The trend of drug abuse in Taiwan during the years 1999 to 2011

Comprehensive overview of analytical and bioanalytical methodologies for the opioid analgesics - Tramadol and combinations

Synthetic opioids like Tramadol are used to treat mild to moderate pain. Its ability to relieve pain is about a tenth that of morphine. Furthermore, Tramadol shares similar effects on serotonin and norepinephrine to several antidepressants known as serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine. The present review paper discusses the recent developments in analytical methods for identifying drugs in pharmaceutical preparations and toxicological materials, such as blood, saliva, urine, and hair. In recent years, a wide variety of analytical instruments, including capillary electrophoresis, NMR, UV-visible spectroscopy, HPTLC, HPLC, LC-MS, GC, GC-MS, and electrochemical sensors, have been used for drug identification in pharmaceutical preparations and toxicological samples. The primary quantification techniques currently employed for its quantification in various matrices are highlighted in this research.

Quality of life and associated factors of heroin-dependent patients receiving methadone and buprenorphine maintenance treatment

AIM

Although studies in Western countries have investigated the quality of life (QoL) of heroin users, limited research on this topic has been conducted in Asia. The present study assessed QoL in patients with heroin dependence receiving medications to treat opioid use disorder.

METHODS

We performed a cross-sectional study of patients with heroin dependence receiving methadone and buprenorphine treatment. The demographic and substance use variables of patients receiving methadone and buprenorphine were compared. The Chinese Health Questionnaire (CHQ-12), Obsessive Compulsive Drug Use Scale (OCDUS), and World Health Organization Quality of Life Short Form Taiwan version (WHOQOL-BREF-T) were administered to measure patient mental health problems, addiction severity, and QoL, respectively. Multivariate regression was used to identify the factors associated with QoL.

RESULTS

A total of 149 patients receiving methadone and 31 receiving buprenorphine completed the questionnaires. Individuals in the buprenorphine group were more likely to be married (p = 0.024) or employed (p = 0.024), have a higher educational level (p = 0.013), have lower drug craving (OCDUS: p = 0.035), or have higher QoL (WHOQOL-BREF-T: p = 0.004) than those in the methadone group. After adjustment for other variables, employment was positively associated with the physical, psychological, and environmental domains of QoL. Receiving buprenorphine treatment (p = 0.032) and longer treatment duration (p = 0.016) were associated with higher psychological QoL.

CONCLUSION

Several factors were associated with QoL in patients with heroin dependence. Some measures may improve their QoL, such as reducing employment barriers, improving treatment adherence, or increasing accessibility to buprenorphine treatment.

A nationwide study of prenatal exposure to illicit drugs and risk of neurodevelopmental disorders and disruptive behavioral disorders

This cohort study aimed to examine the association between prenatal exposure to illicit drugs and neurodevelopmental and disruptive behavioral disorders (DBD) in children aged 7-12 years, using data from four national databases in Taiwan from 2004 to 2016. We linked parental and child IDs from the Taiwan Maternal and Child Health database to track children's health status from birth to at least age 7 and identify those diagnosed with neurodevelopmental disorders. The study included 896,474 primiparous women who gave birth between 2004 and 2009, with 752 pregnant women with illicit drug use history and 7520 matched women without. The results of the study showed that prenatal illicit drug exposure was significantly associated with the development of neurodevelopmental disorders and DBD in offspring. The adjusted hazard ratios for developmental delay, mild-to-severe intellectual disability, attention deficit hyperactivity disorder, and DBD were 1.54 (95 % CI: 1.21-1.95), 2.63 (95 % CI: 1.64-4.19), 1.58 (95 % CI: 1.23-2.03), and 2.57 (95 % CI: 1.21-5.48), respectively. Furthermore, prenatal exposure to methamphetamine increased the risk of neurodevelopmental disorders and DBD in offspring, while opioid use was significantly associated with a higher risk of three types of neurodevelopmental disorders, but not with DBD. The use of sedative hypnotic drugs alone was not associated with any increased risk of the three types of neurodevelopmental disorders or DBD. However, we found a significant interaction effect between prenatal illicit drug exposure and the use of sedative hypnotic drugs, which increased the risk of developmental delay.

Recidivism of Individuals Who Completed Schedule I Drugs Deferred Prosecution Treatment: A Population-Based Follow-Up Study from 2008 to 2020 in Taiwan

Deferred Prosecution with Condition to Complete the Addiction Treatment (DPCCAT) is a judicial diversion program in Taiwan that shifts people who use drugs away from the label drug offender and toward the label patient. However, little is known about the effectiveness of completing a DPCCAT program on people who use drugs. Using a nationwide population-based retrospective panel data from 2008 to 2020, recidivism is defined as a person was caught urine positive and charged by a prosecutor after their completion of DPCCAT. After controlled gender, age, and region, comparisons of recidivism rates and time to relapse between Schedule I drug use only, Schedule I & II drug use, and heterogeneous group were examined. Of 24,248 participants with DPCCAT, 11,141 (46%) completed the one-year treatment program. Of completers, the five-year recidivism rates are significantly lower for the Schedule I drug use only (26%) than Schedule I & II drugs use (52%) and heterogeneous group (47%). Results from Cox regression indicated that the duration of recidivate to drug use is significantly longer for the Schedule I drug only than the other two groups after controlling for demographics. The main findings support that completion of a DPCCAT program only reduces the risk of recidivism for people who use Schedule I drug only and is less effective for polydrug users and heterogeneous group. We suggest that characteristics of people who use drugs and other criminal offenses should be taken into consideration for triage when DPCCAT is offered.

The impact of Taiwan's implementation of a nationwide harm reduction program in 2006 on the use of various illicit drugs: trend analysis of first-time offenders from 2001 to 2017

Background

After implementing a nationwide harm reduction program in 2006, a dramatic decline in the incidence of human immunodeficiency virus (HIV) infection among people with injection drug use (IDU) was observed in Taiwan. The harm reduction program might have sent out the message discouraging the choice of IDU among illicit drug users in early stage. Based on the yearly first-time offense rates from 2001 to 2017, this study aimed to examine (1) whether the nationwide implementation of the harm reduction program in 2006 led to changes in first-time offenders’ use of heroin; (2) whether the intervention had a similar effect on the use of other illicit drugs; and (3) whether the effect of the intervention was limited to the first-time offenders of young age groups.

Methods

Yearly first-time illicit-drug offense rates from 2001 to 2017 in Taiwan were derived from two national databases for drug arrests that were verified using urine tests: the Criminal Record Processing System on Schedule I/II Drugs and the Administrative Penalty System for Schedule III/IV Substances. A hierarchy of mutually exclusive categories of drug uses was defined by the drug with the highest schedule level among those tested positive in an arrest. Segmented regression analyses of interrupted time series were used to test for the impact of the 2006 intervention.

Results

There was a decrease of 22.37 per 100,000 in the rate for heroin but no detectable level changes in that for methamphetamine or ecstasy after the 2006 intervention in Taiwan. There were baseline decreasing trends in the first-time offense rate from 2001 to 2017 for heroin and ecstasy and an increasing trend for methamphetamine, with the slopes not altered by the 2006 intervention. The postintervention decrease in the first-time offense rate for heroin was detectable among offenders less than 40 years old.

Conclusions

Our results indicate a diffusion effect of the 2006 intervention on decreasing heroin use among young offenders and have policy implications for better prevention and treatment for different age groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-021-00566-5.

Changing Pattern of Chemsex Drug Use Among Newly Diagnosed HIV-Positive Taiwanese from 2015 to 2020 in the Era of Treat-All Policy

Chemsex drug use (CDU) is a frequent, yet neglected issue in the era of treat-all policy. We evaluated the temporal pattern of CDU, factors associated with CDU, and drug-drug interactions (DDIs) between chemsex drugs and initial antiretroviral therapy (ART) by surveying 621 Taiwanese individuals (mean age: 29.7 years; 99.2% men; 92.9% men who have sex with men) diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) from 2015 to 2020 [2015 to 2016 (period 1), 2017 to 2018 (period 2), and 2019 to 2020 (period 3)]. CDU was defined as chemsex in the past 1 year before HIV diagnosis. CDU remained prevalent across three periods (34.3-30.5%). Among CDU, methamphetamine (43.4%) was most frequently used, followed by amphetamine (40.0%) and poppers (various alkyl nitrites) (39.5%). We identified significantly increasing amphetamine use (37.0-61.5%) and decreasing ecstasy (methylenedioxy-methamphetamine) use (32.1-17.9%) in CDU across three periods. Besides, polydrug chemsex also significantly increased in CDU across three periods (23.5-43.6%), with amphetamine plus gamma-hydroxybutyrate being the most commonly used combination. CDU was associated with multiple sexual partners and a history of sexually transmitted diseases (STDs). DDIs between chemsex drugs and initial ART remained stable across three periods (10.6-7.8%), with cobicistat/elvitegravir and methamphetamine most common combination. In summary, the magnitude of CDU remained high across 2015-2020 in Taiwan, causing DDIs with initial ART agents. Strategies to reduce the frequency of high-risk sexual practices, STD transmission, and DDIs for newly diagnosed HIV-positive patients engaging in chemsex should be implemented.

Synthetic cathinone poisoning from ingestion of drug-laced "instant coffee packets" in Taiwan

BACKGROUND

Synthetic cathinone abuse is a global health issue. Synthetic cathinones emerged in Taiwan in 2009, and their prevalence rapidly rose. They are usually made into "instant coffee packets," and these so-called "toxic coffee packets" may also contain psychoactive drugs other than synthetic cathinones. Due to the diversity of the ingredients, clinical presentations can be complex.

METHODS

Retrospective analysis of emergency department (ED) patients who reported ingesting toxic coffee packets at three Chang-Gung Memorial Hospitals located in northern Taiwan between January, 2015 and December, 2019.

RESULTS

Sixty patients were included. Their mean age was 28.85 ± 9.24 years and 47(78.33%) were male. The most common presentations were palpitation, agitation, hallucination, and altered consciousness. Tachycardia and hypertension were common, while hyperthermia was observed in only three patients. Three patients (5%) developed rhabdomyolysis, and one underwent transient hemodialysis. Most patients were discharged from the ED, but 15(25%) were admitted, of whom nine (15%) were admitted to the intensive care unit (ICU), and one eventually died. Confirmation tests (mass-spectrometry-based analysis) were available in 10 patients; all reported positive for at least one type of synthetic cathinone. Polysubstance exposure was common. In multivariate logistic regression analyses, Glasgow coma scale ≤13 and the presence of seizure were associated with ICU admission.

CONCLUSION

Patients who report ingesting toxic coffee packets are very likely to have been exposed to synthetic cathinones. Polysubstance exposure is common following ingestion. Cardiovascular and neurological symptoms are the main presentations, and severe complications such as rhabdomyolysis and life-threatening dysrhythmia can occur.

Risk of Renal Function Decline in Patients with Ketamine-Associated Uropathy

Ketamine-associated diseases have been increasing with the rise in ketamine abuse. Ketamine-associated uropathy is one of the most common complications. We investigated the effects of ketamine-associated uropathy on renal health and determined predictors of renal function decline in chronic ketamine abusers. This retrospective cohort study analyzed 51 patients (22 with ketamine-associated hydronephrosis and 29 with ketamine cystitis) from Kaohsiung Veterans General Hospital in Taiwan. Primary renal outcome was end-stage renal disease or estimated glomerular filtration rate decline >30% from baseline. Compared with the ketamine cystitis group, the hydronephrosis group had lower initial and final estimated glomerular filtration rates and higher alkaline phosphatase and gamma-glutamyl transferase levels (p < 0.05). Elevated cholestatic liver enzyme levels correlated with renal dysfunction in ketamine-associated uropathy. The hydronephrosis group had a higher proportion of patients reaching endpoints than the ketamine cystitis group (50% and 7%, respectively, p < 0.001). After adjusting for age, sex, and initial serum creatinine level, hydronephrosis remained an independent risk factor for renal function deterioration. Ketamine-associated hydronephrosis was a poor renal outcome and strong predictor of renal function decline in chronic ketamine abusers. Elevated cholestatic liver enzyme levels correlated with the severity of ketamine-associated uropathy. Ultrasonography screening of these high-risk groups and regular renal function follow-ups are necessary.

Development of an addiction index and delineation 15-year trends of illicit drugs from the Taiwan national drug enhancement database

Illicit drug use contributes to substantial morbidity and mortality. Drug scheduling, a legal measure in drug enforcement, is often structured as a hierarchy based on addiction tendency, abuse trends, and harm, but may lack data-driven evidence when classifying substances. Our study aims to measure addiction tendency and use trends based on real-world data. We used the open access database of National Police Agency, Ministry of the Interior in Taiwan and analyzed all daily criminal cases of illicit drugs from 2013 to 2017 and monthly illicit drug enforcement data from the same database from 2002 to 2017. We hypothesized that repeat and frequent use despite legal consequence may be a reflection of addictive behavior, and empirical mode decomposition was applied in analysis to calculate addiction tendency indices and intrinsic 15-year use trends. Our analysis showed heroin has the highest addiction index, followed by methamphetamine. 3,4-Methyl enedioxy methamphetamine, marijuana, and ketamine had lower addictive propensities. This result is consistent with most drug scheduling hierarchies. 15-year use trends of substances were consistent with previous epidemiological studies.

Taiwan guideline on oral pre-exposure prophylaxis for HIV prevention - 2018 update

Pre-exposure prophylaxis (PrEP) for prevention of human immunodeficiency virus infection is proved to be effective and has been implemented worldwide. This article introduces the guideline development and revised recommendations and guidance on PrEP provision in the updated Taiwan PrEP guideline. The Taiwan PrEP guideline writing group searched randomized controlled trials and guidelines published before October 2017 through Medline/PubMed, Cochrane Database, Embase and ClinicalTrials.gov database. Keywords included pre(-)exposure prophylaxis, PrEP, Truvada, tenofovir, HIV, and AIDS. Each selected article was assessed by two authors using the Grading of Recommendations Assessment, Development and Evaluation. External reviewers were invited to independently evaluate the revised manuscript per the Appraisal of Guidelines for Research and Evaluation II. Before publication, a public consultation was held to reach consensus on the updated guideline among providers, civil society, and Taiwan Centers for Disease Control. Four systematic reviews and 28 original articles were reviewed by Taiwan PrEP writing group. The second version of the Taiwan PrEP guideline was released in March 2018. We recommended daily PrEP use for the following populations: strong recommendation and high quality of evidence for men who have sex with men (MSM) and transgender women (TGW), as well as heterosexual serodiscordant couples; weak recommendation and high quality of evidence for people who inject drugs, while weak recommendation and moderate quality of evidence for at-risk heterosexual men and women. There is high-quality evidence for event-driven PrEP in MSM and likely TGW, and we additionally recognized these key populations could benefit from such dosing regimen.

Urine specimen validity test for drug abuse testing in workplace and court settings

In recent decades, urine drug testing in the workplace has become common in many countries in the world. There have been several studies concerning the use of the urine specimen validity test (SVT) for drug abuse testing administered in the workplace. However, very little data exists concerning the urine SVT on drug abuse tests from court specimens, including dilute, substituted, adulterated, and invalid tests. We investigated 21,696 submitted urine drug test samples for SVT from workplace and court settings in southern Taiwan over 5 years. All immunoassay screen-positive urine specimen drug tests were confirmed by gas chromatography/mass spectrometry. We found that the mean 5-year prevalence of tampering (dilute, substituted, or invalid tests) in urine specimens from the workplace and court settings were 1.09% and 3.81%, respectively. The mean 5-year percentage of dilute, substituted, and invalid urine specimens from the workplace were 89.2%, 6.8%, and 4.1%, respectively. The mean 5-year percentage of dilute, substituted, and invalid urine specimens from the court were 94.8%, 1.4%, and 3.8%, respectively. No adulterated cases were found among the workplace or court samples. The most common drug identified from the workplace specimens was amphetamine, followed by opiates. The most common drug identified from the court specimens was ketamine, followed by amphetamine. We suggest that all urine specimens taken for drug testing from both the workplace and court settings need to be tested for validity.

Highly Sensitive FPW-Based Microsystem for Rapid Detection of Tetrahydrocannabinol in Human Urine

This paper presents a highly sensitive flexural plate-wave (FPW)-based microsystem for rapid detection of tetrahydrocannabinol (THC) in human urine. First, a circular-type interdigital transducer (IDT) was integrated with a circular-type silicon-grooved reflective grating structure (RGS) to reduce insertion loss. Then, with lower insertion loss (−38.758 dB), the FPW device was used to develop a novel THC biosensor, and the results reveal that this FPW-THC biosensor has low detection limit (1.5625 ng/mL) and high mass-sensitivity (126.67 cm²/g). Finally, this biosensor was integrated with field-programmable gate array (FPGA) board and discrete components for prototyping a FPW readout system, whose maximum error was 12.378 kHz to ensure that the linearity of detection up to R-square is equal to 0.9992.

Simultaneous drug identification in urine of sexual assault victims by using liquid chromatography tandem mass spectrometry

According to domestic and international epidemiological investigation, the proportion of substance involved sexual assault has the trend of ascent. In the past, laboratory methods that investigated urine sample of the sexual assault victims was to screen with enzyme immunoassay and then confirmed with mass spectrometry. The objective of the study is to simultaneously identify abused drugs in 126 decoded urine samples of sexual assault victims by liquid chromatography tandem mass spectrometry. The instrument was operated in multiple-reaction monitoring with an electro-spray positive ionization mode. Chromatograms were separated with ACE5 C18 column on a gradient of acetonitrile. After liquid-liquid extraction, samples were passed through a 0.22μm PVDF filter before injection into the system. The limits of quantitation ranged from 0.2 to 10ng/mL. The precision (CV) results were below 12.9% (intraday) and 15.0% (interday). The intraday accuracy ranged from 84.8 to 121.0%, interday accuracy ranged from 72.0 to 117.3%. We found that 29 (23.0%) were positive for drugs. The most common drug identified is flunitrazepam (11.1%), followed by nimetazepam and ketamine (7.9%), some new psychoactive substances, such as 2C-B, mephedrone, methylone, PMA and PMMA were also identified. We identified abused drugs, benzodiazepines, and new psychoactive substances in urine of sexual assault victims by using liquid chromatography tandem mass spectrometry.

Determination of Synthetic Cathinones in Urine Using Gas Chromatography-Mass Spectrometry Techniques

In recent years, the abuse of synthetic cathinones has increased considerably. This study proposes a method, based on gas chromatography/mass spectrometry (GC-MS), to analyze and quantify six synthetic cathinones in urine samples: mephedrone (4-MMC), methylone (bk-MDMA), butylone, ethylone, pentylone and methylenedioxypyrovalerone (MDPV). In our procedure, the urine samples undergo solid-phase extraction (SPE) and derivatization prior to injection into the GC-MS device. Separation is performed using a HP-5MS capillary column. The use of selective ion monitoring (SIM mode) makes it is good sensitivity in this method, and the entire analysis process is within 18 min. In addition, the proposed method maintains linearity in the calibration curve from 50 to 2,000 ng/mL (r(2) > 0.995). The limit of detection of this method is 5 ng/mL, with the exception of MDPV (20 ng/mL); the limit of quantification is 20 ng/mL, with the exception of MDPV (50 ng/mL). In testing, the extraction performance of SPE was between 82.34 and 104.46%. Precision and accuracy results were satisfactory <15%. The proposed method was applied to six real urine samples, one of which was found to contain 4-MMC and bk-MDMA. Our results demonstrate the efficacy of the proposed method in the identification of synthetic cathinones in urine, with regard to the limits of detection and quantification. This method is highly repeatable and accurate.

Differentiation of regioisomeric chloroamphetamine analogs using gas chromatography-chemical ionization-tandem mass spectrometry

In recent years, a large number of clandestinely synthesized new psychoactive substances with high structural variety have been detected in forensic samples. Analytical differentiation of regioisomers is a significant issue in forensic drug analysis, because, in most cases, legal controls are placed on only one or two of the conceivable isomers. In this study, gas chromatography-tandem mass spectrometry (GC-MS-MS) was used to differentiate the regioisomers of chloroamphetamine analogs (chloroamphetamines and chloromethamphetamines) synthesized in the authors' laboratories. Free bases, trifluoroacetyl derivatives, and trimethylsilyl derivatives were subjected to GC-MS-MS using DB-1ms, DB-5ms, and DB-17ms capillary columns, respectively. The regioisomers of chloroamphetamine analogs in all forms were well separated on the DB-5ms column. The electron ionization mass spectra of the chloroamphetamine analogs gave very little structural information for differentiation among these analogs, even after trifluoroacetyl and trimethylsilyl derivatization of the analytes. Characteristic product ions of the 2-positional isomers were observed by electron ionization-MS-MS. In contrast, chemical ionization-MS-MS of the free bases provided more structural information about chloride position on the aromatic ring when [M+H-HCl]+ was selected as a precursor ion. The results suggest that a combination of chromatographic analysis and MS-MS supports differentiation for regioisomers of chloroamphetamine analogs.

Analysis of drug abuse data reported by medical institutions in Taiwan from 2002 to 2011

Drug abuse has become a global issue of concern. It affects not only individual users, but also their families and communities. Data were retrieved from the database of the Taiwan Surveillance System of Drug Abuse and Addiction Treatment (SSDAAT) from 2002 to 2011, and 147,660 cases reported by medical institutions in Taiwan were reviewed. This study showed that the top five reported abused drugs by medical institutions during the last decade were heroin, methamphetamine, benzodiazepines, ketamine, and zolpidem. Heroin and methamphetamine continued to be the first two abused drugs reported by medical institutions. Heroin abuse was significant, but has shown a downward trend. However, emerging abused drugs, such as ketamine and zolpidem, presented upward trends. 3,4-Methylenedioxy-N-methylamphetamine (MDMA) abuse seems to have re-emerged and has increased gradually since 2010. Injection without needle sharing has become the most common route of administration of abused drugs since 2002. The majority of causes for these reported drug abuses were drug dependence, followed by peer influence and stress relief. Hepatitis C was the most commonly reported infectious disease, followed by hepatitis B and AIDS in the drug abusers reported by medical institutions. It should be noted that access to drugs via the Internet increased year by year, and this is clearly an area needing constant monitoring.