Nitrous oxide addiction or not, action is needed. A response to commentaries

While disagreement about the usefulness and appropriateness of classifying nitrous oxide as addictive is evident, the urgency to address nitrous oxide related harms is undeniable. The great variety of views presented in the commentaries in response to our article highlight the need for a thorough discussion on the topic of nitrous oxide (N2O) addiction, the utility of the DSM-5 in the case of atypical substances and the need to classify a substance as addictive in a broader health-care perspective. In our article 1 we argue that there are indications that N2O could well be addictive but that evidence is limited, and that systematic research is needed to confirm the addictive potential of N2O. Furthermore, we argue that treating N2O as a potentially addictive substance is important to highlight the urgency for additional research, but also to encourage adequate education about the risks of N2O use and the accessibility of health-care. From the commentaries it becomes clear that defining a substance such as N2O as potentially addictive is controversial, and that the perceived usefulness and justification of this definition is largely dependent upon the field (i.e. epidemiology or neurobiology). While Victorri-Vigneau & Grall-Bronnec 2 argue that N2O addiction is undeniable and that there is a consensus on the addictive potential of N2O, Brunt 3 argues that classification of N2O as (potentially) addictive—even as part of the inhalant disorder category—is questionable, due to its lack of reinforcing properties in animals and its unclear interaction with mesocorticolimbic pathways implicated in other substance use disorders. All authors agree that N2O-related harms need to be addressed, but the potential harms that a label such as 'addiction' can cause are also important to address. For example, Winstock 4 acknowledges the lack of research into the addictive potential of N2O, but argues that the label 'potentially addictive' may do more harm than good, as the label 'addictive' is not required to 'craft an optimal public health response' and 'may add to stigma and reduce treatment seeking'. While we agree that significant harm reduction can be achieved through education and evidence-based regulation, we strongly believe that more insight into the addictive potential of N2O would strengthen the theoretical foundation of such education efforts. Furthermore, the current lack of knowledge regarding the mechanisms underlying N2O-related problems might harm treatment-seeking more than the additional stigma that comes with an 'addiction' label. As also highlighted by Allan et al. 5, the urgency to address N2O use-related problems is extremely high: the N2O era is here, and we have no time to ignore it. Governments need to take action: research funding is crucial to increase our knowledge on the addictive potential of N2O, and health-care professionals as well as people who use N2O need to be better informed about the 'signs and symptoms of problematic N2O use'. As long as these investments are made, we will eventually come closer to settling the debate surrounding the addictive potential of N2O and the need to classify it as an addictive substance. There are no funders to report. None. N/A.