Whipped Cream With A Side Of Spinal Cord Damage

Nitrous oxide can look like a harmless party trick until you understand how fast it can flip into a medical emergency. We dig into whippets and laughing gas from an addiction medicine perspective, including why the high hits within seconds, why people keep reaching for “just one more,” and how the same drug can functionally mimic ketamine, benzodiazepines, and opioids in the brain. That mix helps explain both its legitimate role in minor procedures and why it can be so addictive outside the clinic. 

We walk through what clinicians and families often miss: standard urine drug screens do not detect nitrous oxide, the detection window is short even with advanced lab testing, and the clearest red flag may be a profound vitamin B12 deficiency in someone who should not have it. From there, the conversation turns to the real stakes of B12 inactivation: spinal cord degeneration, myelopathy, peripheral neuropathy, gait instability, weakness, bladder dysfunction, cognitive changes, and the uncomfortable truth that we often cannot predict whether nerve damage will be permanent. We also cover immediate dangers while using, including hypoxia and sudden unconsciousness, traumatic falls, frostbite and cold burns from direct canister inhalation, pneumothorax and pneumomediastinum, arrhythmias especially when mixed with stimulants, mental health destabilization, increased blood clot risk, and serious pregnancy risks. 

Because there is no proven medication-assisted treatment for nitrous cravings, we focus on what we can do: treat co-occurring anxiety, depression, and trauma, use CBT and group therapy, push hard on vitamin B12 replacement, and apply practical harm reduction when someone is not ready to quit. We close with a vivid patient case that shows how smoke shop access and relapse can spiral into hospitalization and disability, and how recovery is still possible with the right support. 

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To contact Dr. Grover: ammadeeasy@fastmail.com

Transcript

Testing Limits And Detection Clues

Nitrous History And Legit Uses

How People Use Whippets

Brain Effects And Addiction Pathways

Immediate Dangers While Using

Vitamin B12 Damage And Nerves

Other Medical And Mental Harms

Dependence Withdrawal And No MAT

Trauma Anxiety And Dual Diagnosis

Practical Harm Reduction Steps

Sales Loopholes And Regulation Problems

Patient Case From Relapse To Recovery

Final Thanks And Key Message

SPEAKER_00 0:08

Hi, I'm Dr. Casey Grove. I spent years practicing emergency medicine before shifting my focus to addiction medicine. This podcast grew out of caring for patients, hearing their stories, and wanting to do better. Here we talk about recovery, medicine, and compassion. This is Addiction Medicine Made Easy. This episode is on nitrous oxide. I covered this topic once before in 2024, and I rebroadcasted that episode in 2025 after one of my patients had a particularly bad relapse on nitrous, and I wanted to increase awareness about the harms of nitrous oxide. But this is a totally new episode on nitrous oxide. As you've heard me say, I am the medical director for a local drug and alcohol treatment program, and I do monthly lectures on various addiction topics for the staff. And this month, the staff asked for a lecture on nitrous oxide. So I wrote up a new lecture and recorded myself when I gave it to make it into a podcast episode. As I was editing the episode, I realized I needed to clarify a few points. First, detecting nitrous oxide on a urine drug test. I am not aware of any point-of-care immunoassay tests that can detect nitrous oxide. And most definitely, standard point-of-care immunoassay urine drug tests that test for things like cannabis and opiates and benzos do not include a test for nitrous oxide. However, it turns out you can detect nitrous oxide on a liquid or gas chromatography mass spectrometry lab test. But the lab we use at my practice doesn't have this assay set up yet. So I am not currently able to detect this with the lab that we use. I emailed my contact with our lab and they are working on a nitrous oxide assay to add to our panel. Now, because nitrous is metabolized so quickly, the window of detection is very short, meaning that we would only be able to detect nitrous oxide use if a person provides a urine specimen within a day or two of use. One of my colleagues, because of these limitations, if he suspects nitrous oxide use, will just order vitamin B12 levels. And in a young, healthy person, profound vitamin B12 deficiency would be very unusual. So that could also potentially help detect nitrous oxide use. Second, I wanted to add a little bit to the section on the health consequences of nitrous oxide use. I mentioned a spinal condition called myelopathy and referenced that the lower spinal cord controls the bladder. I just wanted to clarify that because the lower spinal cord controls the bladder, if that particular area of the spinal cord is damaged by nitrous oxide use, patients can actually lose control of their bladder function. Also, I completely forgot to mention in my lecture that regular nitrous oxide use increases the risk of blood plots. Okay, I think I covered everything. With that, let's get started on this lecture on nitrous oxide, which just to remind you is also known as Whippets or Laughing Gas. Okay, so today we're going to talk about nitrous oxide. And I did something different with this lecture. I actually tried to have artificial intelligence help me make the slide deck. And it was a bit of a flop. You'll notice that some of the slides are weirdly formatted. So if anyone thinks you can put build me a 30-slide PowerPoint presentation about nitrous oxide into an AI prompt and get a good presentation, that turned out not to be the case. So I went back and fact-checked everything and it's all good, but just want to explain why the formatting is a little weird. Nitrous oxide has a history. The chemical formula is N2O, so two nitrogens and one oxygen. And it was actually first synthesized back in the 1700s. And it turns out that a British scientist realized in 1799 that it actually gave people a euphoric feeling. And it turns out that it actually became fairly popular in Britain, and they would have laughing gas parties where the British upper class would get together and inhale nitrous oxide. Interestingly, it wasn't realized that there were analgesic properties or the ability to relieve pain until shortly thereafter. And its first medical use was much after the first time it was used recreationally. So the first medical use was not until 1844 for a dental extraction. And I did find this old graphic, which displays a man trying to sedate an angry woman into being much happier and laughing. And the tagline is a prescription for scolding wives, and the date is 1830. So it clearly had some cultural significance at the time. And it currently has a lot of uses. It's used in rocket fuel, and it's also used in car racing. The addition of nitrous oxide increases engine power by increasing the amount of oxygen that the car is exposed to during combustion. Additionally, it turns out it's a really good aerosol propellant for food, specifically whipped cream. And we'll talk about the significance of nitrous oxide being the best gas to make whipped cream because it makes it really hard to regulate this substance. And then the third current use is in the medical and dental setting. We use it for anesthesia during minor procedures. Patients don't go all the way to sleep, but it helps with pain, anxiety, and then amnesia. So let's say someone's got a broken arm, we need to reset the fracture and cast them. We might give them nitrous oxide. They'll be more comfortable during the procedure and they may not remember the painful part. And then it also can be used during childbirth. But why we're talking about nitrous oxide today is this. And as you can see, this is a picture of two women at some sort of festival or concert inhaling gas out of a balloon, and that would be nitrous oxide. So, how do people actually consume it? Nitrous oxide is a gas, so it's compressed into canisters. And usually what happens is the canister, the gas is let out of that canister into a balloon, and then people inhale the gas from the balloon. Nitrous oxide is often called whip its, and that comes from the fact that one particular brand of nitrous oxide is called whip it or W H I P I T, as in it's used for whipped cream. These cartridges come in different shapes and sizes. They're usually sold for whipped cream, and we'll talk about how it's actually made, but they're fairly inexpensive and they're sold in a variety of settings. In the medical setting, we actually tend to get these large tanks, almost scuba tank sized. And in the recreational world, this is someone who's much more of a sophisticated nitrous oxide user, and this suggests more of more problematic use. And usually these large cylinders, they'll rig up some sort of tubing so they can let the gas out of the cylinder and then breathe it in. Now, when the gas is released out of the canister, it comes out at an extremely low temperature. And when people breathe the gas directly from the canister, it can actually cause a thermal injury like frostbite to the mouth and airway. And then when the canister is releasing gas, it actually chills because the gas coming out is cold. And so the canister itself is also very cold. In terms of how often it's used, it is the number three recreational drug used globally among youth 16 to 24. So it's fairly common. As many as 10% of high school seniors have used it in the last year, and as many as about four and a half million Americans will use nitrous oxide or other inhalants in their lifetime. And I just want to quickly pause. If you're wondering what class of drug nitrous oxide falls under, it's an inhalant. And then lastly, and this is some UK data, we've seen a 300% increase in presentations to the emergency departments in the UK related to nitrous oxide between 2015 and 2022. So it's common, and we're seeing complications of it and use of it on the rise. Now there are some unique demographics who are more drawn to nitrous oxide. The first are young adults and adolescents. And let's just pull these two apart. So, adolescents, because they're young, they don't have a lot of access to substances. They usually can't drive. In the era of buying anything online and social media, that's a little bit different. But huffing or the use of inhalants was often one of the first substances that people would use in their adolescence because household chemicals were very available. So that still continues. Nitrous oxide, for example, can be found in a can of whipped cream from the store and can be used that way. Now, as we get a little bit older, young adults, 18 to 25, and college students, nitrous oxide is very popular in the nightclub festival party drug culture. And a lot of times this demographic mixes it with other substances. Now, we use nitrous oxide in healthcare. When I was an emergency doctor, like I said, if someone's got a bad fracture, we would hook them up to the nitrous oxide. It would sedate them and help with pain during the procedure. So nitrous oxide is very available in healthcare settings. And sometimes we do see healthcare workers getting addicted to it, maybe from an initial exposure in the workplace. From what I was reading, it turns out that there is maybe a trend towards higher use of nitrous oxide compared to other substances in the LGBTQ community. And then I mentioned there is also a subset that don't use so much recreationally, but more regularly. So a recreational use, as we all know, would be like someone uses it at a particular event or uses it intermittently. You can get an inhalant use disorder where there is more regular use. And these are people that, again, are using bigger tanks, and we're going to see more health consequences from the heavy use. In terms of how nitrous oxide works in the brain, it appears to have four major neurotransmitter systems that it's involved with. So the first is it blocks the NMDA receptor. And if you remember back to our lecture on ketamine, that is how ketamine works. Nitrous oxide does have this anesthetic, this dissociative effect because it acts like ketamine at the NMDA receptor by blocking it. Now it turns out that nitrous oxide also causes the release of our own natural opioids or endorphins. So that's where it has its pain-relieving effects. And it also activates our GABA-A receptor, and that is very similar to a benzodiazepine, leading to anxiolysis and amnesia. And then because of this, we actually see dopamine release in the reward centers of the brain, which leads to addiction. So let's think about this. Nitrous oxide acts like ketamine, xanax, and morphine all in one. That's actually very useful in the medical center, right? If someone has a painful procedure, we want to put them in an anesthetic state, we want to be able to treat their anxiety, and we want to be able to treat their pain. This is a really useful medication. But you can imagine it releases dopamine and therefore can be addictive. The other thing it's important to know is that it comes on and comes off very quickly. So when people start breathing in nitrous oxide, they feel it within seconds. It peaks within one to two minutes, and the effects are largely resolved in three to five minutes. So in the medical setting, we will actually hook people up to a mask and they'll breathe it in so we have a sustained effect to do a procedure that's gonna last, let's say, 15 minutes. But when someone inhales it from a balloon, it's a very short-lived effect. So using nitrous oxide does have a lot of health hazards, and we'll go through them. We're gonna start with just what can happen to someone in real time when they're using nitrous oxide. So the first thing is when you're breathing in a gas from a balloon that does not contain air or oxygen, you don't get oxygen when you breathe in. So basically, when people are breathing in nitrous oxide, they don't get enough oxygen, which can lead to hypoxia or low oxygen levels, and people can actually have an episode of unconsciousness because of this. I also mentioned that when the gas is pressurized in a canister and it's released, it comes out hyper-cooled. So inhalation of gas directly from the canister can lead to cold burns of the airway in the mouth. As you can imagine, if there's a risk that nitrous oxide can cause someone to go unconscious, depending on what position they are when they're using it, they will lose control of their muscles and will fall to the ground. So somebody using it, let's say if they're standing, they will fall to the ground. Or let's say they're sitting on an elevated chair like a bar stool, you could actually get injuries from the loss of consciousness. In some cases, often with a comorbid medical illness, when people use large amounts of nitrous oxide, it can cause psychosis. And then the last thing is that inhalants often can cause abnormal heart rhythms and cause cardiac dysrhythmias, and that's going to be more common in someone who's mixing the nitrous oxide with stimulants. Now, the biggest problem with nitrous oxide in terms of how much it harms our body is that nitrous oxide basically deactivates the vitamin B12 in our body. And vitamin B12 is very important in myelin, which is the tissue that surrounds our nerves to help them function well and creating red blood cells. We'll go into this in a little more detail in a second, but we see a lot of medical complications in people that are vitamin B12 deficient. And nitrous oxide profoundly depletes our vitamin B12 rather quickly. In fact, when researchers want to study vitamin B12 deficiency, they actually give lab animals nitrous oxide. So I have a list here of some of the problems that can happen with severe vitamin B12 deficiency, degeneration of the spinal cord, peripheral neuropathy, anemia, cognitive impairment. And in people who are at baseline deficient in B12, this severe B12 deficiency from nitrous oxide can occur even after a single use. And with heavy, regular users of nitrous oxide, we absolutely see severe vitamin B12 deficiency because of the ongoing consumption of nitrous oxide. So let's dig in a little bit more to the neurological complications. And the reason I have a picture of a walker on the screen is as you'll hear when we go through the case at the end of the lecture, one of my patients in his 20s ended up requiring a walker to walk because of neurological damage from nitrous oxide. So the first condition is basically spinal cord injury. And this is a degeneration of the spinal cord. And what we see is certain nerve tracts in the spinal cord get injured. And what happens is it really impairs the control of the lower extremities. So people have trouble walking, they have ataxia or being off balance, they can also have weakness. We can also see peripheral neuropathy, basically where the nitrous oxide damages the nerves going to the hands and the feet. And a lot of times patients don't know why their fingers and toes are tingling and they don't know to link it to the nitrous oxide. We also can see a different type of spinal cord damage called myelopathy from the nitrous oxide use. The lower spinal cord controls our urinary system. People can have problems with walking and weakness. And then we also see in the brain encephalopathy or dysfunction of the brain in general. We do see that sometimes with nitrous oxide use, and you can also get cognitive impairment where people really aren't able to think clearly. So this is really where we see the most damage to our body from nitrous oxide, is because of the vitamin B12 deficiency causing neurological complications. So this is a graphic I found from one of the papers I researched for this lecture. Some again, it goes through the long-term complications: anemia, numbness, gait imbalance, muscle weakness, paralysis. What's really interesting about this is when somebody gets nerve damage from nitrous oxide, we don't know if it's going to be permanent or not. Really, the only way we can tell if someone's neurologic damage is going to get better is to wait and see and give them high dose vitamin B12 supplementation. I do have one patient who's in a wheelchair because of his nitrous oxide use. So a couple other complications that can happen from nitrous oxide use. Again, people can get those cold burns when they pull the gas out of the canister. When people are inhaling, sometimes air can accumulate between the lung and the chest wall that's caused a pneumothorax. You can get air around the heart, that's called pneumomediastinum. And then again, with longer-term use, we tend to see mental health issues, depression, anxiety, sometimes even paranoia or hallucinations. Vitamin B12 is very important for the production of red blood cells. So we do see a particular type of anemia called a metaloblastic anemia. Unfortunately, if a woman who's pregnant uses nitrous oxide, it increases the risk of miscarriage. And we also know that B vitamins are very important in the formation of the fetal spinal cord. And so we can actually get what are called neural tube defects when a woman uses nitrous oxide while she's pregnant because of the B vitamin deficiency. Now, we have all of these health consequences we've talked about, but let's take this to our world, the world of addiction. So, can nitrous oxide be addictive? Yes, absolutely. If you wanted to score someone to get the severity of their use disorder, you would put them under an inhalant use disorder. So again, using more than desired, persistent desire to cut down, using despite medical consequences, cutting back on other desired activities to use. Yes, absolutely, nitrous oxide can be addictive. Tolerance. Just like other substances, people who use nitrous oxide do develop tolerance, which is often why people progress from more intermittent use to heavy daily use. It's frequently, as we've talked about, mixed with other substances, particularly in the party scene, we're going to see things like alcohol or hallucinogens. It tends to be that people use nitrous oxide along with other substances as the rule rather than the exception. And it does have a withdrawal syndrome. Not a lot of research on this, but it's not life-threatening. And it's similar to other withdrawal syndromes from Downers: irritability, anxiety, insomnia, nausea and vomiting, sweating, difficulty concentrating, and mood changes. And unfortunately, there's no MAT for nitrous oxide. We do see nitrous oxide use in dual diagnosis patients in a couple of specific settings. The first is anxiety. As we know, overall nitrous oxide is a downer, and our patients with anxiety largely tend to use downers as they're trying to calm down. But unfortunately, like other downers, like alcohol or benzos, the anxiety is often worse between the sessions of use. Depression often runs hand in hand with substance use. We see this as well with nitrous oxide. Trauma and PTSD. This is a tough one. A brief story from one of my patients. One of my patients was functionally just held hostage by an ex-boyfriend, was held at gunpoint, pistol whipped, sexually assaulted. And as she was able to get away from him, she started using nitrous. And her mom called me, like, Dr. Grover, can you get her in? Can you help? And I said, What's going on? And she said she's using nitrous oxide. She doesn't want to feel anything. And that really just said it so nicely that PTSD and triggering and flashbacks and nightmares are so unpleasant. My patient was using nitrous oxide as an anesthetic basically to escape from her trauma. Again, as we mentioned, when people use nitrous oxide, it's usually in combination with other substances. They may not mix them at the time of use, but it tends to be that people who use nitrous oxide do use other substances, either with nitrous or at other points. In their lives. And then the last thing is unfortunately, in people with underlying severe mental health conditions, nitrous oxide can precipitate psychosis. Now, I do have to give credit to the artificial intelligence that I had helped me build this presentation because I was really not aware of harm reduction for nitrous oxide, but AI was able to come up with some harm reduction strategies. And when I went through them, these make perfect sense. So for if you're working with a client that's using nitrous and they're not ready to stop, how can we reduce the harm that they experience? As with any substance, never use alone, right? There's the risk that they could lose consciousness. So there would need to be someone there to be able to help if the person lost consciousness. Following on that, if you're going to use nitrous oxide, do it in a place where if you lost consciousness, you wouldn't be seriously injured. So this actually recommends being seated on the ground, go somewhere soft, obviously away from anything sharp or dangerous. This one's pretty obvious. Never inhale directly from the canister. Absolutely, it can cause frostbite. You're going to want to use tubing or a balloon. I don't know if I've ever heard anyone do this. So take this one with a grain of salt. But AI was able to scrape off the internet that apparently some people will put a bag over their head and try to rebreathe the nitrous. I've not heard of any of my patients doing this, but obviously putting a bat over your head is a horrible idea. Now, let's say somebody is using nitrous, they're willing to engage with you. Maybe you should encourage them to get their vitamin B12 levels checked. And we would start supplementation to try to prevent some of these neurological conditions. And again, it's trying to avoid the heavy daily use because that's what that's what causes the most profound B12 deficiency. So trying to limit frequency of use and quantity of use. Okay. Now there is no MAT for nitrous oxide, unfortunately. Really, all we have is to treat comorbid psychiatric conditions, and then therapy, particularly cognitive behavioral therapy for nitrous oxide is great. And group therapy. I wish we had an altrexone for nitrous oxide. I've even tried it in patients with nitrous oxide. We just don't have any medication that really helps with cravings the way we do for some of our other substances. And then again, we really need patients to be on high dose vitamin B12. They need to replace their vitamin B12 stores and reverse any further neurologic damage. So let's look at how this stuff is sold. So I like to occasionally go play secret shopper at smoke shops near me. So this is a picture I actually took when I was doing some secret shopping around vaping, and I it caught my eye. You can see there's a section there for nitrous oxide in the middle of the picture. So let's zoom in. So you can see again that brand nitrous oxide N2O cream charger, whip it like whipped cream. And if you look to the left, the next one is called Best Whip. To the right, it's called Nitro Whip. They're all around whipped cream. And then if you look there on the left of the screen, it labels that the nitrous oxide is for food use only. Now that to me is a farce, right? You don't go to a smoke shop to buy pans or butter or olive oil. So the fact that they can try to justify that they sell nitrous oxide for food use at a smoke shop is a farce, but it is what it is. And so unfortunately, this is the loophole, right? This is an addictive substance that is a medicine used at hospitals that's being sold at a smoke shop. And because there is really not any better gas for whipped cream, this still happens. One of my staff who's actually in recovery recalls working at Starbucks and actually stealing the nitrous oxide canister to make whipped cream from Starbucks, and she'd take it home and use it. Now, if you're wondering, you can actually buy this on Amazon. So take a look. This is from Amazon. There is no age restriction, right? I took this picture as a screenshot from Amazon on Tuesday, and they were able to get it to be next day. And you can buy large or small canisters of nitrous oxide. So this is again the problem is that it's really hard to regulate this because it is a very effective gas for the preparation of whipped grain. Some local legislators have actually tried to restrict this. So the county to the north of us is Santa Cruz County. And I actually worked with some of their supervisors to put together a ban on recreational nitrous oxide use. It got really difficult, right? If somebody wants to use nitrous oxide to make whipped cream, they still need to have access to that. So then how did they enforce it? What they basically said is bulk purchases are not needed to make whipped cream. So they basically banned bulk purchases. Large tanks were not needed for whipped cream, so they banned those. And then the smoke shops were basically told if you suspect someone is using it recreationally, you can't sell to them. But again, let's look at the picture from the smoke shop near me. They have a sign up that says food use only. So that would allow the smoke shop to sell to anyone because apparently they can read the sign. So it's a frustrating drug to regulate. Okay, so let's go through a clinical case. This is one of my patients. I've changed their information so that they can't be identified. So this was a 25-year-old male who was referred to me for alcohol use disorder. And the patient came to me after residential treatment. The patient had completed a social model program and wanted to start MAT for his alcohol addiction. So we started him on oral naltrexone and then transitioned him to long-acting injectable naltrexone, also known as vivitrol. Initially, the patient was seen monthly and was doing fairly well. He went to some meetings here and there. And when we usually do a vivitrol, we check a urine drug test. So his urine drug test had been negative. He wasn't using anything besides naltrexone. If you're wondering though, nitrous oxide does not show up on urine drug tests, and it's really hard to detect because it's in a person's system for such a short time. So he could have been using nitrous at this time, and I would not have known. The next visit comes up, and he brought his significant other with him. And both of them were in recovery. And the significant other raised concern about the patient using nitrous oxide. And as we went through the visit, it came out that they were both using nitrous together, and they had actually purchased it at their local smoke shop where they bought their vapes. So they'd go into the smoke shop. A lot of our folks in recovery use nicotine, and they'd go in to buy a vape, and they got interested in this nitrous oxide product, and that's how it started. And it sounds like it was a really difficult relationship because one might not want to use it on a given day, but didn't want to use a loan, so they've asked the other to use, and vice versa. So it was a tough relationship. And it turns out that as I counseled them about the potential neurologic damage from nitrous, the significant other piped up that she'd been having tingling and paresthesias in her feet. And so I encouraged them to stop. I talked to them about how we don't know if it's reversible or not. And so for my patient, we I put him on vitamin B12 supplementation. We continued his vivitrol because we didn't want him to relapse on alcohol. And I told him part of the way that nitrous works is by activating our endorphins, maybe adding some oral naltrexone on top of the vivitrol would help. So we agreed to bring him back in another few weeks for his next Vivitrol. And his girlfriend decided she was going to go see her doctor about getting on vitamin B12. Unfortunately, the patient was a no-show for his next visit. And we all know in our line of work, when the patient doesn't show up, a relapse is possible. And that's unfortunately what had happened. So he and his significant other separated because of the stress of the separation. He increased his use of nitrous oxide and had stopped his vitamin B12 supplementation. And unfortunately, his neurological damage had absolutely worsened. He was hospitalized. He wasn't able to walk. He basically was so unable to walk, his family brought him to a local ER. They couldn't figure out what was wrong in the ER. He got admitted. And ultimately, an astute neurologist, while he was admitted, realized that this was profound vitamin B12 deficiency from nitrous oxide use. So they were able to get him some physical therapy. They were able to get him using a walker. And then he went back to residential. Unfortunately, he left residential and then returned to nitrous oxide use. And I don't know exactly what was going on at the time that made him leave treatment. Something happened and his use of nitrous oxide escalated even further. He started inhaling it directly out of the canister. And then ultimately his family contacted me after what he and they described as an overdose on nitrous. So apparently, what it was is he was really struggling and he was consuming directly out of the canister. And a family member found him basically slumped over a canister of nitrous in the living room on the couch. And they called 911. 911 came out. They took the canister away. There was an altercation because he didn't want to stop using. He got placed into the ambulance. He wasn't really able to resist because his neurologic damage had recurred in his legs. But they also found another issue, which is that the patient, this was in, I think, May, the patient was wearing shorts and he had the canister of nitrous oxide between his legs and was huffing directly out of it. So there weren't any uh thermal burns to his mouth or nose or throat. But there's been some case reports of this particular circumstance where my patient basically developed frostbite on the inner thighs from huffing out of the tank. And if you think about it, he couldn't feel it, right? Nitrous oxide is an anesthetic and analgesic. He couldn't feel his thighs getting this thermal burn as it was happening. And I guess thank goodness he had an episode of unconsciousness because he stopped huffing then, and then his family found him and called 911. So this ended up being another hospitalization. His case was very complicated. They had to have him see psychiatry. His mental health was worsening, his neurological damage got worse again. And now he had these wounds. He had to have wound care, very prolonged hospitalization. The hospital team was great. They involved me in his care. I was able to advocate for him to go back to residential treatment. And he went back to residential. The hospital put him on very high doses of vitamin B12. And then he was pretty committed to recovery this time. That nitrous oxide overdose, the thermal burns, was really his rock bottom, if you will. So he agreed to a 90-day stay in residential. And he and I checked in through telemedicine. His neurological damage slowly improved. And he was actually able to graduate residential. And after that, he moved into a sober living and has been attending an intensive outpatient program and meetings. And as I mentioned, I really tried to tell him like, I just please don't use any more nitrous. I don't know if your neurological damage is going to be reversible or not. And he was actually very lucky. So his neurological damage completely resolved and he was able to go back to work. It really helps others find the show. And a huge thank you to Central Coast Overdose Prevention for supporting this podcast. And always remember treating addiction saves lives.