Inhalants withdrawal from

Much remains unknown about the physiology of withdrawal from various subcategories of inhalants and the best ways to address withdrawal symptoms. In early 2002, the National Institute on Drug Abuse, which had not funded a study specifically looking at treatment for inhalant abusers, was actively encouraging researchers to submit proposals in this area. 

Buratti T, Joannidis M, Pechlaner C, Wiedermann CJ. Systemic hypotension on withdrawal from inhaled nitric oxide in an adult patient with acute respiratory distress syndrome. Grit Care Med 1999 27(2) 441. 

Repetitive abuse can cause crusting skin lesions and telangiectasis (angioma or hyperemic spots). Tracheobronchial irritation with dyspnea and hemoptysis has been reported. Withdrawal from industrial exposure has resulted in respiratory failure, left ventricular hypertrophy, and myocardial infarctions. Damage to the lungs, liver, kidneys, bone marrow, and brain is possible. Nitrite inhalants are thought to be carcinogenic and immunosuppressive. Tolerance occurs. 

Molander L, LuneU E, Andersson SB, Kuylenstiema F (1996) Dose released and absolute bioavaU-abUity of nicotine from a nicotine vapor inhaler. CUn Pharmacol Ther 59 394 00 Murphy JK, Edwards NB, Downs AD, Ackerman BJ, Rosenthal TL (1990) Effects of doxepin on withdrawal symptoms in smoking cessation. Am J Psychiatry 147 1353-1357 Nabi Biopharmaceuticals (2007). Nabi biopharmaceuticals announces positive results of phase Ilb trial of NicVAX. Medical News Today, 3 May 2007. See http //www.medicalnewstoday.com/ articles/69666.php, accessed October 11, 2007... 

During the initial evaluation, providing for the safety of the patient is of paramount importance. The severity of intoxication and potential for withdrawal must be quickly and accurately determined. Extreme alcohol intoxication can be fatal either by the production of cardiac arrhythmias, aspiration (the inhalation of stomach contents that are vomited), or other causes. We have all seen reports of college students dying from alcohol poisoning. Likewise, up to 10% of patients in severe alcohol withdrawal can die without treatment. Fortunately, most patients do not experience the most severe forms of alcohol withdrawal such as the DTs. Mild withdrawal can be managed in the outpatient setting with appropriate support and patient adherence, but severe withdrawal requires an inpatient hospitalization. See Section 6.5 for further discussion of the initial evaluation. 

When a patient switches from oral or parenteral therapy to inhalation therapy, the systemic effect is reduced, just as if the dose of systemic glucocorticoid is reduced, and precautions should be taken to avoid withdrawal symptoms. 

Bromine is toxic when inhaled or ingested. Like chlorine and fluorine, it is an irritant to the respiratory tract and eyes because it attacks their mucous membranes. Pulmonary edema may result from severe bromine poisoning. The severely irritating nature of bromine causes a withdrawal response in its presence, thereby limiting exposure. 

Most inhalant abusers have tried to but are unable to quit, and have reported this to treatment facilities. In spite of knowing the adverse consequences of their continued use, addicted individuals continue using inhalants. Relapse into use of the drug because of withdrawal symptoms and desire for the drug can prevent addicted users from quitting. 

Pulmonary delivery of drugs is the administration route of choice in respiratory diseases such as chronic obstructive pulmonary disease and asthma. Different devices are available, including metered-dose inhalers, dry powder inhalers, and nebulizers, and nearly 80% of asthmatic patients worldwide use metered dose inhalers (1). Chlorofluorocarbons have been used as an aerosol propellant in metered-dose inhalers however, they deplete the ozone layer and are being replaced by more environment-friendly propellants, even though the contribution of aerosols of this type to the total global burden of chlorofluorocarbons is less than 0.5%. The first chloro-fluorocarbon-free metered-dose inhaler for asthma treatment was approved by the FDA in 1996 (2) and the European Union has set 2005 as a target date for the withdrawal of all chlorofluorocarbon-based inhalers (1). In the USA, prescriptions for chlorofluorocarbon-free medications rose from 16.4 million in 1996 to 33.8 million in 2000 (2). Most of the chlorofluorocarbon-free medications were steroids for nasal use (27.2 million). However, chlorofluorocarbon-containing medications stiU represented two-thirds of all prescriptions and increased from 63.0 to 67.6 million dispensed (2). 

More patients using the hydrofluoroalkane (18%) withdrew from the study than patients using the chlorofluorocarbon (4.8%). Most of the withdrawals in both groups were unrelated to safety (9 and 3.2% respectively). The reasons for withdrawal included intercurrent illness, loss to followup, and inadvertent prescription errors. More patients using the hydrofluoroalkane withdrew because of an adverse event or because of the taste of the inhaler, 3.8 versus 0.9% and 3.1 versus 0.2% respectively. The authors concluded that the data supported the evidence already obtained in clinical trials that reformulation of salbutamol in a hydrofluoroalkane propellant does not result in changes in safety compared with a chlorofluorocarbon formulation. 

A feature of the inhalation study of MTBE in male F344 rats [93,94] that could complicate tumour evaluation was the large increase in mortality diagnosed as due to CPN. This led to termination of exposure and withdrawal of rats from the experiment at different times according to group. Deaths due to... 

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