Citation

van Aerts L, de Morais J, Evans-Brown M, Jorge R, Gallegos A, Christie R, Nefau T, Planchuelo G, Sedefov R, Victorri-Vigneau C, Povilanskienė R, Grasaasen K, Palmqvist DF, Mongan D, Killeen N, Duarte AO, Santos AS. European Monitoring Centre for Drugs and Drug Addiction. Luxembourg: Publications Office of the European Union, 2022.

Copyright

(Copyright 2022, European Monitoring Centre for Drugs and Drug Addiction)

The full document is available online.

Abstract

This review is based on information from the scientific and medical literature. Initial searches were developed around the following terms and areas: nitrous oxide, laughing gas, N2O, chemistry, analytical methods, manufacture, pharmacology, pharmacodynamics, pharmacokinetics, toxicology, recreational, dependence, abuse, addiction, epidemiology, behaviour, health risks and social risks. PubMed was used as the main literature database for retrieving information; Web of Science was also used. Results from searches were screened for relevance and selected publications were reviewed. Additional articles were identified from a review of the references cited in retrieved publications. Selected medical specialty societies and international, national and local government agency websites were searched to identify relevant grey literature. When preparing the different sections of the review, further searches were performed using additional terms to identify additional information. As well as this, colleagues within our scientific network were contacted to obtain further information. For the case study of the Netherlands, public data available within the national early warning system network was used as well. In addition, selected national focal points provided case studies on the situation with nitrous oxide at the national level based on the information collected within their national networks. For the case study of the United Kingdom, open-source information published in the scientific and medical literature were used alongside grey literature, such as public government reports.


Since around 2010, some countries in Europe have seen an increase in the recreational use of nitrous oxide. This has become a particular concern from around 2017, as both supply and use of the gas have increased. In part, this is linked to the recent availability of larger cylinders of the gas that deliberately target the recreational market — making nitrous oxide significantly cheaper and promoting broader, more regular and heavier use. Most use is in young people, including teenagers. As the number of people using nitrous oxide has grown, so too has the number of poisonings. While still relatively small in number, they typically involve neurotoxicity from more frequent or heavier use of the gas. Other concerns include severe burns and lung injuries, typically caused by larger cylinders. Meanwhile, car accidents involving the gas have also significantly increased in at least one country. The purpose of this report is to examine the current situation, risks and responses to the recreational use of nitrous oxide in Europe. To support this, the report also provides a state- of-the-art review of the chemistry, pharmacology and toxicology of the gas. It is intended for policy makers and practitioners.

The report is structured as follows.

- Section 1 provides a summary of the current situation, established risks and responses.

- Section 2 is a technical review of the chemistry, pharmacology, toxicology, individual risks and legitimate uses.

- Section 3 provides an overview of the epidemiology and social risks. In addition, it includes detailed country case studies from Denmark, France, Ireland, Lithuania, the Netherlands and Portugal. A case study is also provided on the United Kingdom, where the use of nitrous oxide has been established in young people for a longer period, and these experiences, including the response, may be helpful in informing responses in other countries (even though the UK is no longer a member of the EMCDDA, having left the EU on 31 December 2020)