March 31, 2025 • 26 mins
Exploring the growing problem of recreational nitrous oxide use and its serious medical complications, including paralysis and permanent nerve damage. I share personal patient cases and investigate how this addictive substance is readily available in smoke shops and even on Amazon with minimal warning labels.
• Multiple patients experiencing serious neurological complications from recreational nitrous oxide use
• Personal investigation revealing easy access to nitrous oxide on Amazon marketed for whipped cream making
• How nitrous oxide depletes vitamin B12, leading to potential spinal cord and peripheral nerve damage
• Examination of labeling issues with commercial nitrous oxide products
• Comprehensive overview of nitrous oxide's history, effects, and recreational use patterns
• Medical complications including acute risks (seizures, cardiac issues) and chronic effects (neurological damage)
• Treatment approaches focusing on vitamin B12 supplementation and addiction therapies
• Growing prevalence of nitrous oxide use, especially among young people
Remember that treating addiction saves lives. If you or someone you know is struggling with substance use, please reach out for professional help.
To contact Dr. Grover: ammmadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today we are going to be talkingabout nitrous oxide.
(00:43):
I have a number of patientsthat use it recreationally.
It's a substance that we use atthe hospital, where it's often
referred to as laughing gas.
It has amnestic and anestheticqualities and it can also be
euphoric.
Now you might be wonderingwhere patients who use it
recreationally get it.
(01:03):
Well, it turns out that thisstuff is fairly easy to get.
I was under the impression thatyou had to buy a can of whipped
cream to get it.
If you didn't know, nitrousoxide is the propellant used in
cans of whipped cream that youbuy at the grocery store.
It's actually the gas that isin the can that pushes out the
(01:24):
whipped cream.
However, I have recentlylearned that they sell nitrous
oxide at smoke shops In fact,the local smoke shop that I have
gone to a few times to do myown research on how Kratom is
sold, carries it.
I actually found this out, as Isaid, when I was going to go to
(01:45):
the smoke shop to buy Kratomand while I was waiting for the
person to ring up my purchase, Inoticed that there was a
section for nitrous oxide andthey sold multiple different
products.
Unfortunately, I've recentlyheard from a few of my patients
who have relapsed on nitrousoxide.
One of them is a young man whowas using it for several months.
He actually got some tinglingin his feet after using it for
(02:07):
quite a while and fortunately herealized it was from the
nitrous oxide and he stopped.
He actually appears to be doingfairly well.
Unfortunately, I have anotherpatient who is a young female
and she is not doing so well.
She was recently in thehospital for this.
I actually haven't seen herdischarge summary, but she has
(02:28):
significant weakness in her legswhich, unfortunately, is one of
the known medical complicationsof nitrous oxide use.
Nitrous oxide, as we will hearlater in this episode, can cause
significant nerve damage.
So as I was talking to thissecond patient about how she was
doing, I asked her about whereshe was getting her nitrous
(02:49):
oxide and if it had any warninglabels on it and I was just
curious does the product saythat recreational use can lead
to significant medicalcomplications?
And she said no.
So I figured I was going toneed to go back to the smoke
shop and pick up one of thepackages and see how the product
(03:09):
was labeled.
But she told me that she wasgetting her nitrous oxide from
amazon and I thought, huh, Ineed to investigate this more.
So this morning, while I was outwalking my dog, I opened up the
Amazon app on my phone andindeed you can buy nitrous oxide
(03:31):
on Amazon and it's actuallysold for people who want to make
homemade whipped cream, and Ithought wait, wait, wait, wait,
wait.
This is the dumbest idea ever.
Why are we selling an addictiveand harmful substance as a
propellant for whipped cream?
There must be a better option.
So I went on some food blogsand websites about food and
(03:56):
apparently not.
Nitrous oxide is apparently thebest propellant for some foods,
including whipped cream.
Nitrous oxide makes the whippedcream really fluffy and light,
which is what makes people likeit so much.
I don't know about all of you,but I'm going to guiltily fess
up that I have absolutely onmultiple occasions, squirted
(04:19):
whipped cream out of the canright into my mouth.
It's just so light, fluffy,sweet and delicious, and
unfortunately a lot of that isfrom nitrous oxide Bummer.
So I was pretty frustrated bywhat I found.
So I went back to Amazon andwanted to see who was selling it
and how they were labeling it.
I found two companies fairlyquickly that sell nitrous oxide
(04:44):
in canisters and they both sellit as being used for homemade
whipped cream and they had someselling points that it's easy to
use and easy to connect toother tubes, and one of them
even had a sales pitch thathomemade whipped cream is so
much better than what is sold instores.
Now, in terms of the productlabeling for these two products,
(05:06):
one of them said specificallythat the nitrous oxide was for
food use only.
It was not to be used medicallyand not to be consumed
recreationally, and theyactually warned that there were
adverse effects that couldhappen to a person's health if
it were used recreationally.
Unfortunately, it appears to bean international company, so
(05:29):
there were some typos in thatwarning phrase.
It was still intelligible, butat least there was a clear
warning that the nitrous oxidewas only to be used in food
preparation, it was not forhuman consumption and that human
consumption would lead tohealth consequences.
And the second company did notmention anything at all about it
(05:51):
being only to be used for foodpreparation.
And as my dog's walk went on, Ikept looking and unfortunately
I kept finding more and morecompanies that were selling more
and more nitrous oxide products.
So this is where I am at.
We have a harmful substance thatis addictive and can be used
(06:13):
recreationally.
Regular use can be harmful andunfortunately you can buy it in
smoke shops and you can even buyit on Amazon, and the warnings
are terrible or non-existent.
Now, as I mentioned, whenpeople do use it recreationally,
there are some bad healthconsequences that can occur.
(06:35):
The biggest issue is thatnitrous oxide use depletes our B
vitamins, particularly B12, andthis can lead, when there is
significant vitamin B deficiency, to spinal cord injury and
peripheral nerve injury.
In some cases the damage isreversible With vitamin B
supplementation.
(06:55):
In other cases it is permanent.
I do have one patient who nolonger sees me, as he prefers to
see psychiatry as opposed toaddiction medicine, and he is
actually wheelchair-bound from aspinal cord injury because of
his addiction to nitrous oxide.
So my poor patient this week.
(07:15):
I'm sending her good vibes andI hope she's healing quickly.
And as I was talking to herabout what she was going through
, I realized I needed to refreshmy memory on how to treat
nitrous oxide addiction and theconsequences of nitrous oxide
use.
And fortunately, we coveredthis topic on this podcast back
(07:37):
in January of 2024.
And I actually went back andread my notes from that episode
so that I was able to help herunderstand what was going on and
we were able to come up with atreatment plan.
So I know I needed a refresheron nitrous oxide and I'm
assuming many of you may as well.
So with that, let's go backright now and re-listen to that
(08:00):
earlier podcast episode onnitrous oxide addiction.
It provides an overview ofnitrous oxide as in how it's
used, the complications ofnitrous oxide use and how to
treat actual nitrous oxideaddiction.
It is an incredibly good reviewof this very important topic.
I will apologize, it's fairlydry, but there is so much good
(08:25):
content, alright, here we go.
I am actually really excitedabout this episode today.
I have had two of my patientsrecently let me know that they
were using nitrous oxide andthis was a substance that I
didn't know very much about.
I have seen cases of neurologicsymptoms that have developed
(08:48):
after nitrous oxide use, and itwas a subject on my board exam.
But I didn't know much morethan that, and if you've been
listening to this podcast for awhile, you know that if I don't
understand something inaddiction medicine, it's time
for a podcast episode.
So, with that in mind, I wantedto put together an episode to
provide an overview on themisuse of nitrous oxide and
(09:10):
fortunately, I found some greatpapers on the topic.
Our first article is entitledRecreational Nitrous Oxide Abuse
Prevalence, neurotoxicity andTreatment.
It was published in the journalNeurotoxicity Research in 2021,
and Yan Yuan Sheng is the leadauthor.
So let's get started digginginto this article.
(09:33):
It is actually a review articleand it provides an overview of
the topic of nitrous oxide useand recreational use in general.
The article begins with anintroduction section that gives
a great history and backgroundon nitrous oxide.
It was first synthesized in1772, but wasn't used medically
(09:53):
until 1844, when it was used byan American dentist to provide
anesthesia for a dentalextraction.
The term laughing gas comesfrom an early description of the
compound as able to causestamping or laughing.
Current uses of nitrous oxideinclude as a propellant for
(10:14):
whipping cream, as a fuelbooster in the auto industry and
as an inhaled anesthetic in themedical field.
The authors go on to note thatthe recreational use of nitrous
oxide has been on the rise inrecent decades.
According to the authors,common street names of the
substance include hippie, crackand whippets.
(10:36):
When used recreationally,nitrous oxide is usually inhaled
through a balloon or bulb, andthis process may be referred to
as nagging or nanging.
Nitrous oxide produces effectsin the human body within seconds
after inhalation.
The effects, which includeanalgesia, euphoria and
(10:56):
hallucination, peak at oneminute after inhalation and
disappear within minutes withoutany sort of hangover effect.
Some users may use nitrousoxide frequently within a
few-hour period.
The authors move on to look atthe epidemiology of recreational
nitrous oxide use.
They begin by noting thatnitrous oxide is legal in most
(11:19):
countries and can be easilypurchased from the Internet.
Rates of use vary by country,with some of the highest use
being from the United Kingdom,with nearly 39% of the
population in the United Kingdomhaving used nitrous oxide
(11:39):
recreationally at least once intheir lives.
However, in all countries,recreational use of nitrous
oxide is increasing.
Rates of recreational nitrousoxide use have doubled in the
United States between 2003 and2015, and in a study of more
than 30 countries.
Rates of recreational nitrousoxide use have doubled between
2014 and 2019.
Another trend seen withrecreational nitrous oxide use
(12:04):
is that the use in young peopleis increasing.
A study in one US state foundthat as many as 16% of teens had
used nitrous oxide within thepast year.
Another study looking at youthin New Zealand found that 12% of
teens had used nitrous oxidewithin the past year.
And finally, back in the US,data from the US Poison Control
(12:29):
System showed that theprevalence of nitrous oxide use
was highest in the 12 to 17 yearold age group.
The authors move on to look atthe health harms of nitrous
oxide use.
They start by noting that themechanisms of nitrous oxide
toxicity have not been fullyelucidated and then go on to
examine some hypotheses.
(12:49):
They first look at acutetoxicity.
Nitrous oxide is morewater-soluble than oxygen, so
once it is inhaled, it isabsorbed across the alveoli of
the lungs faster than oxygen.
This results in a dilution ofthe amount of oxygen being
absorbed by the lungs, whichresults in decreased oxygen
(13:10):
delivery to the brain.
According to the authors quotea healthy person can tolerate
this type of hypoxia in awell-ventilated space, but for
persons with epilepsy, heartdisease or other comorbidities
it may induce seizures,arrhythmias or even respiratory
or cardiac arrest.
(13:31):
End quote.
The authors then move on to lookat chronic toxicity.
Chronic use and long-termexposure to nitrous oxide can
lead to damage to the nervoussystem, which can include
myelopathy and peripheralneuropathy, mental health
symptoms such as delusion,delirium and depression, venous
(13:51):
thromboembolism, anemia and skindisorders.
The authors note that themajority of these complications
are due to vitamin B12deficiency from the nitrous
oxide use.
The authors then go on to notethat in animal models, nitrous
oxide exposure is actually themost effective way to induce
(14:13):
vitamin B12 deficiency.
The authors then go on to gothrough a deep biochemical
explanation of how nitrous oxidecauses B12 deficiency and how
it causes the adverse healtheffects of nitrous oxide use.
It's pretty detailed.
I'll leave it to you to checkout the paper if you want to dig
in to the detailed biochemicalexplanation.
(14:37):
The authors then move on todiscuss other ways, besides
inducing B12 deficiency, thatnitrous oxide causes adverse
health effects.
First, nitrous oxide causesNMDA antagonism, leading to
neuronal cell death and damageto mitochondria within the cells
.
And second, nitrous oxidealters cerebral blood flow and
(15:00):
the synthesis and release ofmultiple neurotransmitters,
including norepinephrine,dopamine and serotonin, which
leads to neurotoxicity.
The authors then pivot to lookat the clinical manifestations
of the adverse health effects ofnitrous oxide use.
First, they look at acuteexposure.
Acute inhalation of nitrousoxide can cause respiratory
(15:24):
irritation, interstitialemphysema and pneumomediastinum.
When high concentrations ofnitrous oxide are used, or when
it is used repeatedly in anenclosed space, patients may
experience hypoxia, asphyxia,arrhythmia or sudden cardiac
death.
Next, the authors look atchronic exposure.
(15:48):
The most common adverse healtheffects from chronic nitrous
oxide use are neurological.
Patients may developmyeloneuropathy, subacute
combined degeneration,peripheral neuropathy or
myelopathy.
And, if you're wondering,subacute combined degeneration
refers to demyelination of thespinal cord and white matter of
(16:09):
the brain.
Along with peripheralneuropathy.
Most common symptoms thatpatients who use nitrous oxide
recreationally experience areparesthesia, gait instability
and weakness.
One study found that lower limbinvolvement was more common
than upper limb involvement.
Movement disorder symptoms suchas dystonia have been observed
(16:32):
with nitrous oxide use, but arerare.
As dystonia have been observedwith nitrous oxide use, but are
rare, the authors note that themain reason for these neurologic
conditions is from the vitaminB12 deficiency caused by chronic
nitrous oxide use.
Neurologic conditionsdeveloping from nitrous oxide
use are therefore more common inpatients with pre-existing or
(16:54):
co-existing vitamin B12deficiency.
The authors move on noting thatvenous thromboembolic disease
can be caused by nitrous oxideuse, which has been reported in
several cases, and the authorsconclude with a list of other
complications of recreationalnitrous oxide use, including
depression, anxiety, mania,agranulocytosis,
(17:18):
thrombocytopenia, anemia,myelosuppression and skin
hyperpigmentation.
Now, all of these conditionsdevelop with recurrent nitrous
oxide use, but there does notappear to be a known dose and
duration of use that causes them.
The authors then move on todiscuss dependence and tolerance
(17:41):
.
They note that current researchdoes not indicate that regular
nitrous oxide use causesphysical dependence, but use can
become compulsive and habitual.
With regular nitrous oxide use,tolerance does develop, so
higher amounts may be used toachieve the desired effects in
regular users.
(18:01):
Next, the authors looked at whattesting could be ordered when
caring for a patient withrecreational nitrous oxide use.
First, due to reductions invitamin B12 levels, a CBC may be
considered, as it can showanemia, thrombocytopenia,
myelosuppression and an elevatedMCV level.
A vitamin B12 level could alsobe checked, but the authors note
(18:26):
that serum levels are notalways a reliable indicator of
the amount of B12 in tissue.
As nitrous oxide has a veryshort half-life, there is no
serum test to detect its use.
When looking at patients withneurological symptoms.
Mri is the best test to assessfor spinal cord lesions or other
nervous system lesions causedby recreational nitrous oxide
(18:50):
use.
And finally, the authorsconclude this article with a
discussion of the treatment ofnitrous oxide use, as well as
the prognosis.
It's important to note thatthis paper is published in a
neuroscience journal, so theyare focusing on the neurological
symptoms.
They begin by noting that thereare no treatment guidelines for
the treatment of recreationalnitrous oxide use.
(19:13):
Cessation of nitrous oxide isthe primary treatment to reverse
any adverse health effects thatdevelop from recreational
nitrous oxide use, along withvitamin B12 supplementation.
The authors note that there isno consensus on dosing of
vitamin B12 supplementation, butcommon treatment regimens
(19:34):
include intramuscular vitaminB12 at a dose of 1,000
micrograms every day or everyother day for a week, then once
weekly for four to eight weeks,then once a month after that.
There is also some evidencethat high-dose oral vitamin B12
can be used instead ofintramuscular, at a dose of
(19:56):
1,000 to 2,000 micrograms orally.
The authors note that whilemost neurological symptoms will
improve with vitamin B12supplementation, some patients
may have permanent neurologicaleffects.
The authors conclude thisarticle with a brief summary and
a reminder of the overall themefrom this article that
(20:18):
recreational nitrous oxide useis on the rise and carries
significant health risks.
So this was a great paperlooking at recreational nitrous
oxide use and the medicalcomplications from use, but I
felt the discussion on treatmentwas lacking.
They really just recommendedstopping nitrous oxide use.
But I felt the discussion ontreatment was lacking.
They really just recommendedstopping nitrous oxide use.
What therapies can help ourpatients stop using?
(20:41):
And I was wondering are theremedications that can be used
off-label to control cravings?
So I dove back into theliterature and there is article
after article on the medicalcomplications of nitrous oxide
use, after article on themedical complications of nitrous
oxide use, but I couldn't findanything on how to treat the
behavior of nitrous oxide use.
I finally found another articlethat discussed inhalant use in
(21:05):
general, which provided someinsight.
The article is entitled theClinical Assessment and
Treatment of Inhalant Abuse andit was published in the
Permanente Journal in 2023, withSina Radparvar as the sole
author.
Unfortunately, the articlediscusses the misuse of all
(21:26):
different inhalants rather thanjust focusing on nitrous oxide
specifically.
Oh well, so the article has asection on the treatment of
inhalant use disorder, so Ijumped ahead to that.
The author reviews theliterature on medications for
inhalant use disorder, and it'slargely small studies, case
(21:47):
reports and case series.
One small study found thatbaclofen at a dose of 50 mg per
day reduced cravings forinhalants.
Another study found thatbaclofen at a dose of 50 mg per
day reduced cravings forinhalants.
Another study found thatlamotrigine at a dose of 100 mg
per day reduced cravings forinhalants.
A case report found thatbuspirone at a dose of 40 mg per
(22:09):
day reduced cravings forinhalants.
And a second case report foundthat risperidone at a dose of
0.5 mg per day reduced cravingsfor inhalants.
And a second case report foundthat risperidone at a dose of
0.5 milligrams per day reducedcravings for inhalants.
And a final study found thatcarbamazepine and haloperidol
reduced psychiatric symptomsassociated with inhalant use.
(22:30):
The author then moves on to lookat behavioral interventions for
inhalant use.
Quote treatment should addressthe emotional, social, academic,
cultural and demographicfactors related to inhalant
abuse.
Treatment options includecognitive behavioral therapy,
dialectical behavioral therapy,group therapy, individual
(23:04):
therapy, family therapy andteachers about the harms of
inhalant use, to prevent use inthe first place.
Additionally, the author notesthat education about identifying
behaviors that can suggestinhalant use is needed so that,
once inhalant use is identified,treatment can be initiated
promptly to prevent the harms oflong-term inhalant use.
(23:26):
And that is the end of thesecond article.
It's time to wrap up thisepisode with some take-home
points.
Number one nitrous oxide is agas that is used medically as an
anesthetic that has potentialfor misuse and recreational use.
It is also used as a propellantin whipped cream.
2.
(23:47):
Nitrous oxide, when usedrecreationally, is usually
inhaled from a balloon or bulb.
After inhalation, effects arefelt within seconds, peak within
one minute and wear off withina few minutes.
Patients using nitrous oxidewill feel analgesia and euphoria
and may hallucinate.
Number three recreationalnitrous oxide use is on the rise
(24:11):
in multiple countries and is acommon recreational drug in
youth.
4.
Adverse health effects of acutenitrous oxide use include
seizures, hypoxia, cardiacarrhythmia and cardiac arrest.
5.
Adverse health effects ofchronic nitrous oxide use
include damage to the nervoussystem, mental health symptoms,
(24:34):
venous thromboembolism, anemiaand skin changes.
Number six many of nitrousoxide's adverse health effects
from chronic use are the resultof vitamin B12 depletion caused
by the nitrous oxide.
Number seven when patientsexperience adverse health
effects from chronic nitrousoxide use, the treatment is
(24:58):
vitamin B12 repletion andcessation of nitrous oxide use.
8.
There are no FDA-approvedmedications to reduce the use of
nitrous oxide, but there aresome small studies and case
series of medications that havebeen used to reduce cravings to
use.
And number nine treatment ofproblematic nitrous oxide use
(25:21):
involves behavioralinterventions such as cognitive
behavioral therapy, grouptherapy, individual therapy and
motivational enhancement.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
(25:43):
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesabout how to treat addiction and
prevent overdoses To thosehealthcare providers out there
treating patients with addiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(26:05):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today we are going to be talkingabout nitrous oxide.
(00:43):
I have a number of patientsthat use it recreationally.
It's a substance that we use atthe hospital, where it's often
referred to as laughing gas.
It has amnestic and anestheticqualities and it can also be
euphoric.
Now you might be wonderingwhere patients who use it
recreationally get it.
(01:03):
Well, it turns out that thisstuff is fairly easy to get.
I was under the impression thatyou had to buy a can of whipped
cream to get it.
If you didn't know, nitrousoxide is the propellant used in
cans of whipped cream that youbuy at the grocery store.
It's actually the gas that isin the can that pushes out the
(01:24):
whipped cream.
However, I have recentlylearned that they sell nitrous
oxide at smoke shops In fact,the local smoke shop that I have
gone to a few times to do myown research on how Kratom is
sold, carries it.
I actually found this out, as Isaid, when I was going to go to
(01:45):
the smoke shop to buy Kratomand while I was waiting for the
person to ring up my purchase, Inoticed that there was a
section for nitrous oxide andthey sold multiple different
products.
Unfortunately, I've recentlyheard from a few of my patients
who have relapsed on nitrousoxide.
One of them is a young man whowas using it for several months.
He actually got some tinglingin his feet after using it for
(02:07):
quite a while and fortunately herealized it was from the
nitrous oxide and he stopped.
He actually appears to be doingfairly well.
Unfortunately, I have anotherpatient who is a young female
and she is not doing so well.
She was recently in thehospital for this.
I actually haven't seen herdischarge summary, but she has
(02:28):
significant weakness in her legswhich, unfortunately, is one of
the known medical complicationsof nitrous oxide use.
Nitrous oxide, as we will hearlater in this episode, can cause
significant nerve damage.
So as I was talking to thissecond patient about how she was
doing, I asked her about whereshe was getting her nitrous
(02:49):
oxide and if it had any warninglabels on it and I was just
curious does the product saythat recreational use can lead
to significant medicalcomplications?
And she said no.
So I figured I was going toneed to go back to the smoke
shop and pick up one of thepackages and see how the product
(03:09):
was labeled.
But she told me that she wasgetting her nitrous oxide from
amazon and I thought, huh, Ineed to investigate this more.
So this morning, while I was outwalking my dog, I opened up the
Amazon app on my phone andindeed you can buy nitrous oxide
(03:31):
on Amazon and it's actuallysold for people who want to make
homemade whipped cream, and Ithought wait, wait, wait, wait,
wait.
This is the dumbest idea ever.
Why are we selling an addictiveand harmful substance as a
propellant for whipped cream?
There must be a better option.
So I went on some food blogsand websites about food and
(03:56):
apparently not.
Nitrous oxide is apparently thebest propellant for some foods,
including whipped cream.
Nitrous oxide makes the whippedcream really fluffy and light,
which is what makes people likeit so much.
I don't know about all of you,but I'm going to guiltily fess
up that I have absolutely onmultiple occasions, squirted
(04:19):
whipped cream out of the canright into my mouth.
It's just so light, fluffy,sweet and delicious, and
unfortunately a lot of that isfrom nitrous oxide Bummer.
So I was pretty frustrated bywhat I found.
So I went back to Amazon andwanted to see who was selling it
and how they were labeling it.
I found two companies fairlyquickly that sell nitrous oxide
(04:44):
in canisters and they both sellit as being used for homemade
whipped cream and they had someselling points that it's easy to
use and easy to connect toother tubes, and one of them
even had a sales pitch thathomemade whipped cream is so
much better than what is sold instores.
Now, in terms of the productlabeling for these two products,
(05:06):
one of them said specificallythat the nitrous oxide was for
food use only.
It was not to be used medicallyand not to be consumed
recreationally, and theyactually warned that there were
adverse effects that couldhappen to a person's health if
it were used recreationally.
Unfortunately, it appears to bean international company, so
(05:29):
there were some typos in thatwarning phrase.
It was still intelligible, butat least there was a clear
warning that the nitrous oxidewas only to be used in food
preparation, it was not forhuman consumption and that human
consumption would lead tohealth consequences.
And the second company did notmention anything at all about it
(05:51):
being only to be used for foodpreparation.
And as my dog's walk went on, Ikept looking and unfortunately
I kept finding more and morecompanies that were selling more
and more nitrous oxide products.
So this is where I am at.
We have a harmful substance thatis addictive and can be used
(06:13):
recreationally.
Regular use can be harmful andunfortunately you can buy it in
smoke shops and you can even buyit on Amazon, and the warnings
are terrible or non-existent.
Now, as I mentioned, whenpeople do use it recreationally,
there are some bad healthconsequences that can occur.
(06:35):
The biggest issue is thatnitrous oxide use depletes our B
vitamins, particularly B12, andthis can lead, when there is
significant vitamin B deficiency, to spinal cord injury and
peripheral nerve injury.
In some cases the damage isreversible With vitamin B
supplementation.
(06:55):
In other cases it is permanent.
I do have one patient who nolonger sees me, as he prefers to
see psychiatry as opposed toaddiction medicine, and he is
actually wheelchair-bound from aspinal cord injury because of
his addiction to nitrous oxide.
So my poor patient this week.
(07:15):
I'm sending her good vibes andI hope she's healing quickly.
And as I was talking to herabout what she was going through
, I realized I needed to refreshmy memory on how to treat
nitrous oxide addiction and theconsequences of nitrous oxide
use.
And fortunately, we coveredthis topic on this podcast back
(07:37):
in January of 2024.
And I actually went back andread my notes from that episode
so that I was able to help herunderstand what was going on and
we were able to come up with atreatment plan.
So I know I needed a refresheron nitrous oxide and I'm
assuming many of you may as well.
So with that, let's go backright now and re-listen to that
(08:00):
earlier podcast episode onnitrous oxide addiction.
It provides an overview ofnitrous oxide as in how it's
used, the complications ofnitrous oxide use and how to
treat actual nitrous oxideaddiction.
It is an incredibly good reviewof this very important topic.
I will apologize, it's fairlydry, but there is so much good
(08:25):
content, alright, here we go.
I am actually really excitedabout this episode today.
I have had two of my patientsrecently let me know that they
were using nitrous oxide andthis was a substance that I
didn't know very much about.
I have seen cases of neurologicsymptoms that have developed
(08:48):
after nitrous oxide use, and itwas a subject on my board exam.
But I didn't know much morethan that, and if you've been
listening to this podcast for awhile, you know that if I don't
understand something inaddiction medicine, it's time
for a podcast episode.
So, with that in mind, I wantedto put together an episode to
provide an overview on themisuse of nitrous oxide and
(09:10):
fortunately, I found some greatpapers on the topic.
Our first article is entitledRecreational Nitrous Oxide Abuse
Prevalence, neurotoxicity andTreatment.
It was published in the journalNeurotoxicity Research in 2021,
and Yan Yuan Sheng is the leadauthor.
So let's get started digginginto this article.
(09:33):
It is actually a review articleand it provides an overview of
the topic of nitrous oxide useand recreational use in general.
The article begins with anintroduction section that gives
a great history and backgroundon nitrous oxide.
It was first synthesized in1772, but wasn't used medically
(09:53):
until 1844, when it was used byan American dentist to provide
anesthesia for a dentalextraction.
The term laughing gas comesfrom an early description of the
compound as able to causestamping or laughing.
Current uses of nitrous oxideinclude as a propellant for
(10:14):
whipping cream, as a fuelbooster in the auto industry and
as an inhaled anesthetic in themedical field.
The authors go on to note thatthe recreational use of nitrous
oxide has been on the rise inrecent decades.
According to the authors,common street names of the
substance include hippie, crackand whippets.
(10:36):
When used recreationally,nitrous oxide is usually inhaled
through a balloon or bulb, andthis process may be referred to
as nagging or nanging.
Nitrous oxide produces effectsin the human body within seconds
after inhalation.
The effects, which includeanalgesia, euphoria and
(10:56):
hallucination, peak at oneminute after inhalation and
disappear within minutes withoutany sort of hangover effect.
Some users may use nitrousoxide frequently within a
few-hour period.
The authors move on to look atthe epidemiology of recreational
nitrous oxide use.
They begin by noting thatnitrous oxide is legal in most
(11:19):
countries and can be easilypurchased from the Internet.
Rates of use vary by country,with some of the highest use
being from the United Kingdom,with nearly 39% of the
population in the United Kingdomhaving used nitrous oxide
(11:39):
recreationally at least once intheir lives.
However, in all countries,recreational use of nitrous
oxide is increasing.
Rates of recreational nitrousoxide use have doubled in the
United States between 2003 and2015, and in a study of more
than 30 countries.
Rates of recreational nitrousoxide use have doubled between
2014 and 2019.
Another trend seen withrecreational nitrous oxide use
(12:04):
is that the use in young peopleis increasing.
A study in one US state foundthat as many as 16% of teens had
used nitrous oxide within thepast year.
Another study looking at youthin New Zealand found that 12% of
teens had used nitrous oxidewithin the past year.
And finally, back in the US,data from the US Poison Control
(12:29):
System showed that theprevalence of nitrous oxide use
was highest in the 12 to 17 yearold age group.
The authors move on to look atthe health harms of nitrous
oxide use.
They start by noting that themechanisms of nitrous oxide
toxicity have not been fullyelucidated and then go on to
examine some hypotheses.
(12:49):
They first look at acutetoxicity.
Nitrous oxide is morewater-soluble than oxygen, so
once it is inhaled, it isabsorbed across the alveoli of
the lungs faster than oxygen.
This results in a dilution ofthe amount of oxygen being
absorbed by the lungs, whichresults in decreased oxygen
(13:10):
delivery to the brain.
According to the authors quotea healthy person can tolerate
this type of hypoxia in awell-ventilated space, but for
persons with epilepsy, heartdisease or other comorbidities
it may induce seizures,arrhythmias or even respiratory
or cardiac arrest.
(13:31):
End quote.
The authors then move on to lookat chronic toxicity.
Chronic use and long-termexposure to nitrous oxide can
lead to damage to the nervoussystem, which can include
myelopathy and peripheralneuropathy, mental health
symptoms such as delusion,delirium and depression, venous
(13:51):
thromboembolism, anemia and skindisorders.
The authors note that themajority of these complications
are due to vitamin B12deficiency from the nitrous
oxide use.
The authors then go on to notethat in animal models, nitrous
oxide exposure is actually themost effective way to induce
(14:13):
vitamin B12 deficiency.
The authors then go on to gothrough a deep biochemical
explanation of how nitrous oxidecauses B12 deficiency and how
it causes the adverse healtheffects of nitrous oxide use.
It's pretty detailed.
I'll leave it to you to checkout the paper if you want to dig
in to the detailed biochemicalexplanation.
(14:37):
The authors then move on todiscuss other ways, besides
inducing B12 deficiency, thatnitrous oxide causes adverse
health effects.
First, nitrous oxide causesNMDA antagonism, leading to
neuronal cell death and damageto mitochondria within the cells
.
And second, nitrous oxidealters cerebral blood flow and
(15:00):
the synthesis and release ofmultiple neurotransmitters,
including norepinephrine,dopamine and serotonin, which
leads to neurotoxicity.
The authors then pivot to lookat the clinical manifestations
of the adverse health effects ofnitrous oxide use.
First, they look at acuteexposure.
Acute inhalation of nitrousoxide can cause respiratory
(15:24):
irritation, interstitialemphysema and pneumomediastinum.
When high concentrations ofnitrous oxide are used, or when
it is used repeatedly in anenclosed space, patients may
experience hypoxia, asphyxia,arrhythmia or sudden cardiac
death.
Next, the authors look atchronic exposure.
(15:48):
The most common adverse healtheffects from chronic nitrous
oxide use are neurological.
Patients may developmyeloneuropathy, subacute
combined degeneration,peripheral neuropathy or
myelopathy.
And, if you're wondering,subacute combined degeneration
refers to demyelination of thespinal cord and white matter of
(16:09):
the brain.
Along with peripheralneuropathy.
Most common symptoms thatpatients who use nitrous oxide
recreationally experience areparesthesia, gait instability
and weakness.
One study found that lower limbinvolvement was more common
than upper limb involvement.
Movement disorder symptoms suchas dystonia have been observed
(16:32):
with nitrous oxide use, but arerare.
As dystonia have been observedwith nitrous oxide use, but are
rare, the authors note that themain reason for these neurologic
conditions is from the vitaminB12 deficiency caused by chronic
nitrous oxide use.
Neurologic conditionsdeveloping from nitrous oxide
use are therefore more common inpatients with pre-existing or
(16:54):
co-existing vitamin B12deficiency.
The authors move on noting thatvenous thromboembolic disease
can be caused by nitrous oxideuse, which has been reported in
several cases, and the authorsconclude with a list of other
complications of recreationalnitrous oxide use, including
depression, anxiety, mania,agranulocytosis,
(17:18):
thrombocytopenia, anemia,myelosuppression and skin
hyperpigmentation.
Now, all of these conditionsdevelop with recurrent nitrous
oxide use, but there does notappear to be a known dose and
duration of use that causes them.
The authors then move on todiscuss dependence and tolerance
(17:41):
.
They note that current researchdoes not indicate that regular
nitrous oxide use causesphysical dependence, but use can
become compulsive and habitual.
With regular nitrous oxide use,tolerance does develop, so
higher amounts may be used toachieve the desired effects in
regular users.
(18:01):
Next, the authors looked at whattesting could be ordered when
caring for a patient withrecreational nitrous oxide use.
First, due to reductions invitamin B12 levels, a CBC may be
considered, as it can showanemia, thrombocytopenia,
myelosuppression and an elevatedMCV level.
A vitamin B12 level could alsobe checked, but the authors note
(18:26):
that serum levels are notalways a reliable indicator of
the amount of B12 in tissue.
As nitrous oxide has a veryshort half-life, there is no
serum test to detect its use.
When looking at patients withneurological symptoms.
Mri is the best test to assessfor spinal cord lesions or other
nervous system lesions causedby recreational nitrous oxide
(18:50):
use.
And finally, the authorsconclude this article with a
discussion of the treatment ofnitrous oxide use, as well as
the prognosis.
It's important to note thatthis paper is published in a
neuroscience journal, so theyare focusing on the neurological
symptoms.
They begin by noting that thereare no treatment guidelines for
the treatment of recreationalnitrous oxide use.
(19:13):
Cessation of nitrous oxide isthe primary treatment to reverse
any adverse health effects thatdevelop from recreational
nitrous oxide use, along withvitamin B12 supplementation.
The authors note that there isno consensus on dosing of
vitamin B12 supplementation, butcommon treatment regimens
(19:34):
include intramuscular vitaminB12 at a dose of 1,000
micrograms every day or everyother day for a week, then once
weekly for four to eight weeks,then once a month after that.
There is also some evidencethat high-dose oral vitamin B12
can be used instead ofintramuscular, at a dose of
(19:56):
1,000 to 2,000 micrograms orally.
The authors note that whilemost neurological symptoms will
improve with vitamin B12supplementation, some patients
may have permanent neurologicaleffects.
The authors conclude thisarticle with a brief summary and
a reminder of the overall themefrom this article that
(20:18):
recreational nitrous oxide useis on the rise and carries
significant health risks.
So this was a great paperlooking at recreational nitrous
oxide use and the medicalcomplications from use, but I
felt the discussion on treatmentwas lacking.
They really just recommendedstopping nitrous oxide use.
But I felt the discussion ontreatment was lacking.
They really just recommendedstopping nitrous oxide use.
What therapies can help ourpatients stop using?
(20:41):
And I was wondering are theremedications that can be used
off-label to control cravings?
So I dove back into theliterature and there is article
after article on the medicalcomplications of nitrous oxide
use, after article on themedical complications of nitrous
oxide use, but I couldn't findanything on how to treat the
behavior of nitrous oxide use.
I finally found another articlethat discussed inhalant use in
(21:05):
general, which provided someinsight.
The article is entitled theClinical Assessment and
Treatment of Inhalant Abuse andit was published in the
Permanente Journal in 2023, withSina Radparvar as the sole
author.
Unfortunately, the articlediscusses the misuse of all
(21:26):
different inhalants rather thanjust focusing on nitrous oxide
specifically.
Oh well, so the article has asection on the treatment of
inhalant use disorder, so Ijumped ahead to that.
The author reviews theliterature on medications for
inhalant use disorder, and it'slargely small studies, case
(21:47):
reports and case series.
One small study found thatbaclofen at a dose of 50 mg per
day reduced cravings forinhalants.
Another study found thatbaclofen at a dose of 50 mg per
day reduced cravings forinhalants.
Another study found thatlamotrigine at a dose of 100 mg
per day reduced cravings forinhalants.
A case report found thatbuspirone at a dose of 40 mg per
(22:09):
day reduced cravings forinhalants.
And a second case report foundthat risperidone at a dose of
0.5 mg per day reduced cravingsfor inhalants.
And a second case report foundthat risperidone at a dose of
0.5 milligrams per day reducedcravings for inhalants.
And a final study found thatcarbamazepine and haloperidol
reduced psychiatric symptomsassociated with inhalant use.
(22:30):
The author then moves on to lookat behavioral interventions for
inhalant use.
Quote treatment should addressthe emotional, social, academic,
cultural and demographicfactors related to inhalant
abuse.
Treatment options includecognitive behavioral therapy,
dialectical behavioral therapy,group therapy, individual
(23:04):
therapy, family therapy andteachers about the harms of
inhalant use, to prevent use inthe first place.
Additionally, the author notesthat education about identifying
behaviors that can suggestinhalant use is needed so that,
once inhalant use is identified,treatment can be initiated
promptly to prevent the harms oflong-term inhalant use.
(23:26):
And that is the end of thesecond article.
It's time to wrap up thisepisode with some take-home
points.
Number one nitrous oxide is agas that is used medically as an
anesthetic that has potentialfor misuse and recreational use.
It is also used as a propellantin whipped cream.
2.
(23:47):
Nitrous oxide, when usedrecreationally, is usually
inhaled from a balloon or bulb.
After inhalation, effects arefelt within seconds, peak within
one minute and wear off withina few minutes.
Patients using nitrous oxidewill feel analgesia and euphoria
and may hallucinate.
Number three recreationalnitrous oxide use is on the rise
(24:11):
in multiple countries and is acommon recreational drug in
youth.
4.
Adverse health effects of acutenitrous oxide use include
seizures, hypoxia, cardiacarrhythmia and cardiac arrest.
5.
Adverse health effects ofchronic nitrous oxide use
include damage to the nervoussystem, mental health symptoms,
(24:34):
venous thromboembolism, anemiaand skin changes.
Number six many of nitrousoxide's adverse health effects
from chronic use are the resultof vitamin B12 depletion caused
by the nitrous oxide.
Number seven when patientsexperience adverse health
effects from chronic nitrousoxide use, the treatment is
(24:58):
vitamin B12 repletion andcessation of nitrous oxide use.
8.
There are no FDA-approvedmedications to reduce the use of
nitrous oxide, but there aresome small studies and case
series of medications that havebeen used to reduce cravings to
use.
And number nine treatment ofproblematic nitrous oxide use
(25:21):
involves behavioralinterventions such as cognitive
behavioral therapy, grouptherapy, individual therapy and
motivational enhancement.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
(25:43):
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesabout how to treat addiction and
prevent overdoses To thosehealthcare providers out there
treating patients with addiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(26:05):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
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