A new report released this month details a notable increase in the recreational use of nitrous oxide, or N2O, in Michigan over a five-year period. The colorless, odorless and nonflammable gas is widely available and often misused by youth and adults. Misuse can come with adverse clinical effects, including an abnormal heart rhythm, neurological issues and death.
In “Notes from the Field: Recreational Nitrous Oxide Misuse-Michigan, 2019-2023,” written by Varun Vohra, M.D., senior director of the Michigan Poison and Drug Information Center and associate professor of Emergency Medicine at the Wayne State University School of Medicine, data from the MiPDC ToxSentry database, and emergency medical services and hospital emergency room data highlight annual increases in cases involving nitrous oxide misuse in the five-year observation period.
In late 2023, MiPDC staff detected an increase in the number of patients hospitalized with neurologic signs and symptoms secondary to nitrous oxide misuse. Toxic surveillance monitoring was prompted by an observed corresponding increase in nitrous oxide–associated poisoning consultations involving the poison center and its toxicologists. MiPDC and the Michigan Department of Health and Human Services collaborated to investigate poison center cases, emergency department visits and emergency medical service responses to analyze trends in nitrous oxide-associated poisoning exposures and health care encounters in Michigan.
Screening for nitrous oxide misuse was based on diagnostic and clinical findings, including neurologic effect, psychiatric symptoms and hematologic findings.
The results were published in the U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report released April 10.
From Jan. 1, 2019, to Dec. 31, 2023, 144 poison center cases, 132 ED visits and 192 EMS responses involving nitrous oxide were identified. Notable increases were observed in 2023 as compared with 2019 in poison center calls, from 10 to 48, ED visits (seven to 60) and EMS responses (15 to 78). Nitrous oxide events occurred most frequently among people aged 20–39 years and in metropolitan counties Among the 192 EMS responses, 7.3% involved fatalities, including three suspected suicides. Cause of death could not be determined in EMS data, but nitrous oxide involvement was documented among the fatalities. Multiple substance involvement occurred in 30% of poison center cases, most commonly benzodiazepines, cannabis/delta-9-tetrahydrocannabinol and alcohol. The most common clinical effects among nitrous oxide-involved poison center cases were tachycardia (19.4%), other-neurologic (18.8%) and numbness in the body.
Nitrous oxide is a medical anesthetic, pain reduction agent and anti-anxiety agent. It is also used as a propellent in steel containers used for food production, like whipped cream. The sale of these small steel containers, or “whippets,” in retail stores and online has led to greater access.
The researchers noted that the use of nitrous oxide is increasingly popular among teens and adults between the ages of 20 and 39. Users are not aware of the serious health effects from frequent and long-term use, including neurologic damage due to vitamin B12 deficiency.
Nitrous oxide is not a federally controlled substance, however, legislation has been passed in Michigan making the sale of paraphernalia for nitrous oxide use illegal. Lawmakers are considering expansion of this ruling. The Michigan Poison and Drug Information Center and its partners encourage parents, caregivers and anyone affected by N2O misuse to call the Poison Helpline at 1-800-222-1222 or visit the Substance Misuse page at https://www.poison.med.wayne.edu/substance-use-disorder.
Read the full report in the CDC’s MMWR here or find the link on the MiPDC website.