-year
  inhalant users aged 12-17 (N = 1,313)
Independent variables      Abuse                  Dependence
                           AOR (95% CI) P-value   AOR (95% CI) P-value
Age group                  NS                     NS

Gender                     NS                     NS

Racial/ethnic groups       NS                     NS

Level of family income     NS                     NS

Population density
Large metro vs. nonmetro   2.4 (1.1-5.2) p≤.5     NS
Small metro vs. nonmetro   NS                     NS
   Adjusted odds ratios (AOR) of past-year
   inhalant use disorder among past-year
   inhalant users aged 12-17 (N = 1,313)

Independent variables      Abuse                  Dependence
                           AOR (95% CI) P-value   AOR (95% CI) P-value
Use of mental health
services Yes vs. no        1.9 (1.0-3.7) p≤.05    2.4 (1.2-4.7) p≤.01
History of incarceration
Yes vs. no                 NS                     NS
History of foster care
placement Yes vs. no       NS                     4.9 (1.9-13.1) p≤.001
Number of delinquent
behaviors
1-2 vs. none               NS                     NS
≥ 3 vs. none               2.9 (1.1-7.6) p≤.05    NS
  Adjusted odds ratios (AOR) of past-year
  inhalant use disorder among past-year inhalant
  users aged 12-17 (N = 1,313)
Independent variables       Abuse                Dependence
                            AOR (95% CI) P-value AOR (95% CI) P-value
Alcohol use disorder
Yes vs. no                  NS                      NS
Other drug use disorder
1 drug vs. no               NS                      NS
2 drugs vs. no              3.7 (1.4-9.9) p≤.01     8.9 (2.8-28.3) p≤.001
≥ 3 drugs vs. no            8.4 (3.6-19.7) p≤.001   11.8 (3.3-42.4) p≤.001
Use of inhalants weekly
Yes vs. no                  NS                      2.6 (1.1-5.8) p≤.05
Age of first inhalant use
< 13 vs. 15-17              NS                      5.1 (1.4-18.0) p≤.01
13-14 vs. 15-17             NS                      6.0 (1.7-21.3) p≤.01
  Adjusted odds ratios (AOR) of past-year
  inhalant use disorder among past-year
  inhalant users aged 12-17 (N = 1,313)

Independent variables       Abuse                  Dependence
                            AOR (95% CI) P-value   AOR (95% CI) P-value
Number of different types
of inhalants used
2 vs. 1                     4.2 (1.5-11.4) p≤.01   NS
≥ 3 vs. 1                   3.7 (1.4-9.3) p≤.01    NS
Survey year
2000 vs. 2001               NS                     NS
                      Conclusion
• Among adolescents who used inhalants in the past year,
  11% met the criteria for abuse or dependence in that year.

• A high proportion (60%) of past-year inhalant users reported
  using multiple types of inhalants.

• Using inhalants weekly or more (20%), and for more than
  one year (35%), was not uncommon.

• Inhalant use disorder was associated with early first inhalant
  use and repeated use.

• There also was a significant association between other drug
  abuse or dependence and progression to inhalant abuse or
  dependence.
                  Implications
• Adolescents who met criteria for inhalant abuse or
  dependence reported coexisting delinquent
  behaviors, multiple drug abuse and dependence,
  and utilizing mental health services for other
  emotional problems.


• Inhalant use prevention should start early.
                Limitations
• Self-reported data -- recall and reporting
  biases (under-reporting?)

• Cross-sectional design – association, not
  causality

• Exclusion of a small but high-risk group
  (incarcerated, homeless, and transient
  adolescents) in the survey
           II.
 Inhalant Use and Other
Substance Use Disorders

Wu LT, Pilowsky DJ, Schlenger WE. High prevalence of
substance use disorders among adolescents who use
marijuana and inhalants. Drug Alcohol Depend. 2005 Apr
4;78(1):23-32.
               Background
• Marijuana use has been conceptualized as
  a gateway to other illicit drug use, and
  inhalant use has been found to be
  associated with multiple drug use.

• Studies of either marijuana or inhalants
  typically do not consider that many
  adolescents use both drugs.
                  Aims
To examine the likelihood of progression to
 substance use disorders among
 adolescents who used both marijuana
 and inhalants compared with those who
 used either drugs, i.e., marijuana users
 who did not use inhalants, inhalant
 users who did not use marijuana, and
 with adolescents who used other drugs
 but no marijuana and inhalants.
                 Samples
Lifetime adolescent drug users aged 12-17 who
  participated in 2000-01 NHSDA (N = 10,180)

• Users of both marijuana and inhalants

• Marijuana users who did not use inhalants

• Inhalant users who did not use marijuana

• Other drugs users who had never used
  marijuana and inhalants
       Lifetime prevalence of inhalant and
       marijuana use among adolescents
Drug     Inhalants   Marijuana   Inhalants   Other
Use      without     without     and         Drugs
         marijuana   inhalants   marijuana
Overall 4.4%         14.6%       4.4%        4.2%
Age
12       4.1%        1.4%        0.8%        3.1%
13       5.9         3.9         1.7         3.9
14       6.2         9.0         3.5         4.2
15       4.7         17.8        5.8         4.9
16       3.2         24.6        6.7         4.7
17       1.9         30.9        7.8         4.5
Substance use characteristics among
adolescent drug users (N = 10,180)
Drug           Inhalant    Marijuana      Inhalant     Other
Use            without     without        and          Drugs          T test
               marijuana   inhalant       marijuana

Mean age of 11.8 years                    13.2 years
first        (0.07)        ............   (0.07)       ............   <.001
inhalant use

Mean age of                13.8           13.0
first       ............   (0.03)         (0.06)       ............   <.001
marijuana
use
Mean # of      1.4         1.7            3.9          1.2            <.001
drugs ever     (0.02)      (0.02)         (0.05)       (0.01)
used
  Lifetime prevalence of substance use among
  lifetime adolescent drug users (N = 10,180)
Lifetime        Inhalant    Marijuana   Inhalant    Other   2 test
prevalence of   without     without     and         Drugs
use, %          marijuana   inhalant    marijuana

Alcohol         60.2%       91.2%       96.6%       55.4%   <.001

Cocaine         0.6         7.4         26.5        1.4     <.001


Heroin          0.1         0.7         5.3         0.2     <.001

Hallucinogen    5.0         20.6        48.6        9.8     <.001


Pain reliever   18.3        18.7        48.1        76.6    <.001

Sedative        2.8         1.0         7.7         3.8     <.001


Stimulant       8.4         9.6         32.9        15.6    <.001

Tranquilizer    4.1         6.6         24.9        7.9     <.001
Prevalence of past-year DSM-IV substance
use disorders among lifetime adolescent drug
users (N = 10,180)
Prevalence of Inhalant    Marijuana   Inhalant    Other
disorder, %   without     without     and         Drugs
              marijuana   inhalant    marijuana
Inhalant       3.2%       ……….        5.3%        ……….
use disorder
Marijuana      ……….       14.4        31.7        ……….
use disorder
Any drug       6.0        16.0        38.9        7.0
use disorder
Alcohol        6.0        16.8        35.0        6.2
use disorder
  Adjusted odds ratios (AOR) of Past-year drug
  use disorder among adolescent drug users
  aged 12-17 (N = 10,180 )
Independent variables                   Drug use disorder
                                        AOR    P-value
Lifetime drug Use
Marijuana vs. inhalants                 2.5   p≤ .001
Marijuana and inhalants vs. inhalants   3.0   p≤ .001
Other drugs vs. inhalants               1.5   p≤ .05
Age in years
14-15 vs. 12-13                         1.3   p≤ .01
16-17 vs. 12-13                         1.3   p≤ .01
Gender                                  NS


Level of family income                  NS
  Adjusted odds ratios (AOR) of Past-year
  drug use disorder among adolescent drug
  users aged 12-17 (N = 10,180 )
Independent variables                           Drug use disorder
                                                AOR    P-value
Race/ethnicity
White vs. African American                      0.9   NS
Hispanic vs. African American                   1.0   NS
Native American vs. African American            1.2   NS
Asian vs. African American                      1.7   p≤ .05
More than one race vs. African American         0.8   NS
Population density                              NS

Use of mental health service in the past year
Yes vs. No                                      2.1   p≤ .001
History of incarceration
Yes vs. No                                      2.9   p≤ .001
Adjusted odds ratios (AOR) of past-year
drug use disorder among adolescent drug
users aged 12-17 (N = 10,180 )
Independent variables                        Drug use disorder
                                             AOR    P-value
# of delinquent behaviors in the past year
1-2 vs. None                                 2.3   p≤ .001
≥ 3 vs. None                                 6.1   p≤ .001
# of drugs used in the lifetime
3 vs. 1-2                                    4.1   p≤ .001
≥ 4 vs. 1-2                                  9.4   p≤ .001
Age of first alcohol use                     NS


Age of first inhalant use                    NS


Age of first marijuana use
Before 13 vs. ≥ 13 years/no use              1.4   p≤ .001
  Adjusted odds ratios (AOR) of past-year
  alcohol use disorder among adolescent
  drug users aged 12-17 (N = 10,180 )
Independent variables                   Alcohol use disorder
                                        AOR     P-value
Lifetime drug Use
Marijuana vs. inhalants                 2.3    p≤ .001
Marijuana and inhalants vs. inhalants   3.0    p≤ .001
Other drugs vs. inhalants               NS
Age in years
14-15 vs. 12-13                         2.0    p≤ .01
16-17 vs. 12-13                         2.7    p≤ .01
Gender
Male vs. Female                         0.8    p≤ .001
Level of family income
$0-$19,999 vs. 75K+                     0.7    p≤ .01
$20K-$39,999 vs. 75K+                   0.7    p≤ .001
$40k-$74,999 vs. 75K+                   NS
  Adjusted odds ratios (AOR) of past-year
  alcohol use disorder among adolescent
  drug users aged 12-17 (N = 10,180 )
Independent variables                           Alcohol use disorder
                                                AOR     P-value
Race/ethnicity
White vs. African American                      1.6    p≤ .001
Hispanic vs. African American                   1.6    p≤ .01
Native American vs. African American            2.5    p≤ .01
Asian vs. African American                      1.9    NS
More than one race vs. African American         1.2    NS
Population density
Large metro vs. Non-metro                       0.8    p≤ .01
Small metro vs. Non-metro                       0.7    p≤ .001
Use of mental health service in the past year
Yes vs. No                                      1.2    p≤ .05
History of incarceration
Yes vs. No                                      1.3    p≤ .05
Adjusted odds ratios (AOR) of past-year
alcohol use disorder among adolescent
drug users aged 12-17 (N = 10,180 )
Independent variables                        Alcohol use disorder
                                             AOR     P-value
# of delinquent behaviors in the past year
1-2 vs. None                                 1.9    p≤ .001
≥ 3 vs. None                                 3.6    p≤ .001
# of drugs used in the lifetime
3 vs. 1-2                                    1.7    p≤ .001
≥ 4 vs. 1-2                                  2.5    p≤ .001
Age of first alcohol use
Before 13 vs. ≥ 13 years/no use              1.6    p≤ .001
Age of first inhalant use                    NS


Age of first marijuana use                   NS
              Conclusion
There is a very high prevalence of alcohol
and drug use disorders (35% and 39%,
respectively) among adolescent drug users
who reported using both marijuana and
inhalants in their lifetime as compared with
those who reported using either inhalants
(6% and 6%) or marijuana (17% and 16%)
and those who reported using other drugs
(6% and 7%).
               Conclusion
Adolescent drug users who reported never
having used marijuana, inhalants, or both
may be different from those with a lifetime
history of using one or both drugs.

Prescription-type drugs are their main drugs
of choices, and they are least likely to use
multiple drugs.
           Implications

Adolescents who reported a lifetime
history of using both inhalants and
marijuana may well be a high-risk group
and deserve more attention from
investigators and clinicians.
             III.
Inhalant Use and Psychiatric
          Disorders
         Preliminary Findings
             Study Sample
• 2000-2001 National Epidemiologic Survey on
  Alcohol and Related Conditions (NESARC)
  (Dawson et al., 2005; Grant et al., 2004)

• A total of 43,093 non-institutionalized household
  residents aged 18 or older participated in the survey:
  persons living in households, the military living off
  base, and persons living in group quarters (boarding
  houses, rooming houses, non-transient hotels or
  motels, shelters, facilities for housing workers,
  college quarters, and group homes )

• Overall survey response rate: 81%
            Designs of NESARC
• National survey of substance use disorders
  and psychiatric disorders among Americans
  aged 18 or older

• Multistage area probability sampling methods

• Face-to-face personal interview conducted at
  the respondent’s home or place of residence
       Designs of NESARC
• Substance use disorders, personality
  disorders, mood disorders, and anxiety
  disorders were assessed by the NIAAA
  Alcohol Use Disorder and Associated
  Disabilities Interview Schedule-DSM-IV
  Version (AUDADIS-IV) -- a state-of-the-art
  structured diagnostic interview designed
  for use by lay interviewers who are not
  clinicians.
Inhalant use and disorders among
adults aged 18 or older in NESARC
(N=43,093)
       Past year use      0.11%

         Lifetime use                    1.74%

 Past year abuse (w/o
    dependence)      0.02%

past year dependence    0.00%

  Lifetime abuse (w/o
      dependence)
                                 0.30%

 Lifetime dependence     0.04%
  Selected characteristics of lifetime
  inhalant users in NESARC (N=664)
                         Men     Women   X2 (df)
Age group
 18-29                   35.79   39.29
 30-44                   37.19   44.24   7.42(2)
 45 or older             27.01   16.47   p <.05
Race/Ethnicity
  White, Non-Hispanic    83.0    80.07
 Black, Non-Hispanic     3.99    3.27
 Other                   6.87    7.09    NS
 Hispanic                6.14    9.58
Educational level
 Less than high school   15.04   10.27
 High school             27.22   26.94   NS
 College or more         57.74   62.78   NS
    Prevalence (%) of lifetime mood disorders among
    adult lifetime inhalant users, by gender

                                                              38
Major depression
                                                                        48


                                     16
      Dysthymia                                     P=.05
                                               24


                                 15
          Mania
                                     16
                                                                        Male

                           9                                            Female
     Hypomania
                       5


                   0   5   10   15        20   25   30   35   40   45    50    55   60
   Prevalence (%) of lifetime anxiety disorders among
   adult lifetime inhalant users, by gender

  Panic disorder w/       4
    agoraphobia           3


Panic disorder w/o                     11
                                                                      P<.01
  agoraphobia                                               25


                                       11
     Social phobia
                                                 16

                                            14
   Specific phobia                                                    P<.01
                                                                 28                     Male

                                  9
                                                                                        Female
Generalized anxiety
     disorder                                15


                      0       5   10        15        20   25    30     35    40   45   50     55   60
  Prevalence (%) of lifetime personality disorders
  among adult lifetime inhalant users, by gender
                                    8
            Avoidant
                                     9

                            2
          Dependent
                            2

                                                 18
Obsessive-complusive
                                            15

                                           13
            Paranoid                      12

                                    7
            Schizoid                 8

                                     8                                            Male
           Histrionic               7
                                                                                  Female
                                                                  35
           Antisocial                                 22              P<.01
                        0       5    10    15    20    25   30   35    40   45   50   55   60
 Prevalence (%) of past-year psychiatric
 disorders among adult lifetime inhalant users,
 by gender
                                                                          17
              Major depression                                                           23 Male
                                                      7
                    Dysthymia                                  11                          Female
                                                      7
                         Mania                5                           Mood disorders
                                              5
                   Hypomania                  5
                                      2
 Panic disorder w/ agoraphobia        2
                                          4
Panic disorder w/o agoraphobia                                 11 P<.05

                 Social phobia                    6
                                                                12
                                                                      Anxiety
                                                               11     disorders
               Specific phobia                                                      21   P<.05
                                              5
   Generalized anxiety disorder                            10

                                  0       5               10         15        20         25       30
Prevalence (%) of lifetime personality disorders
among adult lifetime inhalant users, by age of onset
of first inhalant use
                                               10
              Avoidant
                                      5                  P=.05                          before 18 years
                                                                                        old
                                  3
            Dependent                                                                   18 or older
                              1

                                                               20
  Obsessive-complusive
                                                    14

                                                         16
              Paranoid                     9              P<.05
                                           8
              Schizoid                    7

                                           9
             Histrionic               6

                                                                                        41
             Antisocial                                       19                              P<.001
                          0       5        10       15        20    25   30   35   40        45   50   55   60
 Prevalence (%) of past-year psychiatric disorders
 among adult lifetime inhalant users, by age of onset
 of first inhalant use
                                                                                      20.3
  Major depression
                                                                         15.1

                                                           9.3
        Dysthymia
                                            5.6

                                              6.6
             Mania
                                             6.2                             Mood disorders
                                              6.5
       Hypomania
                                3.2

  Panic disorder w/             3
    agoraphobia           1.2

Panic disorder w/o                          6.1
  agoraphobia                             5.3
                                                                             Anxiety disorders
                                                         8.5
     Social phobia
                                                  6.9

                                                                 12.5            before 18 years old
   Specific phobia
                                                                         15.1

Generalized anxiety                                7.4                           18 or older
     disorder                         4.4

                      0               5                    10           15       20            25      30
Number of lifetime psychiatric disorders
among adult lifetime inhalant users, by gender

                                                   31
  0 diagnosis
                                             26


                                                         36
1-2 diagnoses
                                                        35


                                   20
3-5 diagnoses
                                         25

                                                                                           Male
                             13
 6+ diagnoses                                                                              Female
                             13


                0   5   10   15   20    25    30    35       40   45   50   55   60   65   70     75   80
Number of past-year psychiatric disorders
among adult lifetime inhalant users, by gender

                                                                                      66
  0 diagnosis
                                                                       52




                                             26
1-2 diagnoses
                                                   33




                        8                                                             Male
   3 or more
   diagnoses                  15
                                                                                      Female


                0   5   10   15    20   25    30   35   40   45   50   55   60   65    70    75   80
Number of lifetime psychiatric disorders among
adult lifetime inhalant users, by age of onset

                                             25
  0 diagnosis
                                                             38


                                                            36
1-2 diagnoses
                                                       34


                                        22
3-5 diagnoses
                                       20                                   before 18 year old

                                  17                                        18 or older
 6+ diagnoses
                        8


                0   5   10   15   20        25    30   35    40   45   50    55   60   65   70   75   80
Number of past-year psychiatric disorders
among adult lifetime inhalant users, by age of
onset

                                                                              59
   0 diagnosis
                                                                                        68




                                                   31
 1-2 diagnoses
                                         23


                                                                        before 18 year old

    3 or more             10
                                                                        18 or older
    diagnoses            9



                 0   5   10    15   20   25   30    35   40   45   50    55   60   65   70   75   80
                Limitations
• Self-reported data -- recall and reporting
  biases (forgetting, under-reporting?)

• Cross-sectional design – association, not
  causality

• Exclusion of a small but high-risk group in
  the survey (e.g., incarcerated, homeless,
  and institutionalized adults)
Acknowledgments
• National Institute on Drug Abuse (R21DA015938),
  National Institute of Health.
• Office of Applied Studies, Substance Abuse and
  Mental Health Services Administration
• Substance Abuse and Mental Health Data Archive
• Dan Pilowsky, Columbia University
• Bill Schlenger, RTI International
• Chris Ringwalt, Chapel Hill Center, Pacific
  Institute for Research and Evaluation