Nitrous oxide is often taken in combination with other medications. Thus, its effects can be unpredictable as it depends on the other medications that are taken with it. The use of nitrous oxide is currently still legal, although the ruling coalition is trying to include the gas in the list of drugs prohibited by the Opium Act.   On June 12, 2020, the proposal to include nitrous oxide in Schedule II of the Opium Act was submitted for online consultation, allowing the public to submit “ideas or suggestions” related to the ban. The government aims to bring the proposed ban into force on January 1, 2021.  In anticipation of the planned ban, approximately 90 municipalities have introduced local bans on the substance.  On average, five people die from nitrous oxide each year, with an increase in deaths as the number of people using it has increased in recent years. However, most deaths are due to accidental suffocation and were caused after plastic bags or other devices were placed on the head at high pressure when inhaling the gas or directly from large cartridges. Although no medication is safe, inhaling nitrous oxide through balloons significantly reduces the risk of choking. He started treatment with intravenous immunoglobulin 0.4 g/kg/day for 5 days on the basis of acute demyelinating neuropathy consistent with Guillain-Barré syndrome.
He admitted to using nitrous oxide in the form of “whippits” – small cartridges of nitrous oxide used in whipped cream dispensers. His consumption had risen sharply in the six weeks prior to the presentation, and he consumed about 120 g (15 whippits) per day. Serum vitamin B12 was normal, as were haematological indices; however, methylmalonic acid concentrations increased significantly to 29 653 nmol/L (<280). We started treatment with intramuscular vitamin B12. His sensory symptoms and strength gradually improved over the next six months, although he still needed a cane to walk. High-dose intramuscular vitamin B12 replacement is recommended. There is limited evidence that methionine replacement also helps, although this is currently hard to find in the UK. Methylmalonic acid and homocysteine concentrations return rapidly to normal after the start of B12 preparations. Recovery of nitrous oxide neuropathy can be slow and incomplete: Despite the replacement of vitamin B12 in high doses, each of our patients has persistent symptoms after several months. Nitrous oxide is a neurotoxin and its use can cause long-term neurological damage.  When one mole of nitrous oxide breaks down, it releases half a mole of O2 (oxygen gas) molecules and one mole of N2 (nitrogen gas) molecules.
Thanks to this decomposition, an oxygen concentration of 36.36% can be achieved. Nitrogen gas is non-flammable and does not tolerate combustion. Air that contains only 21% oxygen, the rest is nitrogen and other gases that are just as non-flammable and not conducive to combustion, allows a maximum oxygen content 12% lower than that of nitrous oxide. This oxygen promotes combustion; It combines with fuels such as gasoline, alcohol, diesel fuel, propane or compressed natural gas (CNG) to form carbon dioxide and water vapor, as well as heat, causing the first two combustion products to expand and pressure the pistons, driving the engine. The answer to the question “Isn`t it illegal?” is quite complicated. It is treated as a psychoactive substance under the Psychoactive Substances Act 2016. This means that possession is legal, but delivery and import/export will earn you an unlimited fine and jail time. Nitrogen oxide injection systems for cars are illegal for road traffic in some countries. In New South Wales, Australia, for example, section 22.214.171.124.3 of the Roads & Traffic Authority`s Code of Practice for Light Vehicle Amendments (in force since 1994) states that the use or installation of nitrous oxide injection systems is not permitted.  In anecdotal reports, some people have reported developing cravings or feelings that they want to continue using nitrous oxide. The tightening of access to nitrous oxide in 2016 does not appear to have had an impact on demand, with nearly one in ten 16- to 24-year-olds reporting using nitrous oxide in 2019/2020.
In this context, it may be understandable that the government wants to take a new path. This raises important questions about the purpose and function of drug laws. Nitrous oxide – commonly known as nitrous oxide, NOS, nitro or nitro – is an odourless and colourless gas. When inhaled, the gas produces feelings of euphoria, dizziness and relaxation, and can cause auditory and visual hallucinations. If no more gases are inhaled, the effects disappear after a few minutes. In the late 1700s, the substance was used as a source of entertainment at upper-class social gatherings in Europe – appreciated for its dreamy, sedation, and often laughing effects. In the years 1844, nitrous oxide was first used in a tooth extraction process and proved effective as an anesthetic for dental and medical procedures. It may be reasonable to conclude that the focus on nitrous oxide is more about the emergence of “drugs” than the serious harms of the drug. There are several ways to do this without toughening criminal penalties.
Giant online retailers could actively remove offers. Food service providers could crack down on bulk purchases by limiting the number of nitrous oxide cans that can be purchased at one time and limiting sales to approved or registered buyers. Repeated and intensive use of nitrous oxide can cause vitamin B12 deficiency, which can lead to nerve damage. These cases seem most often associated with very intensive use (dozens of cans consumed per day for several months) or occupational exposure (dentists and anaesthetists). Suction on a nitrous oxide balloon was the norm at music festivals. But no more. Most of Britain`s major festivals have banded together to ban legal highs from their events to send the message that they are not safe. The use of whips – as well as other “legal highs” that are considered “safe” in everyday language – is not safe. We should communicate this fact to our patients, adolescents and children, and the government should take a strong stance to limit the availability of this drug. Physicians should be smart enough to know and understand the impact of different legal highs on the market, recognize their potential complications, and work to educate the public about their harms, as well as identify and treat those affected.
If the police catch people selling illegal drugs in a home, club, bar or hostel, they may be able to prosecute the owner, club owner or anyone else involved in the management of the premises. Using nitrous oxide directly from a large can makes it harder to track how much you ingest, so you`re more likely to suffer the negative effects of using a lot of gas. In England and Wales, it is not illegal to possess nitrous oxide, but that may soon change. UK Home Secretary Priti Patel has asked her scientific advisers to review the evidence of harm associated with its use. It may be possible to become psychologically dependent on nitrous oxide, meaning users develop an increased desire to continue using it despite the harm it can cause, but evidence is limited. The toxic effects of nitric oxide are mediated by the oxidation of cobalt ions to vitamin B12 and therefore cause its inactivation. This results in a reduction in the recycling of homocysteine into methionine. This prevents methylation of myelin proteins and thus leads to demyelination of the central and peripheral nervous system.
However, demyelination may not be the only pathophysiological mechanism: the second case had no pathological evidence of demyelination, but of ischemic neuropathy. In most cases reported in the literature, the neurological presentation associated with nitrous oxide abuse is that of myelopathy, which particularly affects the dorsal abutments – subacute combined degeneration of the spinal cord.3–5 Two of our patients had no clinical signs of myelopathy and their spinal cord imaging was normal.