The substance class we haven’t talked about: inhalants, and why nitrous oxide is in the headlines for the worst reason

Inhalants are the substance class our newsroom hadn’t covered yet, and the reason is not that nothing is happening. It is that the surveillance signal is hidden in places most clinicians and most reporters don’t look — poison-control logs, county EMS run sheets, unbranded gas-station coolers — and the medicine is unfamiliar enough that the harms can present months after exposure, in clinics that don’t think to ask.

The most useful place to start is with the numbers we have.

What surveillance data shows

The CDC MMWR’s Michigan analysis (April 2025) is the cleanest recent picture. Between 2019 and 2023, Michigan poison-control calls for nitrous oxide misuse rose <span class="stat">533%</span>. Emergency department visits rose <span class="stat">757%</span>. The state recorded <span class="stat">144</span> poison-control cases, <span class="stat">132</span> ED visits, and <span class="stat">192</span> EMS responses across the period — and that is one state, in a category where most cases are never coded as “inhalant” in the first place because nitrous oxide is not a scheduled substance and most chart-review pipelines don’t catch it.

A separate national mortality analysis (PMC12311712, summarized by Ole Miss) found a <span class="stat">>500%</span> increase in nitrous-oxide-attributable deaths across the most recent decade. International data echo the trend: in Victoria, Australia, <span class="stat">4</span> nitrous-oxide-linked deaths were recorded in 2025 alone — versus <span class="stat">4</span> across the entire 2000–2019 period.

The biology, plainly

Nitrous oxide is not pharmacologically inert. When inhaled in repeated, recreational doses, it irreversibly oxidizes the cobalt center of cobalamin (vitamin B12), producing a functional B12 deficiency that the body cannot resolve simply by eating more leafy greens. The clinical syndrome that follows — subacute combined degeneration of the spinal cord — looks like demyelination of the dorsal columns: numbness in the feet and hands, loss of vibration and position sense, ataxia (a halting, broad-based gait), and in advanced cases bowel and bladder dysfunction. There is also a separate peripheral neuropathy and, rarely, a true myelopathy that can leave patients permanently impaired.

The catch is that all of this can present weeks to months after the heaviest exposure, when the patient is no longer using and has no reason to mention nitrous oxide to a primary-care provider. Clinicians who see a young adult with new neuropathy and ataxia in 2026 should be asking about whippits the way they ask about alcohol. The Lancet Public Health editorial on the burden of nitrous oxide-induced public health harms makes this point explicitly: the diagnostic blind spot is at least as much of a problem as the substance itself.

Why retail is the policy lever

The reason inhalants don’t fit the standard substance-policy frame is that the supply chain is legal, mainstream, and adjacent to ordinary kitchen and food-service equipment. Nitrous oxide cartridges (“whip-its”) are sold for legitimate culinary use; larger tanks (“Galaxy Gas,” “GreatWhip,” and similar brands) are marketed under “infusion” or “barista” framing but are stocked behind the counter at gas stations and convenience stores in many states. The FDA’s 2024–25 enforcement actions against several brands disrupted some retail distribution, but the regulatory architecture is patchy and primarily state-level.

States that have moved aggressively — including New York, California, and Louisiana — restrict retail to age 21+, limit container sizes, or ban flavored variants. Most states have not, and federal action has been limited to enforcement against deliberate “human consumption” marketing rather than the underlying retail.

Where the field genuinely disagrees

Three live debates are worth naming. The first is whether nitrous oxide should be scheduled federally; the harm-reduction position is that scheduling would push consumption into less-regulated channels without addressing the demand, while the public-health position is that scheduling would at minimum end the gas-station retail problem. The second is whether B12 supplementation pathways should be built into ED protocols for any young patient presenting with neurological symptoms (the cost is trivial; the diagnostic gain may be substantial). The third is the cultural piece: nitrous oxide use has become normalized in some music and influencer subcultures in a way that mirrors how vaping was normalized in 2017–18 — and the field is still figuring out whether peer-led messaging or top-down labeling will move the needle faster.

Why this matters for people who use inhalants, and the people who love them

If you use nitrous oxide and you are reading this, two things are worth knowing. First, there is no “safe” dose pattern for repeated recreational use; the B12-mediated harms are dose-dependent but the threshold for damage is lower than most users expect. Second, neurological symptoms — tingling, weakness, an unsteady gait, trouble feeling your feet — should be evaluated by a clinician, even if you’ve stopped, even if it’s been a few weeks. Recovery from the neurological harms is possible but is more likely the earlier intervention starts, with appropriate B12 repletion and physical therapy.

First, there is no “safe” dose pattern for repeated recreational use; the B12-mediated harms are dose-dependent but the threshold for damage is lower than most users expect.

If you are a parent or a loved one: the conversation worth having is not about morality. It is about what the substance actually does to the spine and the peripheral nerves, and about the (unsexy, life-altering) fact that you can wake up and not be able to feel your feet.

→ Find a treatment program in Arizona that addresses inhalant use → Read our family primer on inhalants

If you or someone you know is in crisis, the 988 Suicide and Crisis Lifeline is available 24/7. For substance-use support, SAMHSA’s National Helpline is free, confidential, and 24/7.