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Chapter 5: Successful Prevention of VSA
Introduction
In many ways, VSA is a 'hidden' problem. The inconspicuous nature of the products used, the short term outwardly visible effects of VSA and the high incidence of use within the home (and also, and perhaps more importantly, use in 'hidden' outdoor locations), all combine to make tackling VSA a challenge.
Whilst effective communication regarding VSA clearly plays a key role in the prevention of VSA, the evidence suggests that this needs to be complemented by awareness of harm minimisation strategies, raising the profile of VSA among professionals so that the risks are better understood, providing suitably targeted services and trained staff, legislative provision for restricting sales of dangerous substances and modifying products to minimise opportunity to abuse. All must be undertaken, however, with caution not to raise awareness of 'how' to abuse solvents which might, potentially, encourage more young people to experiment.
This chapter discusses some of the practical measures that have been used in an attempt to target VSA.
Harm Minimisation
The risk of instant death from solvent abuse, even on first time use, makes it difficult to offer advice on 'safe use' or harm minimisation for volatile substance users. In sum:
"Whilst the harm reduction type of evidence, provided in relation to a wide range of other drugs, may consist of information on how specific drugs may be used with less risk, in the case of VSA the preferred message is one of discouraging any use of volatile substances whatsoever. The reason for this is the recognition that serious health risks can result from even one-off instances of VSA." (McKeganey, unpublished, p.2).
Indeed, most research asserts, without reservation, the need to communicate the high risk nature of VSA and fact that it can never be carried out safely ( HEBS and Ives, 1999).
Despite this, the Advisory Council on the Misuse of Drugs ( ACMD) in their 1995 overview of VSA suggests that there are some methods of administration and environments of abuse that may present greater risks to users than others. For example, spraying substances directly into the mouth or inhaling by placing a plastic bag over the head are especially high risk, and environments that are close to water and railway lines may be especially dangerous.
Research carried out with a sample of Aboriginal volatile substance users also provides some indication of harm minimisation strategies. Interviews with users revealed that sniffing in groups, and in public, were considered to be 'safer' ways of practising VSA (Sandover, Houghton and O'Donoghue, 1997). Having contact with family members and being a social user were also cited and interviews revealed that effective strategies for reinforcing the risks of VSA included witnessing other sniffers suffering major facial burns, sickness or death (ibid).
Whilst the NCB, among others, encourages educators to be realistic and truthful about the real harms of drug misuse, in the case of VSA, the possibility of sudden death, even on first use, is realistic. This presents a unique challenge to VSA education.
Effective Interventions
The guidance for professionals produced by HEBS and Ives (1999) summarises the types of treatment available to volatile solvent participants as including:
- psychotherapeutic approaches
- individual or group counselling
- family therapy or counselling
- self-help groups
- temporary removal of young people from risk environments.
Discussions with stakeholders suggest that these services are currently offered to VSA participants as part of wider drug treatment programmes.
The Scottish Drugs Misuse Information Strategy Team ( DMIST) collect, maintain and disseminate data from drug treatment agencies across Scotland. This data is held in the Scottish Drug Misuse Database ( SDMD) and includes data relating to solvent abuse referrals by Local Authority and health board area.
In 2004/05, a total of 78 people presented to services in Scotland with current solvent abuse problems, accounting for just over 1% of all adults with presenting drug misuse. The number of people presenting to services for whom solvent abuse was the main drug of abuse was just 32, most of whom were under 18. These comparatively low figures (when compared to other types of drug misuse), are often presented in the literature as being the main reason that additional resources have not been targeted at VSA in recent years.
The majority of support for users, carers and others who encounter VSA is currently provided via telephone help-lines or specialised drug charities and other organisations (including those offered by Re-Solv, SOLVE IT, Scottish Drugs Forum and LOST).
Excepting these services, a search of the various websites of agencies with an interest in solvent abuse, and discussions with key stakeholders, suggests that there are no dedicated services for working with volatile substance abuse. Anecdotally, those consulted in the research suggested that this means that there is no obvious referral routes for cases of VSA that are alerted to social services and others professionals.
The lack of services specifically working with inhalant or solvent abusers is not a new observation. Merrill (1985) noted a lack of treatment centres for young people with chronic solvent abuse problems.
Anecdotally, it seems that one reason for VSA not being taken seriously is the view that VSA is, for the most part, a 'fad' that most young people grow out of. The perceived short-term nature of VSA means that resources are often targeted at more serious and prolonged forms of alcohol, tobacco and illegal drug misuse. This does not help those older users, as the St Georges data shows, over 18s account for a notable proportion of all deaths. Also, the view that VSA is a 'youth problem' means that there is often less material for those aged over 18 and no obvious referral route.
Given the evidence that suggests that VSA is not taken seriously (because young people grow out of it and because illegal drug use has become a clearer priority), and alcohol and tobacco have long been recognised as significant factors in drug-related problems, there may be opposition to the setting up of such dedicated services. Any consideration of future service introductions would require a closer analysis of the potential demand for such services and their effectiveness.
Availability and Sales of Substances
There are 2 crucial pieces of legislation that affect the availability of volatile substances and which may play a part in preventing future emergence of VSA to the high levels previously recorded.
The first of these is the Intoxicating Substances (Supply) Act 1985 (which applies to England and Wales only) and which makes it illegal for retailers to sell volatile substances to anyone under the age of 18 if there is reason to believe that they will use it for inhalation and intoxication purposes.
Whilst this places the onus on retailers to sell responsibly, the legislation has been criticised by VSA campaigners as failing to specify which products should be restricted (Ives, 1999) and does not effect the widespread availability of abuseable solvents in the public domain (for example, in the home, schools and workplace). Further, it has been reported that the legislation has failed to bring many cases to court, most probably due to complications with establishing proof that retailers knowingly acted irresponsibly.
In 1999, the Cigarette Lighter Refills (Safety) Legislation was introduced as means of specifically controlling sales of the most widely used solvent among young people. Since this time, it has been illegal to sell lighter fuel to anyone under 18 in England and Wales, and retailers found breaking the law can receive penalties of a fine of £5000 or 6 months in prison.
Whilst the register of VSA deaths held by St George's, University of London may suggest that the introduction of such legislation reduced abuse of butane gas (with a drop in deaths associated with cigarette lighter refills among under 18s in 2000) a return to similar numbers of pre-legislation deaths for this group in 2001 and 2002 suggest that this relationship may not be robust. There is also anecdotal evidence to suggest that such legislation has simply changed the nature of VSA, rather than reducing its prevalence.
Scotland is covered under the UK-wide Regulations which make it illegal to sell lighter fuel refills to anyone under 18. It is a common-law offence if solvents are supplied to people of any age in the knowledge that they are to be used for the purpose of abuse. Enforcement is the responsibility of local trading standards and local authorities.
In addition, the Solvent Abuse Scotland Act (1983) was introduced with the aim of reducing the incidence of solvent abuse amongst children. This Act and the subsequent Children (Scotland) Act (1995) make VSA a ground for referral to the Scottish Children's Reporter Administration.
In 2001 in Scotland, the Lord Advocate granted permission for a pilot scheme to assess test purchasing in Scotland to help achieve more effective enforcement of the law prohibiting the sale of tobacco products. In 2003, this was complemented by the launch of a Fife-based initiative specifically to tackle the illegal sales of potentially lethal butane gas to under 18s.
A survey carried out on behalf of Re-Solv in England and Wales ( LACORS, unpublished), following Test Purchasing Campaigns to Enforce Cigarette Lighter Refill (Safety) Regulations 1999 showed reasonable concurrence with the 1999 Cigarette Lighter Refills (Safety) Legislation. Similar research, carried out on a systematic basis, may be required in Scotland to test more local levels of concordance following the Lord Advocate's moves to allow test purchasing.
Product Modifications
The Department for Trade and Industry has responsibility for monitoring the packaging and modification of products to make sure that they do not present risks to consumers. By modifying products such as aerosols, producers can also play a part in the successful prevention of VSA.
In 2004, the British Aerosol Manufacturers' Association ( BAMA), a trade association that represents the interests of all sections of the aerosol industry, from the suppliers of components and chemicals to fillers and marketers of aerosol products, presented an overview of BAMA's efforts towards making solvents safe to the Scottish Drugs Forum conference. These include promotion of the use of the ' SACKI' warning on many commonly abused products ('Solvent Abuse Can Kill Instantly') and the appearance of skull and crossbones warning signs on bleach and other products.
Other modifications to solvents include the possible addition of Bitrex to solutions to make them less appealing to consume and this was taken forward by Shell for inclusion in lighter gas refills, but is not possible for aerosol products.
Discussions with stakeholders suggest that, in Australia, consideration is also being given to the addition of isopropyl mercaptan, a smelly compound that is added to piped natural gas and, uniquely to the UK, to piped LPG (a mixture of ethane, propane and butanes) in remote areas of Scotland to butane lighter fuel canisters.
Much of the work carried out by producers and associations such as BAMA remains hidden from public scrutiny, mostly as a means of limiting the awareness of modifications among abusers who might use the information to find alternative solutions to abusing the products. Indeed, research carried by BAMA with chronic glue sniffers showed that they were sufficiently determined that they would find away around most proposed product modifications to ensure that they could continue abusing (Ives, 2001).
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