“Laughing gas”: what you need to know

TEveryone has already noticed these small stainless steel cartridges which have been strewn for some time in certain public places. Before being emptied by their users, they contained a gas, nitrous oxide – “proto” for friends – better known as “laughing gas”.

Used in particular in industry, the food industry, the kitchen or medicine, nitrous oxide has regularly been entitled to the headlines of the newspapers for several years. And for good reason: its euphoric effects on inhalation, quick and fleeting, have made this cheap and easily available gas a very popular recreational hallucinogenic drug.

Unfortunately, the growing success of these diverted uses of the prototype is not funny: the increase in consumption has indeed been accompanied by an increase in direct and indirect cases of death, especially among young people. If we must not demonize or give in to alarmism, it is nevertheless essential to inform and raise awareness of the risks associated with inhaling this substance.

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A widely used gas

Nitrous oxide (N2O) was discovered in 1772 by English philosopher and chemist Joseph Priestley. In 1799, Humphrey Davis, another British chemist, described the physical and chemical properties of this gas by experimenting on himself and on volunteers. It thus highlights the short-lived euphoric and analgesic effects of this substance.

Used from the 19th centurye century in the literary and scientific circles of the English bourgeoisie, where it is synonymous with inspiration and artistic creation, or as an attraction at fairgrounds as laughing gas, nitrous oxide entered the medical field in the middle of the 20th centurymainly in anesthesia and analgesia (removal of pain).

In France, the mixture of oxygen and nitrous oxide for medical purposes (known under the term MEOPA) has had marketing authorization since 2001. In addition, since 2009, MEOPA has been authorized for use outside hospitals.

The medical sector is not, far from it, the only one to use nitrous oxide, which is also used in the electronics, petroleum, aerospace and automobile industries (as an oxidizer for engines), as well as in the food industry (as conditioning gas). The N2O is also used as a propellant in siphons and other whipped cream bombs.

It is very easy to obtain nitrous oxide, which can be purchased in particular in the form of bottles in local shops or on the Internet. This availability facilitates the diversion of this product and increases the risk of acute poisoning. This poses a regulatory problem, as this substance also has authorized commercial uses.

An increasing consumption

Based on the frequency of emergency visits for problems related to nitrous oxide listed in the 2022 report of the European Monitoring Center for Drugs and Drug Addiction, its use among young people seems to be on the rise.

This increase had already been reported in previous years by hospitals in the Euro-DEN Plus network in Amsterdam (15 in 2020, compared to 1 in 2019) and Antwerp (44 in 2019 and 2020, compared to 6 in 2017-2018). In 2020, the French poison centers declared 134 cases (compared to 46 in 2019), while the Dutch poison centers declared 144 (compared to 128 in 2019).

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In 2019, the Global Drug Survey, which took stock of the situation in more than thirty states around the world, highlighted at least one use of nitrous oxide during life in 23.5% of respondentswhich places this gas in 13e position of the most consumed substances. Use during the year concerned 11.9% of participants (which ranks this gas in 10e position, excluding tobacco, alcohol and caffeine).

The Crime Survey for England and Wales 2018-2019 revealed that nitrous oxide was the second most used substance after cannabis among 16-24 year olds, with a prevalence of 8.7%.

A broadening of consumption contexts

Since the early 2000s, nitrous oxide has been consumed at student parties, particularly in medicine and pharmacy, due to the knowledge of the product by the participants. A quantitative survey carried out in 2017 and 2018 among 30,000 students indicates relatively high levels of nitrous oxide use: 6.2% of male students and 3% of female students had consumed it in 2018

Since 2017, the French Observatory of Drugs and Addictive Tendencies (OFDT) has reported uses of nitrous oxide extending beyond alternative party spaces. The presence of metal caps in public spaces has become more frequent, often near places frequented by younger audiences, such as high school students.

What are the effects of inhaling nitrous oxide?

After cracking the canister to open it, users inhale the gas through a balloon. The main effects sought during this diverted use of nitrous oxide are euphoria, mad laughter, the feeling of drunkenness, disinhibition, exaltation, hallucinations, even dissociation.

The peak of effect is generally reached after one minute and the effects dissipate two to three minutes after inhalation, hence often repeated uses.

Fleeting effects, which are felt quickly, low price, easy accessibility: nitrous oxide is a substance that attracts young people, who for all these reasons have the impression that this gas is not dangerous.

However, as early as 1970, researchers reported in The New England Journal of Medicine what could have been first deaths linked to nitrous oxide. Since then, several dozen serious cases have been reported in the past two years alone. Miscellaneous facts of death which are repeated frequently in our country, because the inhalation of nitrous oxide can be accompanied by complications.

Acute poisoning can have serious consequences

There are a number of possible complications in the context of acute poisoning, and this from the first take. Commonly reported problems include: dizziness, headache, tinnitus, decreased manual dexterity, difficulty speaking, confusion, loss of consciousness, falling from height, cold burns (nose, lips, vocal cords, respiratory tract), asphyxia due to lack of oxygen.

Users may also experience cardiac disturbances (rhythm disturbances, decreased heart rate), nausea, vomiting, abdominal pain, diarrhea, pulmonary edema, acute anxiety attacks.

Consuming proto over a short period of time does not appear to cause major neurological complications, unless there is a pre-existing vitamin B12 deficiency, or the consumption is in a poorly ventilated environment. However, this risk increases significantly for repeated consumption and at short intervals and/or at high doses (50 to 100 cartridges inhaled in less than 3 hours or more than 70 cartridges per week).

In case of chronic consumption, the toxicity is not negligible. It mainly results from a lack of oxygen in the brain (cerebral hypoxia) and neurotoxicity due to vitamin B12 deficiency.

(Nitrous oxide irreversibly oxidizes this vitamin, which leads to deficiencies. This molecule is involved in several essential processes, including the formation and maturation of red blood cells, DNA synthesis – and therefore cell division –, or nerve function in particular, Ed.)

A neurotoxicity that can leave sequelae

The neurotoxicity of nitrous oxide results in numbness, tingling of the extremities of the limbs, and potentially irreversible neurocognitive disorders, which can leave significant sequelae: communication disorder such as aphasia, or memory disorders such as ‘amnesia.

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Cases of progressive muscle weakness of the lower and upper limbs, loss of vibrational sensitivity and sense of position, difficulty walking, incoordination of the limbs, balance disorder, or sphincter disorders affecting the bladder , intestine, have also been described.

Serious pathologies such as neuropathies (damage to the peripheral nervous system, in other words the nerves located outside the brain and the spinal cord, Editor’s note) also exist, as do cases of myeloneuropathy (damage to the spinal cord), or subacute combined sclerosis of the spinal cord, a condition that constitutes a real neurological emergency.

At the hematological and cardiovascular level, damage such as arrhythmia, coronary syndrome, stroke or pulmonary embolism may occur. Doctors have also documented kidney damage (lithiasis, urinary tract infections), liver damage, localized or diffuse skin hyperpigmentation, erectile dysfunction.

Finally, on the psychiatric level, delusional episodes with hallucinations, mood disorders, suicidal risk, paranoia have been observed. And let us specify that the addiction to nitrous oxide is of course possible…

How to limit the risks?

Abstaining from consuming nitrous oxide is obviously the number one advice. But in the event of consumption, the observation of certain behaviors makes it possible to reduce the risks and the potential damage. Above all, avoid consuming alone, and do not consume standing up, because loss of balance can cause you to fall heavily from your height and cause injury.

As far as inhalations are concerned, always use a balloon. Indeed, the prototype is a very cold gas, the inhalation of which at the outlet of the cartridge, siphon or detonator can cause burns. It is also important to breathe air between gas intakes, in order to avoid asphyxiation, and not to multiply intakes, despite the fleeting effect of the product. In the same vein, it is not recommended to consume at close intervals and (or) in high doses.

Nitrous oxide should not be mixed with other products (alcohol, cannabis, or other drugs, etc.), and it is of course not recommended to take your car, scooter, or bicycle just after consumption.

From a practical point of view, the cartridges must be kept away from any flame. And avoid throwing them anywhere (just like rubber or latex balloons), because it is a source of pollution.

If unusual symptoms occur after consumption, in an emergency, call the emergency services (15 or 18). And if you or one of your acquaintances has difficulty controlling your consumption, consult your doctor or a structure specializing in the management of addictions: consultation for young consumers, CSAPA (centres for care, support and prevention in addictology), hospital service, etc.

To conclude, let us recall that Law No. 2021-695 of 1er June 2021 to prevent the dangerous uses of nitrous oxide in particular prohibits the sale or offering of nitrous oxide to minors, whatever the packaging, in all shops, public places and on the Internet. It is also prohibited to sell and distribute any product specifically intended to facilitate the extraction of nitrous oxide in order to obtain psychoactive effects (such as “crackers”). Contravening these provisions is punishable by a fine of €3,750. Provoking a minor to misuse a consumer product to obtain psychoactive effects is an offence, punishable by a fine of €15,000.

* Laurent Karilaprofessor of addictology and psychiatry, member of the PSYCOMADD research unit, Paris-Saclay University, and Amine Benyaminaprofessor of psychiatry and addictology, president of the French Federation of Addictology, AP-HP.

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“Laughing gas”: what you need to know

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