Nitrous Oxide - The New Drug in Town
And I don't mean the car engine..
You see, I’m someone that really analyses and questions my surrounding and for a long time I noticed small metal canisters on the floor and wondered what they were.
I soon found out as a young, 20 year old chap walked in through A&E and complained of “tingling” on his arms bilaterally. I’ll be honest, tingling is never a symptom that makes us urgently want to do something. “Loss of sensation”, “vision loss” or “leg or arm giving way” is always slightly more exciting. With this in mind, the patient was triaged into the ambulatory area of the department where I assessed him.
He told me that he’d been taking nitrous oxide (N2O) and took out one of the canisters. I asked him how many he had taken and he quoted something crazy like 100 a week. He said it made him feel better, give him a laugh and that all his friends did it. He’d been on N2O for the past 2 years. On examination he had reduced sensation in the peripheries of the upper and lower limb. He couldn’t even walk straight as I assume his proprioception was completely off.
I was a bit dumbfounded really. I had heard this was something becoming more common but the sudden onset of ataxia and paraesthesia makes you think the worse. Do we perform a CT or MRI scan or should I admit to neurology for further review? Turns out it was much more simpler. Here’s why:
N2O oxidises the cobalt atom that is integral to vitamin B12 function. Vitamin B12 is really important for myelin synthesis and neuronal regeneration so a reduction in its level can give one all sorts of symptoms with the most significant being subacute combined degeneration of the spinal cord. For the person taking it, it gives the person a sense of euphoria and is commonly called “laughing gas.”
It’s currently the second most commonly used drug in the UK and has recently been classed as a Class C substance in the UK. This means possession is not illegal but supplying it is banned.
Here is some guidance on investigation and treatment:
Suspect N2O poisoning? Carry out bloods testing for FBC, U&Es, vitamin B12 and methylmalonic acid (which is raised first in B12 deficiency).
Red flags include visual changes, ascending symptoms, low BP/tachycardic (spinal shock), back pain or fever.
Treatment involves giving patients some good old intramuscular vitamin B12 injections.
Don’t forget to liaise with drug and alcohol service.
Most of the symptoms are reversible but there are occasions when the subacute combined degeneration is permanent.
What I’m reading or watching this week?
I’m watching a really interesting show called “Painkiller” on Netflix. It’s about the case levied against Purdue Pharmacy who sold oxycontin as a general pain killer despite being aware of its addiction potential. It is said that in 2021, there were 107,000 deaths due to drug overdose with 75% due to opioids.
I would really recommend watching it! check it out here: https://www.netflix.com/title/81095069
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