Nitrous Oxide Deaths Among Children and Young People is No Laughing Matter!

Emeritus Professor Alan Glasper from the University of Southampton discusses the negative aspects of nitrous oxide abuse among children and young people.

Recently, this journal covered the alarming rise in children becoming addicted to nicotine through vaping. Similarly, a trend among young people of using nitrous oxide as a stimulant is reaching worrying levels. Nitrous oxide (N₂O) was commonly known as “laughing gas” but is better known now among young people as NOS. This gas has been used medicinally and recreationally since its discovery by Joseph Priestley in the late 18^th century. Over the years that followed, nitrous oxide has had several medicinal uses but especially until recently as a dental anesthetic and from the 1960’s as Entonox (i.e., nitrous oxide mixed with oxygen commonly known as gas and air) to relieve pain but especially during childbirth. Gillman (2019) outlines how the gas was also used by psychiatrists to treat mental health conditions and ironically substance abuse.

Its use as a music festival drug among young people has soared in recent years, but its misuse was exacerbated during the periods of COVID-19 societal lockdowns when it became the drug of choice for getting “high.” The UK Office for National Statistics shows that in 2022 3.9% of young people aged 16–24 years were abusing nitrous oxide second only to the use of cannabis. Between 2001 and 2020, there were 716 deaths related to its use in England and Wales, with an average of 36 deaths each year. The most common cause of death is suffocation resulting from a lack of oxygen when the gas is used in a confined space such as a car or when a plastic bag is placed over the head. However, it should be stressed that deaths from nitrous oxide use pale in comparison to those caused by alcohol misuse (Jones, 2022).

Although this gaseous drug does not have the death toll that for example opiate use has, it is now associated with significant and life-changing morbidity but especially of the nervous system. Of concern is that nitrous oxide is freely available but especially over the internet because currently at least in the UK it is not an illegal drug. Similarly, in many states of the USA, although nitrous oxide is not considered a drug and can therefore be legally obtained, it is illegal to sell or distribute nitrous oxide to a child or young person, and in many states, it is illegal to use nitrous oxide for recreational purposes.

Kaar et al. (2016) confirm that nitrous oxide is commonly used by young people but in particular the UK and US (38.6% and 29.4% lifetime prevalence). The drug is commonly inhaled via a balloon filled from a small canister of the gas and for many users it is an infrequent event and usually causes no significant harm. When nitrous oxide is inhaled from the balloon the user experiences a sense of euphoria or high and if combined with other drugs it can have a hallucinogenic effect.

Although most consumers of nitrous oxide are not habitual users of the gas its abuse is rapidly rising in the United States and data is emerging which shows that its use in the Netherlands, Australia and elsewhere is responsible for an upsurge in young people presenting to hospital with neurologic symptoms (Marcus, 2021).

In contemporary societies, it is now commonplace to see the evidence of an increase in nitrous oxide abuse via the discarded shiny aluminum canisters covering the ground like spent gun cartridges in recreational areas such as parks.

Preventable neurological harm from nitrous oxide abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of the gas has led to an apparent rise in cases of nitrous oxide induced myeloneuropathy in several areas of the UK. Manufacturers and sellers of nitrous oxide should be held accountable for the apparent increase in harm through policy implementation and/or legislation. However, in context myeloneuropathy induced by this popular gas oxide has only been reported in a relatively small series of case studies (Mair et al., 2023).

It is the ease of access to nitrous oxide which now worries health care professionals as this ability to buy the gas both cheaply and easily is leading to greater numbers of young people becoming addicted to its effects. In pathological terms nitrous oxide is a neurotoxin which adversely effects myelin sheath physiology by the inactivation of vitamin B12 culminating in peripheral and central nervous system demyelination. Evans and Evans (2021) believe that early recognition of the symptoms of nervous system involvement in persistent nitrous oxide users is essential to prevent permanent damage. The initial symptoms of nervous system involvement are a tingling sensation in the hands and feet of the user and if left untreated uncoordinated walking and lower limb weakness. Later symptoms include bladder and bowel incontinence or retention with associated sexual dysfunction (BBC News, 2003).

Preventable neurological harm from the misuse of nitrous oxide is now a world-wide phenomenon and the ease through which young people can access this drug is responsible for the rise in cases of nitrous oxide neuropathy (Mair et al., 2023).

Nitrous oxide is not fully controlled by governmental regulators and where, for example, in the UK, it is not currently regulated by the Misuse of Drugs Act. The gas is primarily used legally as a culinary ingredient for whipping cream and will be found in most proprietary kitchens. Such is the concern related to the long-term pathological effects of nitrous oxide misuse that some governments are taking political action to highly restrict its sale out with legitimate use. The British Home office is currently preparing plans that will ban the sale and possession of nitrous oxide as part of its strategy to reduce overall antisocial behavior, which is associated with its abuse, this is because the biggest users of nitrous oxide are young people. This ban will apply only to the recreational use and supply of the gas without restricting its use for legitimate use (Walker, 2023).

It is widely believed that adolescence is associated with heightened risk-taking, and recklessness and it is therefore no surprise that nitrous oxide misuse has become so popular among this group (Steinberg, 2010). As a reflection of this trait, Lan et al. (2019) stress that all clinical staff such as children’s nurses should be aware of the way in which neurotoxicity can present itself in chronic users of nitrous oxide.