Nitrous oxide – just fun or huge risks for the user? From heart, neurological, motor and many other problems, to the consequences for the psyche and severe long-term health effects... Dr. Neyko Neykov, a neurologist and sleep medicine specialist at “Acibadem City Clinic UMBAL Tokuda“, spoke in front of FACT.
- Dr. Neykov, nitrous oxide is often perceived by adolescents as something harmless and “just for fun“. What actually happens to the brain and nervous system when it is inhaled?
- The very name “nitrous oxide“ is a bit misleading. It sounds like something harmless. And in fact, we are talking about a substance that acts directly on the brain. The effect occurs very quickly - literally within seconds. Mood and perceptions change. A person can suddenly feel a good mood, causeless laughter, relaxation, lightness, sometimes a feeling of being detached from the environment or even from their own body. And this is exactly the expected effect.
However, along with these sensations, other processes also occur. Judgment worsens, reactions slow down, coordination and balance can be impaired. That is, a person can subjectively feel wonderful, but objectively their brain no longer works in the usual way. This is also one of the dangerous features - &ldash; “I feel good“ does not necessarily mean “everything is fine“.
Here it is important to say that laughing gas is not an exotic substance unknown to medicine.
On the contrary - it has been used for many years for pain relief and sleep. The difference is that in medicine this is done in a controlled environment. We know what concentration we are giving, for how long, it is usually given in a mixture with oxygen, the patient is monitored and there are clear safety rules. The dose is not determined “by balloon“ - another one, because the previous one did not work enough.
And even in medicine today we are much more cautious with it. In a number of situations we have other means and its use is more limited than it was in the past. That is, the fact that a substance has a medical application does not in any way mean that it is harmless when used freely and without control.
There is also another, more insidious effect that a person does not feel immediately. Nitrous oxide prevents the body from using vitamin B12 properly. And this vitamin is extremely important for maintaining the nervous system and the protective covering of the nerves. With repeated or more intense use, the nerves in the arms and legs can gradually begin to suffer, and in more severe cases, the spinal cord. So we actually have two very different types of effects. One is the immediate one – the brief pleasant feeling that the substance is used for. The other is the quiet, cumulative damage to the nervous system that can manifest itself days or weeks later. And there is no warning light in between. A person can have used laughing gas several times, then feel completely fine, and that is precisely what gives them the false feeling: “If nothing has happened to me so far, then it must be safe.“
- What are the first neurological symptoms that can appear with regular use of laughing gas, and are there any signs that parents can recognize?
- The first symptoms are often not very dramatic and that is precisely why they can be easily underestimated. It usually starts with numbness, tingling, or decreased sensitivity in the feet and hands. Some people describe it as a feeling of stepping on something or that their feet are somehow “foreign”. Uncertainty when walking, easier staggering, weakness, clumsiness of the hands, dropping objects may occur. In more serious cases, there may already be a clear gait disturbance and a person may begin to have difficulty even with normal daily activities.
However, I want to clarify one thing here - none of these symptoms in themselves mean that someone is using laughing gas. Numbness, unsteadiness, or weakness can have many different causes. I would not like to create the attitude that if a child staggers or complains of numbness, the parent should immediately conclude: “He is using something.“
The role of the parent is not to be an investigator. It is more important to know your child and to notice when there is a lasting change. If he starts complaining of unusual numbness, if his gait changes, if weakness, unsteadiness appear, or these symptoms gradually worsen, this is a reason to first talk, and then - if the complaints persist - for a medical evaluation.
The goal is not for the parent to "recognize laughing gas". The goal is to recognize that their child may have a neurological problem and that they should not just wait for it to go away.
Of course, if these symptoms are accompanied by information about the use of nitrous oxide, then it is already very important to share this with the doctor. Sometimes it is this information that guides correctly and saves time. But the approach should be a conversation, not an interrogation. If the child expects an accusation or punishment, he is much more likely to simply hide the use, and this can delay treatment.
- You mentioned that nitrous oxide affects vitamin B12. Why exactly can a deficiency of this vitamin lead to serious damage to the nervous system?
- Vitamin B12 is one of the substances without which the body can hardly maintain and restore its body normally. It participates in the formation of blood cells, in the growth and renewal of cells, but for us as neurologists it is especially important that it is necessary for the normal maintenance of the nervous system.
Our nerves are not just “wires“. They also have a protective sheath that allows them to transmit signals quickly and correctly. Vitamin B12 is very important for maintaining this shell. Nitrous oxide does something insidious – it can make vitamin B12 in the body practically unusable. That is, a person may even have vitamin B12 in their body, but the body cannot use it normally. It is as if you have the necessary material for repair, but it is locked in a warehouse and no one knows where the key is. When this continues, the nervous system begins to suffer. First, changes in sensitivity such as numbness and tingling may appear. Then, balance, gait, and strength of the limbs may be impaired. In more severe damage, the nerves themselves and the spinal cord may be affected. That is why the problem with nitrous oxide is not simply a “vitamin deficiency”. The vitamin is part of a system without which the nervous tissue cannot be maintained normally. If we block it for long enough, real structural damage begins.
And this is one of the reasons why people are mistaken – The effect of nitrous oxide wears off in a few minutes, but the disruption it causes to the functioning of vitamin B12 may remain even after that. That is, the balloon is long gone, the "pleasure" has passed, but the process that can damage the nervous system has already begun.
- A scientific publication by a team from “Tokuda“ describes cases of young people with neurological complications after nitrous oxide abuse. What were the complaints of these patients and do they fully recover?
- This is actually one of the questions that is difficult for me to answer with just “yes“ or “no“, because in these patients we saw how differently the same injury can progress. The complaints at the beginning were often exactly those we have already talked about - numbness in the hands and feet, loss of sensitivity, weakness, unsteady gait. In some, however, the process had progressed much further and the patients could no longer walk normally or move at all without assistance. And the recovery is very different. We have a young woman who has still not regained normal sensation in her legs. We also have a patient in whom the symptoms have practically disappeared. That is, yes - recovery is possible, sometimes even very good. But we cannot promise the person in advance that it will be so. We also have another very telling case. A young woman after such an injury subsequently became pregnant. She has recovered to a large extent, but the experience continues to matter years later.
Now, during childbirth, anesthesiologists must take into account the previous damage to the nervous system and the choice of pain relief and anesthesia becomes more complicated.
That is, the consequence is not necessarily just “my legs were tingling for a few months and then it went away“. Sometimes this remains part of a person's medical history and influences decisions that will be made much later.
Perhaps the most striking example for me is two students who used nitrous oxide together - in the same room, within about a week. At first glance, you would expect the consequences to be similar. They were not. One of them now uses crutches. The other is still in a wheelchair.
This is very important, because with nitrous oxide, you cannot draw conclusions like "I used this much, my friend used the same and he is fine." Our bodies are not the same. It matters what kind of vitamin B12 reserves a person has, how they eat, how often they use it, in what period, and probably a number of individual characteristics that we cannot know in advance.
That is why the answer to the question "do they recover completely?" is - some yes, some no. The nervous system has the ability to recover, especially in young people and when the problem is recognized and treated in time. But there is a point after which some of the damage may remain.
And for me, these young people are the strongest argument against the line "it won't happen to me". None of them started out with the idea that after a few balloons they would one day have to learn to walk again.
- Can the use of nitrous oxide lead to permanent damage to the brain, spinal cord or peripheral nerves? Which of the consequences can last a lifetime?
- Yes, it can. And this is actually one of the most important things that should remain from this conversation - with nitrous oxide we are not just talking about temporary dizziness or numbness, which will definitely pass.
Peripheral nerves - the nerves of the arms and legs - as well as the spinal cord can be affected. In severe cases, the consequences can be weakness, impaired sensitivity, problems with balance and gait, and sometimes loss of the ability to move independently.
How much of this will recover varies from patient to patient. Some people recover almost completely. Others may experience numbness, decreased sensitivity, weakness, or difficulty walking. In the most severe cases, some of the damage may be permanent.
Regarding the brain, the situation is a little different. Most often, with abuse, we see problems in the peripheral nerves and spinal cord, but in severe acute poisoning, especially if there is also a lack of oxygen, the brain itself can be damaged.
So the short answer is - yes, the consequences can remain for life. Not for everyone and we cannot say in advance who it will happen to. It is this unpredictability that is part of the risk.
- What are the immediate risks of inhaling large amounts of nitrous oxide – for example, loss of consciousness, lack of oxygen, injuries or other acute conditions?
- Yes, and this is the other side of the problem - so far we have talked more about the damage that accumulates over time, but with nitrous oxide there are also very immediate risks. Some of them can occur during the use itself.
When large quantities are inhaled, especially one after another, a person may not receive enough oxygen. The brain is extremely sensitive to this. Initially, there may be severe dizziness, confusion and an even greater change in perceptions, and in a more severe case - loss of consciousness. If the lack of oxygen is severe enough or prolonged, we can already talk about permanent brain damage, and in extreme cases - a fatal outcome.
But in my opinion, one of the most underestimated risks is the combination. A person simultaneously perceives the world differently, assesses the situation worse, his reactions are delayed and his coordination is impaired. If we add to this a lack of oxygen, we get a great recipe for trauma. A fall from one's own height may end with only a bruise, but the same person may be on the stairs, on a terrace, by a pool, on the street or behind the wheel. Then the consequences no longer have anything to do with “a few minutes of fun“.
There is also a very specific risk associated with the method of use itself. Nitrous oxide is stored under pressure and when released, it cools down extremely strongly. If inhaled directly from a bottle or vial, it can literally cause frostbite – of the lips, mouth and throat. Among users, you can even find the expression “NOS lips“ for the characteristic damage around the lips. This is not just a cosmetic problem – Severe frostbite of the mouth and throat has been described, and direct inhalation under high pressure can also damage the lungs.
Cold burns can occur without a person inhaling directly from the bottle. When the gas is released, the metal container itself becomes extremely cold. Severe burns to the thighs have even been described in people who have held the large bottle between their legs while filling balloons. An additional problem is that nitrous oxide dulls the sensation and a person may not immediately realize how seriously they are burned.
So the immediate risk is not one. We have oxygen deficiency, loss of consciousness, altered perceptions, impaired judgment and coordination, cold injuries and trauma - and these things can happen at the same time. It is the combination that makes them particularly dangerous.
And again we come to the same problem - in recreational use, no one measures concentrations, no one monitors oxygen, and no one knows in advance at what point "one more balloon" will turn out to be one more balloon.
There is another very important practical point - laughing gas is rarely used alone.
Especially at parties, it often goes hand in hand with alcohol, cigarettes or vapes, and sometimes with other substances. Then the risks are no longer separate from each other, but begin to overlap. Alcohol, for example, also impairs judgment, slows down reactions and disrupts coordination. If we add to this laughing gas, altered perception and a possible lack of oxygen, the risk of falling, loss of consciousness or other trauma increases significantly.
Nicotine works by a different mechanism, but it can also add dizziness, nausea, palpitations and additional stress on the body. So a person often does not take a single risk, but several at once.
This is what makes use at parties and parties particularly unpredictable. It is not just a question of "how much laughing gas has been inhaled", but what else has been drunk or used, how much sleep has been taken, whether he has eaten, whether he is dehydrated and what kind of environment he is in. At some point, these factors begin to reinforce each other and the risk is much greater than it would be from each one separately.
- You and your colleagues participate in meetings with students, where they are told about the harm of nitrous oxide and other substances. How do the children themselves react - do they accept the doctors' warnings, or do they still consider it a harmless fad?
- They are definitely impressed. What affects them the most is not so much the abstract warnings like "this is harmful", but the concrete consequences - that a permanent disability may remain, that a person may not walk normally for months, may need rehabilitation, medication, tests, and sometimes that treatment can cost a lot of money and last a long time.
When we speak with specific examples, and not just in an edifying tone, then they listen. Especially when they realize that these are not some distant cases of “people who have overindulged terribly”, but their peers – schoolchildren, university students, young people.
But something else is also striking, which is more worrying to me. Almost immediately after the questions about laughing gas, the questions about everything else begin – nicotine pouches, snus, vapes, marijuana, CBD, THC and its various modifications, stimulants and the so-called “study drugs“, including methylphenidate and modafinil.
And here we are talking about children in 9th, 10th and 11th grades.
Sometimes they know the terminology, the different products and the way they are used, surprisingly well. Of course, this does not mean that every child who asks a question necessarily uses them. Curiosity is normal. But it shows how accessible and how close to their daily lives this information has become.
And that, I think, is the big problem - a lot of these things are no longer necessarily perceived as “drugs“ in the classic sense. A vape is just a vape. A pouch is “just nicotine“. CBD seems harmless because it is sold legally in many places. And when a substance is also a drug, like methylphenidate or modafinil, it sometimes creates the additional feeling that if doctors prescribe it, then it is safe for everyone.
And that is why I think these meetings make sense not when we just say “don't do this“, but when we explain what these substances actually do, what the risks are and why it is “legal“, “trendy“ or “over the counter“ is not synonymous with “safe“.
- Where is the line between experimental use and already dangerous abuse?
- I would be a little careful with the very concept of “experimental use“, because it easily creates the feeling that there is some kind of safe trial period – the first few times we are just experimenting, and only then does the danger begin.
From a medical point of view, there is no such clear line. There is no number of balloons, cigarettes, tablets or uses, after which we suddenly cross a line and say: “From now on it is already dangerous.“ Use is use and the effect on the body begins from the first time.
Of course, this does not mean that a person who has tried a substance once is automatically addicted. These are two different things. Addiction usually develops over time and involves loss of control, an increasing desire for the substance, continuing despite the harm, and gradually organizing one's life around use.
But the danger can appear long before addiction.
A person may never become addicted and yet fall, crash, lose consciousness, or suffer another serious complication during a single use. And with laughing gas, we have already discussed the fact that people do not start from the same starting point - one person may have good vitamin B12 stores, while another may be borderline deficient and not know it.
That's why I don't approve of the phrase "just trying it." It describes the person's intention, but it doesn't describe the risk. The body doesn't know if you're doing it out of curiosity, for fun, or because you already have a problem with use. For it, there's only the substance, the amount, and the effect. This is perhaps the simplest way to put it: not every use means addiction, but every use means exposure to risk. And with some substances, sometimes even one use is enough to have very serious consequences.
- When should a parent seek medical help, even if the child denies using laughing gas?
- A parent shouldn't wait for the child to admit it to seek medical help. If there are real symptoms - prolonged numbness, weakness, a change in gait, staggering, problems with coordination or sensitivity - this in itself is sufficient reason for an examination.
I say this from quite a lot of practical experience. In recent years we have seen many such patients - the cases we have described alone are already over 50. And denial or downplaying of use is something we encounter constantly.
Sometimes it is categorical: "I have never used." Other times it starts with versions like "Yes, but it was only once, years ago". Most recently we had another young girl whose story changed in this way. And this does not necessarily mean that we are dealing with a "bad child" who is simply lying. Often there is fear - of the parents, of the doctor, of the consequences, of how it will be perceived.
We also had a very telling case in which a young patient categorically denied use. In the meantime, several needle EMG tests, two MRIs, and a lumbar puncture were necessary, because the clinical picture led us to look for other serious diseases of the nervous system. We got to the point where we were discussing complex and very expensive treatment for another possible disease. Only later did she share her use with a young colleague who had managed to gain her trust. For me, this is very indicative - pressure does not always lead to the truth. Sometimes the truth comes out when the patient feels that the person in front of him wants to help him, not judge him.
But there is also the other extreme with parents.
I had a patient whose mother knew about the use, but did not want to be the “bad parent”, did not want to forbid her, and tried to maintain a more friendly relationship. This is also understandable as a human reaction, but at some point the parent has to be a parent.
Having trust with your child does not mean accepting everything he does. You can simultaneously say: “I will not judge you and you can tell me the truth“, and at the same time: “This is dangerous and we need to set a limit here.“
That's why I would say to parents: be neither an investigator nor an accomplice. Be a parent.
If there are symptoms - see a doctor, regardless of whether the child admits to using. If you have doubts, share them with the doctor calmly, as an opportunity, not as a verdict. And all the examples I give are deliberately generalized and without details that would allow the patients to be recognized. They are only a small part of many similar cases that we have seen. The important thing here is not the specific person, but the recurring pattern.
Ultimately, the goal is not to extract recognition or win an argument. The goal is for the young person to get the right diagnosis and treatment in time.
- What is the most important message you would send to a teenager who thinks that a few puffs “can't hurt”?
- My most important message is very simple: don't count on you being the one person who “can't hurt”.
Yes, it's possible for someone to have tried it a few times and not have any visible consequences. But we've already talked about why that doesn't mean the substance is safe. You don't know what vitamin B12 you're starting with, you don't know how your body will react, you don't know what else you've mixed with it, and you don't know if this time you're going to fall, lose consciousness, or get an injury that will take months to treat. I wish young people would understand - none of the patients I've told you about went in thinking: "Today I'm going to damage my nerves and end up in a wheelchair."
They were all expecting a few minutes of fun.
The problem is that the body doesn't care whether we call it "just once," "for the party," or "just trying." It has substance, quantity, and effect.
And if I may allow myself a very personal message to teenagers - Trust me, we have enough work to do without teaching you how to walk again.
It's better to be the person who said "no, thanks" and five minutes later everyone has forgotten, than the person who months later still remembers that night.