Commentary on Nitrous Oxide: Weighing the Toxic Neuropsychiatric Effects of Abuse Against Potential Therapeutic Benefits for Psychiatric Disorders.

A 37-year-old man with no prior psychiatric history developed agitation, self-inflicted arm lacerations, paranoia, and hallucinations after about six months of increasing recreational nitrous oxide use. He had low vitamin B12 and anemia, with normal lab results and head imaging. His symptoms suggested psychosis and delirium with withdrawal-like features due to nitrous oxide abuse. He improved with olanzapine, a diazepam taper, and sertraline. The case underscores challenges in identifying and treating nitrous oxide misuse, as there is no drug test and no consensus on classification or management. Further research on both the risks of misuse and potential therapeutic uses of nitrous oxide is needed.

Study at a glance

Abstract

Nitrous oxide (N2O), an anesthetic gas used for dental procedures, has recently become increasingly recognized as a potential drug of misuse and abuse, with an increasing number of case studies reporting serious adverse effects, including megaloblastic anemia, myelopathy, neuropathy, subacute combined degeneration, psychosis, and even death. There is also growing research support for the use of N2O in the treatment of several psychiatric disorders, including major depressive disorder. In this issue, we present the case of a 37-year-old man with no significant psychiatric history who presented with agitation, self-inflicted arm lacerations, paranoia, and hallucinations. The patient admitted to about 6 months of increasing recreational nitrous oxide use. He was found to have a low vitamin B12 level and anemia with results of other laboratory tests and head imaging within normal limits. His presentation suggested psychosis and delirium with withdrawal-like symptoms due to nitrous oxide abuse. He responded to treatment with olanzapine, a diazepam taper, and the addition of sertraline. The case highlights challenges with identifying and treating patients who misuse N2O, given the absence of a drug test for it and a lack of a consensus on how to classify and manage patients who abuse this drug. Further clinical research should be done, in parallel, on the risks of misuse and abuse of nitrous oxide, along with larger scale, yet measured, investigations of N2O as a treatment option in psychiatry.