Volatile substance misuse: a review of interventions: monograph series no. 65

8.1 Clinical management of VSM

Page last updated: 2008

In 1987 Joseph Westermeyer, a psychiatrist, complained that little research was available to inform the clinician treating clients who misuse volatile substances. While studies since this time have improved our understanding of the various problems and pathologies that accompany VSM, Westermeyer's observation remains apposite.

International literature gives few grounds for optimism about treatment outcomes. Beauvais and Trimble, writing in the US, state that solvent users 'defy conventional treatment and prevention efforts' (Beauvais and Trimble 1997, p. xi). Dinwiddie (1994) reviews approaches to treatment in the US for those whose inhalant use has become long-term or chronic, and concludes that outcomes are very poor. Strategies believed to work with other drug users are often observed to be less effective among those who use inhalants (Beauvais, Jumper-Thurman, Plested, & Helm, 2002; Mackesy-Amiti & Fendrich, 1998). Others have argued that any treatment success is likely to be attributable to the fact that VSM generally declines as people age, rather than the intervention itself (Sakai, Mikulich-Gilbertson, & Crowley, 2006). Very little outcome data is available with regards to any treatment modality other than residential rehabilitation (see section 8.3).

Many young people undergoing treatment for VSM exhibit a range of complex behaviours and are at acute risk of harm. A Canadian treatment provider reported that 'the fear of having to protect a young person who was high on solvents was hard to describe' (cited in Charles & Luca, 1999, p. 67). Over 80% of 550 respondents in a survey of Canadian drug treatment practitioners assessed their inhalant using clients' prospects of recovery as only 'poor' or 'very poor' (Beauvais, Jumper-Thurman et al., 2002). Nonetheless there are also accounts in the literature from people who have found it deeply fulfilling to be involved with young people at a critical junction in their lives. Some practitioners regard VSM intervention as an opportunity to learn to work cross-culturally, valuing both Indigenous and non-Indigenous approaches (Charles & Coleman, 1999; Charles & Luca, 1999).

In the United States, the Substance Abuse and Mental Health Services Administration has issued advice for VSM treatment. The document recommends that VSM treatment is likely to be lengthier and more expensive than treatment required in response to other forms of drug use. The authors acknowledge that their advice to clinicians is 'based on limited experience and research, primarily with disadvantaged Native American and Hispanic populations in Southwestern and Midwestern United States' (Substance Abuse and Mental Health Services Administration, 2003, p. 5).

The most detailed Australian VSM guidelines available concern care for people who are engaged with drug treatment or child protection services in Victoria (Department of Human Services, 2003). While the guidelines argue that a similar approach to other drug treatment should be taken, they also observe that the young age of many involved must be considered in formulating a treatment strategy. The guidelines stipulate that responses to VSM should be aimed at promoting abstinence and that services must not allow clients to use inhalants on their premises. The Office for Aboriginal and Torres Strait Islander Health in conjunction with the National Health and Medical Research Council is, at the time of writing, currently developing national clinical guidelines for the management and treatment of VSM.
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A protocol outlining the respective roles of police and welfare agencies has been produced in Victoria to support the implementation of legislation providing police with powers to intervene in VSM (State Government of Victoria, 2004). In Queensland, again in conjunction with new legislation, guidelines have been produced to assist organisations in responding to VSM (Inner Urban Youth Interagency VSM Working Group, 2005). These guidelines provide advice as to how agencies might engage young people who use volatile substances: suggestions include providing easy treatment access, addressing multiple problems and networking with other agencies. Flow charts for responding to emergency situations involving VSM are provided.

In view of the complex and serious problems believed to co-occur with regular VSM, most treatment advice is that a particularly thorough client assessment is recommended (Department of Human Services, 2003; Jumper-Thurman, Plested, & Beauvais, 1995; Substance Abuse and Mental Health Services Administration, 2003). This should include assessment of family function, co-occurring poly-drug use, co-occurring mental health disorders and a thorough medical examination including screening for cognitive impairment which may impede treatment. Clinicians have recommended screening of clients receiving VSM treatment for depressive or anxiety disorders, given their high prevalence in inhalant-using populations (Evren, Barut, Saatcioglu, & Cakmak, 2006). The effect of the person's family and social situation on their drug use should also be assessed. For chronic users an assessment of neurological impairment is advised, with follow up testing to check for improvement during treatment (Brouette & Anton, 2001; Jumper-Thurman et al., 1995).

Several assessment protocols are outlined in the literature (Central Australian Rural Practitioners, 2003; Department of Human Services, 2003; Richardson, 1989; Shaw et al., 2006). A measure for assessing adolescent inhalant use dependence severity is also described (Ogel, Askoy, Topuz, Liman, & Coskun, 2005).

The requirement for detoxification from VSM is contested; some consider it unnecessary due to the short acting nature of VSM-induced intoxication (Department of Human Services, 2003). Others argue that adverse effects of VSM on brain function endure for weeks beyond the period of acute intoxication and that treatment should not commence until cognitive impairment has diminished (Jumper-Thurman et al., 1995).

No pharmacotherapies are available to treat inhalant dependence, although anti-depressive and anti-psychotic medications are often used to treat co-occurring mental health concerns (Dinwiddie, 1994).

Individuals who misuse volatile substances appear also to have higher rates of mental illness than would be found in the general community. Dual diagnosis services are required to provide concurrent treatment (Butt, 2004). Homelessness also frequently accompanies long-term VSM; however, many housing services will not accept people who are currently substance affected into their programs. The possibility of past sexual abuse should also be considered. Many people engaged in VSM treatment are poly-drug users and treatment attention should not focus solely on one substance (Dell, Dell, & Hopkins, 2005). Some researchers argue that as intensive VSM is a marker of 'global vulnerability' (Wu et al., 2004) or part of a 'risk behaviour syndrome' (Kurtzman et al., 2001), interventions should address the constellation of risks or associated problems, rather than focusing specifically on VSM. Due to the range of problems experienced by many users, a coordinated service response is critical (Lubman, Hides, & Yucel, 2006).

Some studies argue that developing therapeutic relationships with young people who use volatile substances is particularly important as a precursor to any useful intervention (Butt, 2004; Inner Urban Youth Interagency VSM Working Group, 2005). These kinds of relationships often take time to establish. Part of establishing supportive relationships is to approach users with respect and patience and to be clear about what the service is able to offer and the expectations made of service participants (for instance, not to use drugs in the premises). Inhalant users frequently lead rather chaotic lives and find it difficult to attend set appointment times. An outreach approach to treatment and intervention is therefore frequently appropriate (Department of Human Services, 2003).
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The efficacy of group interventions is unclear. Young people who use inhalants have reported being taunted by other drug users attending treatment services (MacLean, 2004). Thus caution should be taken when introducing a young person with a history of VSM to group therapy with other drug users (Substance Abuse and Mental Health Services Administration, 2003). It is important that workers avoid further stigmatising them and ensure, as far as possible, that they are treated with respect within drug treatment services. Avoiding labelling young people as, for instance, 'chromers' is one way to do this (Butt, 2004).

It is important that treatment includes supporting people to participate in diversionary recreation activities. Some users of inhalants have poor living skills and many programs include components to assist young people with hygiene, nutrition and interpersonal skills, as well as encouraging them to attend school or training where this is feasible (Substance Abuse and Mental Health Services Administration, 2003).

Brady (2004) encourages the use of brief interventions by health care professionals in responding to disclosure of alcohol and other drug misuse by Indigenous people. Similarly, Lynskey (2003) observes that brief interventions by doctors have been effective in targeting other forms of drug abuse by adolescents, and ought therefore to be implemented where young people are discovered to be misusing volatile substances. A training package for VSM brief intervention has been developed in Queensland (see National Inhalant Abuse Taskforce, 2006, p. 42).

As indicated earlier, some volatile substance misusers require hospital treatment. One article advises on treatment of patients admitted to acute psychiatric units for inhalant-associated psychotic disorder (Hernandez-Avila, Otega-Soto, Jasso, Hasfura-Buenaga, & Kranzler, 1998).

In the past, when petrol included lead, treatment sought to remove organic lead stored in the bodies of sniffers. The main hospital treatment used was chelation therapy, which involved the use of a chemical compound (a chelating agent) which binds heavy metals. However, as leaded fuel has been phased out in Australia, chelation therapy has little role in the current care of petrol sniffers.

Much of the health care provided to petrol sniffers in remote areas occurs in community clinics. The Central Australian Rural Practitioners Association (CARPA) Standard Treatment Manual (Central Australian Rural Practitioners, 2003) includes advice for health staff on acute and ongoing care of petrol sniffers. It lists the three main acute health issues for sniffers as fits, strange or violent behaviour and, in the longer term, weakness and infections. The manual advises airway protection in the case of acutely affected sniffers and rapid evacuation to a facility where ventilation is available, and provides advice on options for sedation if required.

Recommendations for clinical management and treatment of VSM among Indigenous youth include investigating the young person's sense of cultural identity and belonging, ensuring access to culturally appropriate services, role models and opportunities to learn about and participate in cultural activities (Butt, 2004). A 'resiliency and holistic' approach to VSM treatment for Indigenous youth has been adopted by Canadian treatment centres (Dell et al., 2005). This entails the use of Indigenous and Western techniques to strengthen clients' spirit or 'inner resiliency'.

In the NT, legislation now authorises courts to sentence people to mandatory treatment (see section 10.1). Researchers have found little empirical evidence to indicate the effect of sentencing people to mandatory alcohol and other drug treatment on subsequent drug use or offending (Pritchard, Mugavin, & Swan, 2007). It is therefore important that outcomes for clients in the NT be closely monitored.

One aspect of rehabilitation which appears to have been neglected in the literature is the need for intensive physiotherapy for chronic volatile substance misusers, to enable them to restore wasted muscles, regain coordination, and overcome symptoms of neuropathy. Peggy Brown, of the successful Mount Theo Petrol Sniffer Program, advised a meeting of families working with sniffers to 'work them hard: walking up the river bed a lot, wearing rucksacks on their backs with stones in' (Winbarrku Outstation, 1994).