Monday, March 14, 2011

Whitener Addiction - Death by Inhalant

whitener correction fluid
Whitener (correction fluid) inhalation caused the death of a Pune student recently. Whitener is abused as an inhalant in India. Whitener exerts its effects through trichloroethane, a volatile solvent. Inhalants include other substances such as petrol and toluene. These substances are cheap, accessible and readily available to children and adolescents.

Epidemiology

Solvent abuse is prevalent among street children and working kids. Teenagers start using solvents to gain entry into a gang, and occasionally as experimentation. Its use in a college student is unusual. But this may be a developing pattern indicating spread of the habit into middle class homes. (Kumar S 2008). Most adolescents are one-time or short-term users. Those who abuse inhalants persistently usually have conduct disorders.

Methods of inhalant abuse

  1. Sniffing - direct inhalation from a container or piece of clothing sprayed with the substance.
  2. Huffing - holding a soaked cloth over the nose or mouth to increase the concentration of vapours.
  3. Bagging - breathing from a paper or plastic bag containing the volatile substance to further increase the concentration (Henretig, 1996).

Mechanism of action

Young people abuse volatile solventsby deliberately inhaling available vapours 15–20 times over 10-15 minutes. This results in concentrations of up to 10000ppm as against the industrial standard of 50-100ppm (Bowen et al., 2006).

Inhaled organic solvents like toluene cross from the blood into the brain within minutes. In the brain cells solvents act on specific receptors (NMDA and GABA) to produce effects similar to those of alcohol. Toluene, a common solvent in thinner and paint, increases opiate receptors in the Nucleus Accumbens - a key brain area associated with the reward system and the experience of pleasure. Toluene enhances dopamine release in the Nucleus Accumbens.

Effects on the body

(Lubman 2008)
  • At low concentration (500-4000ppm) transient euphoria and disinhibition make abusers prone to risk taking and accidents.
  • At higher concentrations (6000-15000ppm) dizziness, sleepiness, slurred speech, blurred vision and headaches appear. Users appear confused, unbalanced, or begin responding to hallucinations.
  • Higher doses result in seizures, coma and cardiopulmonary arrest .

Death by inhalant

  • Sudden sniffing death is the most common cause. Even first-time experimental users are at risk of sudden sniffing death as a result of heart rhythm abnormalities especially if the user is startled or agitated. 
  • Suffocation and burns from exploding solvents
  • Accidental injury as a result of impulsive risk taking and impaired motor skills while intoxicated. 
  • Suicide accounts for up to 40% of inhalant-related deaths
  • First-time users are also likely to die, perhaps because they are inexperienced at this dangerous pastime.

Recognition

Inhalant abuse should be suspected in teenagers showing intermittent intoxication,and signs of recent inhalant abuse including paint or oil stains on clothing or skin, spots or sores around the mouth, red eyes, runny nose, chemical odor on the breath, and a dazed appearance (Anderson, 2003).

Mass screening in schools could be undertaken as part of the annual health check. The mental health component for middle and high schoolers should include the CRAFFT. The CRAFFT is a validated short screening instrument for substance abuse in teenagers.

Laboratory diagnosis is not reliable as these volatile substances
  • Do not persist in the body beyond a few hours
  • They are undetectable in urine samples because of their volatility
  • Hippuric acid, a long lasting toluene metabolite is also produced by foods and  raises the question of false positives. Also, it is usually not available for testing in emergency

Outcome

For most adolescents inhalant use should be regarded as a passing phase or fad. A few persistent users have antisocial personality disorder and abuse other substances. Chronic users develop damage to all organ systems - heart, lungs, brain, kidneys, and liver. The good news (Cairney et al., 2005) -
Damage to the brain is reversible with abstinence

Treatment

There is no specific medication to treat intoxication or for abstinence.

If you suspect a child is intoxicated with an inhalant stay calm and do not alarm him or her. Startling or frightening the child precipitates hallucinations and can also lead to ‘sudden sniffing death’ due to the effect on heart rhythm. Initiate cardio-pulmonary resuscitation (CPR) until help arrives if there is no heart beat or breathing.

When the child or adolescent recovers the incident should be discussed non-confrontationally. Remember, even a single inhalation can kill the child. Also abuse of other substances is frequent with regular whitener abusers. After talking it over commit to seeking psychiatric help. Social, environmental and recreational opportunities need to be addressed.

References
  1. Carrie E. Anderson, and Glenn A. Loomis. Recognition and Prevention of Inhalant Abuse. Am Fam Physician. 2003 Sep 1;68(5):869-874. (Also gives good links for information on inhalant abuse and prevention)
  2. Bowen SE, Batis JC, Paez-Martinez N, Cruz SL. The last decade of solvent research in animal models of abuse: mechanistic and behavioral studies. Neurotoxicol Teratol. 2006;28:636–647.
  3. Cairney S, Maruff P, Burns CB, Currie J, Currie BJ. Neurological and cognitive recovery following abstinence from petrol sniffing. Neuropsychopharmacology. 2005 May;30(5):1019-27.
  4. Henretig F. Inhalant abuse in children and adolescents. Pediatr Ann. 1996 Jan;25(1):47-52.
  5. Kumar S, Grover S, Kulhara P, Mattoo SK, Basu D, Biswas P, Shah R. Inhalant abuse: A clinic-based study. Indian J Psychiatry. 2008 Apr;50(2):117-20.
  6. D I Lubman, M YĆ¼cel and A J Lawrence. Inhalant abuse among adolescents: neurobiological considerations. Br J Pharmacol. 2008 May; 154(2): 316–326. Published online 2008 March 10. doi: 10.1038/bjp.2008.76.



61 comments:

  1. Whay is it being sold so easily when we all know how much problem it is creating now a days.. why havnt a strict action been taken for it beinf avaliable so eaisily

    ReplyDelete
  2. Yes, its sale can be restricted. This is already being done by court order in Uttarakhand http://www.indiankanoon.org/doc/122455578/ Restricting whitener purchase by children would probably be enforceable and effective in controlling its use. However, susceptible children would then move onto other volatile substances like petrol. The child's environment that puts them at risk for abusing these substances needs to be addressed.

    ReplyDelete
    Replies
    1. Hello Sir,
      Is recovery of body is possible after inhalation of whitener and diluter is of over more than 3 years an average of 2-3 bottles each of per day. Is there any medicines are availble?

      Delete
    2. Recovery definitely occurs even after many years of inhaling whitener. Remaining abstinent is a process that takes time and commitment to the treatment despite relapses; as with any other drug abuse habit.

      Medications are available to help reduce symptoms and craving of whitener abuse to some extent. The major work is in identifying and dealing with triggers and friends that perpetuate the whitener inhalation habit.

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    3. dear sir, i would like to say that i also use whitener from last few years.. i am not getting rid of my habits.. i really want to leave this addiction, but am unable to get rid of it..pls suggest me a best ideas to improve my self ....

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    4. You've taken the first step, Rohit. You now need to take help. For the rest see below.

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  3. Dear Sir,

    As you said medicines are available. Can you suggest how and where to get those and some more details.I mean how to deal with such a person (with this abuse) you are living with.

    ReplyDelete
    Replies
    1. Medications to reduce symptoms and craving are available. For this you must seek psychiatric consultation. It may not be possible to deal with this addiction without professional help.

      I don't want to give the impression that it is easy to recover from this addiction; it is not.
      Recovery will mean work for the person and the caregivers/family. Here are some of the things you may do
      1. Take a commitment form the addicted person that they will abstain from using inhalants
      2. Take a commitment that they will accompany you to see a psychiatrist. Persistence of whitener use into adulthood is highly associated with psychiatric illnesses like bipolar disorder, adult adhd, and personality disorders. These need to be treated also.
      3. Follow the plan for monitoring and reporting set up by the psychiarist
      4. Ensure you accompany the person for all psychiatry visits to give feedback
      5. Don't get into arguments about drug use and relapses. Relapses will occur. They need to be analysed to prevent future recurrences. This is done at regular psychiatric review.

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    2. This comment has been removed by the author.

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    3. Dear Sunita. Your 17yr son is sniffing whitener regularly since 6-7yrs and this has increased since 8 months. He is being counselled since about 3months and is not showing improvement.

      3 months is a short period in your sons case. However, there should be some imporvemnt in this time. You need to try/add other options. Here are some in case you haven't already done so.

      Psychiatry consultation and treatment
      He may have other co-existing psychiatric illnesses. This is common in adolescents with addictions. Simultaneous treatment of these psychiatric illnesses, if any, will help control the addiction.

      Indoor treatment
      Treatment as an in-patient in a safe environment will ensure a period of abstinence during which relapse prevention is addressed. This may need to be repeated in case of relapse.

      I trust the counselling is addressing issues related to his environment and with motivating him to meaningfully fill in the time that would otherwise be occupied with his addiction.

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    4. This comment has been removed by the author.

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    5. Dear Sunita, its OK for your son to promise abstinence, thats a starting point for the dialogue. The psychiatrist needs your input to corraborate this promise of abstinence. When he is unable to remain abstinent in an office setting the next step is enforced abstinence as an in-patient.

      Arguing, abusiveness and answering back when not associated with craving or withdrawal from whitener could indicate the emergence of other psychiatric problems. Discuss this with the treating psychiatrist.

      Monitoring is definitely required, as also discipline. They are more effective when associated with caring and warmth. The monitoring should get gradually less direct when your son starts improving.

      Take care

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    6. This comment has been removed by the author.

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    7. Dear Sunita, I can't give you feedback on any specific centre. Your own feedback would be more appropriate and meaningful.

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    8. vo sirf ek imaginara world ko sach maan kar whitener kar rha h...jaha use lagta hai ki uski kuch value h ya phir vo us world ka hero h nd jb vo aisa nai karta}whitener{to ek ajeeb sa khalipan use mehsus hota hoga....rehabilitation center me vo apne aap ko sir ek prisoner ki tarah samjhega nd vaha se aane ke baad fir vo hi shuru kar dega...jo cheez vo un bottles me dhund rha h agar uska pata lagayenge to shayad kuch positive result mile

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  4. Dear Sir,

    Your suggestions seem to be very helpful.One can really think of taking psychiatric treatment. It will help boost mental state in a positive side.

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  5. Dear Sir,

    I have heard that inhalation of white ink damages the brain cell.. and it also causes memory loss and nervous break down. And because of this, the victim of the drug abuse is likely to perform bad academically.... would suggest a good diet and exercise and medication to boost up the damaged brain cell and increase concentration and memory?

    ReplyDelete
    Replies
    1. Yes, chronic whitener users develop damage to all organ systems - brain, heart, lungs, kidneys, and liver. But this is shown to be reversible with abstinence.

      The ingredients of a good mental health diet are specifically discussed here http://blog.pathfinderclinic.com/2011/11/diet-and-mental-health.html#quality Do check out the chart link. It gives an excellent idea of the value of each food group. This information is evidence based.

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  6. dear sir,
    i am inhaling whitener from last 2 years .......i can be pregnant or not.....kindly advice

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  7. Dear Adaa
    Whitener abuse in pregnancy can result in Fetal Solvent Syndrome. Affected infants are typically born premature, growth retarded, have a small head, and odd facial appearance (eg, deep-set eyes, small face, low set ears, small jaw), flat fingertips and small fingernails.

    Still-birth or death of the new born can occur from exposure typical of whitener abuse.

    Exposed children up to 3 years of age show developmental delays, language impairment, hyperactivity, difficulty with balance and coordination, and growth retardation.

    These fetal defects can occur when toluene (whitener) is inhaled upto 2 weeks before conception.

    If think you are pregnant you need to consult a gynaecologist at the earliest and discuss your habit with him or her.

    If you are planning pregnancy seriously consider getting help to stop all whitener abuse for at least a month before.

    Reference
    Scott E. Bowen and John H. Hannigan. Developmental Toxicity of Prenatal Exposure to Toluene. The AAPS Journal 2006; 8 (2) Article 49. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3231560/pdf/12248_2008_Article_BF02854915.pdf)

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  8. dear sir
    m takin whitener regularly az 1 btl daily....n m actin lyk abnormal at doz periods....cn u plz say m dat wht hpns aftr takin whitener...i know wht m doin...bt i cnt avoid mah self 2 doing so....m feelin lyk entering in nthr world...n imaginations are takinplace lyk m flying in d air...swimming in water....doin s.x....oll diz....n m going d same place aftr inhaling dis...plz find m some way out...m confused...where m goin...who r doz ppls m meeting daily after inhaling whitener...plz help m...

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  9. dear sir,
    i am inhaling whitener for 2 yrs n i know all its effect but i cant resist my self inhaling it pls help me..i have all the symptoms

    ReplyDelete
    Replies
    1. Acknowledging the need for help is a major positive step. Consult with a psychiatrist to initiate the process towards recovery. Many have overcome the habit; now that you are motivated there's no reason you won't be able to.

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  10. I am a diluter addict for more than 5 years . The hallucinations which i get when i inhale it is amazing but i know its too dangerous for the human body. I have one good suggestion how anybody can leave that :-
    1) Send yourself or the addict to a place where he/she doesnt get the whitner/diluter
    2) Try engaging him to a different thing , maybe something which doesnot remind of the diluters.
    3) Persuade to switch from diluter to any other thing maybe liquor ..

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  11. Dear sir,
    I was a diluter addict for about 1 year but now i have quit.I m not using it from last 1.5 years.But there are some memory problems with me and i face problems when i study,in listening and understanding things,reading-while reading sometimes it is like when i start reading second line i forget the first line.i cant remembers events from past like what i did last summers or the previous one.i remember i went to that place but was it last yr or the previous one.I also face problem in remembering people.1 yr back i was in a relation with a girl for about a month,and now i cant remember her name,how much i try..In exams also i face a lot of problems i cant remember some things even if i have learnt and revised them several times.I m in final year of my graduation.
    Please tell me how can i get out of this problem.

    ReplyDelete
  12. Dear sir,
    I was a diluter addict for about 1 year but now i have quit.I m not using it from last 1.5 years.But there are some memory problems with me and i face problems when i study,in listening and understanding things,reading-while reading sometimes it is like when i start reading second line i forget the first line.i cant remembers events from past like what i did last summers or the previous one.i remember i went to that place but was it last yr or the previous one.I also face problem in remembering people.1 yr back i was in a relation with a girl for about a month,and now i cant remember her name,how much i try..In exams also i face a lot of problems i cant remember some things even if i have learnt and revised them several times.I m in final year of my graduation.
    Please tell me how can i get out of this problem.

    ReplyDelete
    Replies
    1. Your memory problems are residual effects of diluter use. However, these will reduce with time as the brain starts to heal. The memories of past events may remain patchy because they were not laid down in the first place - inhaling diluter interfered with that. Events that take place now will be better converted to serial memories.

      A neuropsychological assessment will deliniate the extent and nature of the memory problems. Based on that a specific program can be designed to help memorise things that you now consider important. Some techniques are given at www.pathfinderclinic.com/study-skills (Habit No5).

      Studying for exams can be an issue with many students. It requires a specific approach described here www.pathfinderclinic.com/exams. Studying to learn needs effort and a systematic approach. Incorporate these techniques into your study schedule.

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  13. sir could you please give me your phone number. I want to visit you

    ReplyDelete
    Replies
    1. 020-66069676. All my contact details can be accessed from the 'my profile' link at the top of this page.

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  14. dear sir,I'm 15years old n i have left inhaling diluter a month back(is used bagging method)...i started inhaling it with my frns...actually i left iz b'coz i stared facing problems lyk chest pain,n i forget things very soon...n nw m afraid to tell all this to my parents..will i recover..?? pls help..

    ReplyDelete
  15. Dear Vinay,

    (also see the comment above dt 17-Jul-12 and my reply of 18-Jul-12)

    You've done good to stay off diluter for a month. Stay on this course and you will start seeing improvements. By two years recovery can be complete.

    Source: Cairney S, Maruff P, Burns CB, Currie J, Currie BJ. Neurological and cognitive recovery following abstinence from petrol sniffing. Neuropsychopharmacology. 2005;30:1019–1027. http://www.ncbi.nlm.nih.gov/pubmed/15714227

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  16. I'll take 2years to recover..?

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  17. sir today i had my sci exam,i guess I've failed...i just can't concentrate on my studies,i keep on thinking tht I've damaged my brains...I'm very afraid i can't even sleep at nights..and the things that makes me afraid is am i having cancer?(cuz I'm having chest pain and itching in my throat)..i'm always worried...nw will i die soon? Pleases help me sir..

    ReplyDelete
    Replies
    1. Vinay, you need to talk to an adult you can trust about this. Tell your parents about what you are experiencing and let them take you to a doctor. In case that's not possible then talk to your school counsellor. You don't need to go through this on your own. A visit with your doctor will clear most of the issues you are worried about. Otherwise please let me know how we can contact you directly.

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  18. Sir, i would prefer to contact you..I'm from Mumbai,do you need my mobile no.? or how can i contact you..? pls let me know...I'll do anything you but please help me...i want to bcome normal the way i ws before..pls help me out..

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  19. hello Sir,
    I'm occasionally whitner inhaler since a year. (whitner+diluter in poly bag) But i'm facing a problem like illusions from last couple of months. means i used to inhale with friends but it ONLY HAPPENED when i'm out of eye-sight of everybody or inhaling it alone. it never happened when anyone notices me. that they could explain what i was doing actually. in most cases i just left/threw my poly bag nothing else but how? i don't know that. n suddenly came out from illusion. and illusions happens twice or 3 times in a row.

    ReplyDelete
    Replies
    1. continuing.
      first i used it to just blank out of get high. so i used to inhale with music. but nowadays, illusions happens whether music is OFF or ON. I like that illusions kinda cool.
      but in other side, i'm ready to stop inhaling. Because i'm not addicted. I used inhale once or couple of times in month.

      Delete
  20. Hi sir i inhaled diluter and whitner for over 4 years but for last 1 year i stopped it and now i really hate these substances. I have different medical issues include sexual issues. Apart from this i also addicted to alcohol and smoking and still drink 3-4 times in a week. Can u please suggest any doctor who can help me to improve my health. I will be married with in year. Sir please help me

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  21. sir i am living in delhi so please suggest any doctor in delhi

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  22. I had used for one and 1/2 month deluter and whitner both. in 2008 Now i am working with a company past 2 years but .My question is that i am recoverd or not ,i have some issues with forgeting names things place names listning and consuntration on work i also took ganja and chuse for two years in between 2007and2009 ?

    ReplyDelete
    Replies
    1. Should have recovered from the effects of inhalant abuse by now. However, persistent memory and concentration issues could be related to other mental health problems. A psychiatric evaluation will clarify this.

      Delete
  23. dear sir,
    does whitener inhalation compulsorily result into a death some day.

    ReplyDelete
    Replies
    1. Death by inhalant (sniffers death) occurs in 1.53/million population every year (UK figures - the most comprehensive) http://www.drugslibrary.stir.ac.uk/documents/vsa7198.pdf. There are no figures for mortality reates in inhalant abusers per se.

      It does not depend on the users experience or on how long they have been inhaling. Upto 43% of those who die are first time users.

      Severe heart beat abnormalities due to inhalant and stress or activity or a combination of these, is a likely cause. Prolonged exposure to high concentrations can result in coma and subsequent death as a result of respiratory depression. Every time you inhale you risk death.

      Delete
  24. hi Doc,

    My brother is inhaling whitener since 2 or more yrs.. dont knw exactly. when i was with him, he hardly used to inhale within those years. but since i got married now, and i live in a different city. and he is staying with his elder brother nw. when his elder brother is at home, he dont inhale. wheneever he goes to office, he starts inhaling for 1 hour atleast, not that much. when i call him, i can understand.. but i he is trying to reduce it. or family is very much worried for him, and my mother got hospitalised after thinking about my brother. Pls suggest! I love my brother very much. i dont want to ruin his life and career like this. he is just 22 yrs of age.

    ReplyDelete
  25. Suggestions will be appreciated!!!! pls help!!!

    ReplyDelete
    Replies
    1. Dear Garima, please go through the following comments on this post by others in a situation similiar to yourself. They cover suggestions for what to do if a loved one is a whitener abuser
      28-Mar-12 http://bit.ly/Q0sOlq
      09-Apr-12 http://bit.ly/SdoRzj

      Delete
  26. hi doctor, i am guru. i had called you and talked about my brothers death due to whitener addiction. P.M report has not come yet. he was doing it from past six months. there wer marks of nails on his face like somebody forcefully tried to open his mouth. u have lot of expirience in these cases. my house back doors were open and all lights wer off.we never turn off lights of pooja room but even that small light was off. i have strong doubt that some of his friends might have done this in mistake. can you please tell something about those marks. usally such marks are done by addicted person or by someone else.
    do addicted persons do those by themself without knowing or someone else might have done? please please tell doctor please

    ReplyDelete
    Replies
    1. Dear guru, I'm sorry for your loss. You need to let the authorities follow-up on the specific cause of death in your brother. In general, inhalant related death is discussed in the main post at http://bit.ly/P67u06. Also see Darpan Bhoirs comment above http://bit.ly/QggVff. Sincerely.

      Delete
  27. Dear sir!
    i m 20 years old... m addicted to this drug from past 4 years...in the start i use to inhale it but after one year i started swallowing it by pouring it onto my thumb nail and then suck it with my tongue...plz tell me how is it harmful for me...because untill now i was unaware of its dangerous effects...now i started searching and your guideline would help me to leave this habbit forever...plz help me.. !

    ReplyDelete
  28. Dear Sir
    Recentlay a death has occured in bangalore in college going student of 20 yrs.It was shocking news for the parents of the student who never came to know about there son involved in addiction till death.

    ReplyDelete
  29. sir,i have been inhaling,bagging diluter for past 2 years?
    Is the effect of it on internal organs and brain reversible?????

    ReplyDelete
  30. sir,
    im 20years old .Im sniffing it from last 3 years but stopped from past 3 months , but having problems with my memory im not as efficient as before .pls tell me how long it will take to recover completely.

    ReplyDelete
    Replies
    1. The most noticeable recovery takes place in the first six months. Subsequently memory continues to improve but more slowly as long as you stay off whitener. Memories for past events may still be patchy. New memories will be laid down more efficiently. Stay away from the inhalant, the rest will follow.

      Delete
  31. Thanks for this post!

    ReplyDelete
  32. Sir i m in class 12 ...when i was in 11 i got addicted to smoking and occasional drinking like twice a week ...i stated having whitener too but now i dont, the last time i used was about 6 month back....now i am in class 12 giving my last exam i.e economics,after giving the last 5 exam i found out that what ever i read , i could'nt remind then in my exam .... i am feeling very depressed. sir i want to know will i ever recover for my memory loss ?
    is whitener the reason for my damage ?
    do cegrate and alchole create damage too ?
    sir plz help me ?

    ReplyDelete
    Replies
    1. You've done well to get off the whitener. Learning to remember for exams requires a different technique. Apply these effective study skills to improve retention and recall.

      Yes, alcohol does interfere with memory and damage the brain. Cigarettes cause extensive harm to your lungs and heart.

      Delete
    2. Sir will i be ever able to recover from this memory loss ?

      Delete
    3. You will recover from memory loss as long as your don't inhale whitener. Some recovery of memory takes place within eight weeks of stopping whitener inhalation. The speed of recovery would depend on how long you were inhaling whitener before you stopped. By two years recovery is complete.

      You should consult with a psychiatrist to establish a baseline for your present state of memory and learning functions.

      Delete
  33. i did a heavy amount of ganja smoking yesterday . and i am a smoker cum alcoholic (occasionally). i feel like i don't remember things properly every memory is blur . sir will i recover from this memory problem ?

    ReplyDelete

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