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

Predictive factors for severe outcomes in substance abuse-related emergency visits: A 5-year retrospective analysis at a medical center in Taiwan

BACKGROUND

Substance abuse is a considerable medical issue worldwide, yet current surveillance systems in Taiwan offer limited insights into the clinical characteristics and outcomes of substance abuse patients. This study aimed to delineate the epidemiology of emergency department visits related to substance abuse at a hospital in Taiwan and to identify factors predictive of severe complications or mortality.

METHODS

A retrospective analysis was conducted on substance abuse-related emergency department visits at a medical center in Taiwan between 2009 and 2013. Eligible participants were individuals aged 20 or older who had confirmed substance abuse through urinalysis. Variables such as patient demographics, substances abused, clinical characteristics, and outcomes were collected. Severe outcomes were defined as admission to the intensive care unit, requirement for endotracheal intubation, or in-hospital death. Logistic regression models were employed to identify factors contributing to severe outcomes.

RESULTS

The cohort consisted of 623 patients, of whom 64.0% were female and 67.1% were aged between 20 and 49 years. Benzodiazepines were detected in 75.3% of patients, while z-drugs (specifically zopiclone, zolpidem, or zaleplon) were found in 27.8%. Depressants, stimulants, and hallucinogens were present in 14.9%, 10.6%, and 0.6% of the cases, respectively. Of the patient, 121 (19.4%) experienced severe outcomes, including 116 (18.6%) intensive care unit admissions, 73 (11.7%) intubations, and 11 (1.8%) in-hospital deaths. Multivariable logistic regression analysis revealed multiple predictors of severe outcomes, such as emergency department triage level, aspiration pneumonia, leukocytosis, abnormal hepatic function, abnormal renal function, hypernatremia, and hypocalcemia.

CONCLUSION

In Taiwan, benzodiazepines emerged as the most prevalent substance of abuse among emergency department visitors, and a significant proportion of these patients experienced severe outcomes. Continuous monitoring of severe outcome predictors is essential for enhanced understanding and management.

Global trends in the consumption of benzodiazepines and Z-drugs in 67 countries and regions from 2008 to 2018: a sales data analysis

STUDY OBJECTIVES

To investigate the trends in the consumption of benzodiazepines (BZDs) and Z-drugs at global, regional, and national levels from 2008 to 2018, across 67 countries and regions.

METHODS

This cross-sectional descriptive study investigated the consumption of BZDs and Z-drugs analyzed by global pharmaceutical sales data from the IQVIA-Multinational Integrated Data Analysis System database between 2008 and 2018. Consumption was measured in defined daily dose (DDD) per 1000 inhabitants per day (DDD/TID). The global, regional, and national trends were estimated using linear mixed models. Additional analyses were conducted by grouping countries by income level. The association between consumption and Gross Domestic Product (GDP) and the prevalence of different medical conditions was explored in univariable linear models.

RESULTS

BZD consumption decreased annually by -1.88% (95% CI: -2.27%, -1.48%), and Z-drugs increased by + 3.28% (+2.55%, +4.01%). In 2008, the top ten countries for BZD and Z-drug consumption were all European, ranging from 63.69 to 128.24 DDD/TID. Very low levels were found in Russia, Kuwait, United Arab Emirates, Saudi Arabia, French West Africa, and the Philippines, with DDD/TID < 1. The consumption in high-income countries was much higher than in middle-income countries. The results showed that increased consumption of BZDs and Z-drugs was statistically associated (p < 0.05) with higher GDP and increased prevalence of anxiety, self-harm, neurological disorders, chronic respiratory diseases, cardiovascular diseases, and cancers.

CONCLUSIONS

Distinct differences in consumption and trends of BZDs and Z-drugs were found across different countries and regions. Further exploration is needed to understand the association and safety of the use of BZDs and Z-drugs in patients with comorbidities.

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.

Determination of Ketamine and Norketamine in Hair and Evaluation of Polydrug Use in Ketamine Abusers Using Hair Analysis in Korea

This study evaluated hair samples from 28 subjects who tested positive for ketamine at Seoul Institute National Forensic Service in Korea between 2016 and 2017. Ketamine in the hair was extracted using a solution of 1% hydrochloric acid in methanol for 16 h. Extracts were analyzed using gas chromatography-mass spectrometry (GC-MS) or liquid chromatography-tandem mass spectrometry (LC-MS-MS). The LC-MS-MS method was validated by determining the limit of detection (LOD), limit of quantification (LOQ), linearity, intra- and inter-accuracy, precision and matrix effect. In 59 ketamine-positive hair or hair segments from 28 ketamine abusers, the ketamine concentration was found to be in the range of 0.011-335.8 ng/mg (mean, 13.6; median, 1.8), and the norketamine concentration was found to be in the range of 0.001-35.7 ng/mg (mean, 7.5; median, 0.44). The ratio of norketamine to ketamine concentrations in hair was in the range of 0.01-1.46 (mean, 0.34; median, 0.26). The distribution of ketamine concentration in hair samples was as follows: 0.01-0.1 ng/mg in 11 samples (18.6%), 0.1-5 ng/mg in 33 samples (55.9%), 5-10 ng/mg in 4 samples (6.8%), 10-15 ng/mg in 2 samples (3.4%), 15-20 ng/mg in 4 samples (6.8%), 40-45 ng/mg in 2 samples (3.4%), 45-50 ng/mg in 1 sample (1.7%) and >100 ng/mg in only 2 samples (3.4%). In the hair of ketamine abusers, 26 of 28 subjects were detected simultaneously ketamine with other drugs, including methylenedioxymethamphetamine (MDMA; n = 9), methamphetamine (MA; n = 3), MDMA/MA (n = 3), MDMA/para-methoxyamphetamine (PMA; n = 3), MDMA/PMA/MA (n = 2), cocaine (n = 1) and other drugs (n = 5, propofol, zolpidem or benzodiazepines). Along with ketamine, other controlled drugs were detected in most of the hair samples: MDMA (60.7%), MA (28.6%), PMA (17.9%), zolpidem (17.9%) and propofol (14.3%) in the frequency of abuse. In conclusion, most of the ketamine abusers (92.9%) were polydrug abusers, who were concomitantly abusing other controlled substances.

Prison sentencing increases the risk of unemployment among illegal heroin users in Taiwan

BACKGROUND

Previous studies have rarely explored the effect of type of sentencing on employment status among illegal heroin users, therefore, we aims to examine the association of the sentencing types and employment outcomes among illegal heroin users in Taiwan.

METHODS

Participants with illegal heroin use were identified through the national prison register system and deferred prosecution system: 2406 with deferred prosecutions, 4741 with observation and rehabilitation, 15 compulsory rehabilitation and 1958 sentenced to prison in calendar 2011. Logistic regression models were built to estimate the effect of sentencing type on unemployment status at 2 years after release. Stratification analysis was conducted to determine the effect of sentencing type based on the offender's employment status before sentencing.

RESULTS

Illegal heroin users receiving a prison sentence were more than twice as likely to be unemployed 2 years later than those receiving deferred prosecution. The unemployment rate was also higher for those with observation and rehabilitation and compulsory rehabilitation than deferred prosecution in the 2 years following sentencing. Males, older users, without a job before sentencing, divorced or widowed and higher prior drug use criminal records were also higher risk of unemployment. Subgroup analysis by prior employment status revealed that being sentenced to prison, observation and rehabilitation and compulsory rehabilitation affected the subsequent employment status only for those heroin users with a job before sentencing. The strength of associations showed dose-dependent relationship between different sentencing types (sentenced to prison> compulsory rehabilitation> observation and rehabilitation) and employment outcomes.

CONCLUSIONS

Illegal heroin users who receive a prison sentence have a much higher risk of unemployment than those who receive deferred prosecution after controlling potential confounders, especially those who had a job before sentencing. The implication is the stronger freedom of punishment, the higher risk of unemployment outcomes. Our study support that illegal heroin user is legally regarded as a patient before being regarded as a criminal, so giving priority to quit addition rather than imprisonment.

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.

Toxicity and postwithdrawal effects of ketamine on the reproductive function of male albino rats: Hormonal, histological, and immunohistochemical study

Ketamine is increasingly used in clinical practice, and ketamine addiction is common in young individuals. There are limited reviews on the chronic effects of ketamine on the testes. Three groups of rats received saline or ketamine 50 mg/kg/day intraperitoneally for 6 weeks with or without a subsequent 4-week drug-free period. Serum follicle-stimulating hormone, luteinizing hormone, prolactin, and testosterone levels, as well as testicular malondialdehyde concentrations, were measured. Epididymal sperm parameters were assessed. Testicular tissues were examined by hematoxylin and eosin staining and immunohistochemical staining using caspase-3 and vimentin antibodies. Chronic ketamine injection significantly decreased the levels of the examined hormones and adversely affected sperm parameters. Testicular tissue showed a significant increase in caspase-3 expression. In addition, Sertoli cell shape and position were disrupted. These effects disappeared 4 weeks after drug withdrawal. Chronic ketamine treatment has revisable hazardous effects on the rat reproductive function. There is a need to increase the knowledge of physicians and the public regarding these harmful effects of ketamine.

Identification of 'Voodoo': an emerging substance of abuse in Egypt

BACKGROUND

'Voodoo' is a new substance of abuse that recently spread among youth in Egypt. It has numerous potentially dangerous effects on humans. However, to date the composition of the main constituents of this compound is unknown.

PURPOSE

We sought to identify the active components of this unknown substance"voodoo".

METHODS

Three samples were collected and analysed by high-performance liquid chromatography with photodiode array detector (HPLC-PAD), gas chromatography/mass spectrometry (GC/MS), and ultra-performance liquid chromatography/mass spectrometry (UPLC-MS/MS) using targeted multiple reaction monitoring (MRM).

RESULTS

HPLC-PAD analysis showed that samples 1 and 2 had some common major peaks, the same retention time, and similar spectra, whereas sample 3 showed different peaks. GC/MS analysis revealed the presence of various putatively identified bioactive compounds, including quinazolines, morphinan alkaloid, cannabinoids, penitrem A, and the well-known synthetic cannabinoid FUB-AMB (methyl(2S)-2-{[1-[(4-fluorophenyl)methyl]indazole-3-carbonyl]amino}-3 methylbutanoate). UPLC-MS/MS analysis revealed the presence of common compounds such as tetrahydrocannabinol (THC), amphetamine, 3,4-methylenedioxyamphetamine, tramadol, and oxazepam.

CONCLUSION

We concluded that Voodoo is a mixture of substances of abuse at varying concentrations.

Hospitalized burn injury risk associated with benzodiazepines and Z-drugs in elders: A population-based case-control study

OBJECTIVE

To examine the association between benzodiazepines (BZDs) and Z-drugs treatment and risk of burn injury in elders.

METHODS

We designed a nested case-control study. All subjects were aged 65 and older and enrolled in the National Health Insurance program in Taiwan, 2003 to 2012; 813 cases were identified with burn injury for the first time in their inpatient claims, and they were individually matched to 4879 controls based on age, gender, and index year. Benzodiazepines and Z-drugs usage (doses, duration, half-life) and the other covariates including comorbidities, health care utilization, and psychotropic medications used in the 365 days before index events were examined.

RESULTS

A significant increased risk of burn injury hospitalization in elders was observed among current Z-drugs users compared with nonusers (adjusted odds ratio [AOR] = 1.59, 95% confidence interval [CI] [1.23, 2.07]). BZDs at high (AOR = 1.81, 95% CI [1.12, 2.94] and medium dosage (AOR = 1.53, 95% CI [1.15, 2.04] and Z-drugs at medium dosage (AOR = 1.60, 95% CI [1.20, 2.12]) were all significantly increased the burn-related injury requiring hospitalization. Polypharmacy of anxiolytic and hypnotic BZDs, long- and short-acting BZDs, and more than one BZD with or without Z-drugs also increased the risk.

CONCLUSIONS

BZDs and Z-drugs prescriptions in elders may be associated with increased risk of burn injury hospitalization. When prescribing BZDs and Z-drugs, clinicians should exercise caution with the elderly to minimize risks.

Factors impeding switching from methadone to buprenorphine in heroin users receiving methadone maintenance therapy - A naturalistic cohort study

INTRODUCTION

Switching from methadone to buprenorphine/naloxone remains a challenge for heroin users receiving methadone maintenance treatment (MMT). The present study aimed to investigate the predictors for failed switching from methadone to buprenorphine/naloxone among patients receiving MMT.

METHODS

This 5-year retrospective study included 168 individuals (138 males and 30 females) with opioid dependence who attempted to switch from methadone to buprenorphine/naloxone at our MMT clinics in Taiwan. We excluded patients with psychiatric comorbidity and other substance use disorders except nicotine. A univariate Cox proportional hazards regression model (Cox model) was used to estimate the potential factors of subsequent failed switching, followed by a multivariate Cox model to identify significant predictors after adjusting for other covariates.

RESULTS

Seventy of the 168 participants (41.7%) failed switching from methadone to buprenorphine/naloxone. After forward selection in the Cox hazard regression model, a greater average dose of methadone (HR = 1.02; P = 0.01), greater maximal maintenance dose of MMT (HR = 1.02; P < 0.001), greater average dose of buprenorphine (HR = 1.10; P = 0.021), and lower average attendance rate during the three months before switching (HR = 0.09; P = 0.002) were significantly associated with failed switching.

CONCLUSIONS

This study with limited participants showed that dose of methadone, dose of buprenorphine, and attendance rates were significantly associated with failed switching. Clinicians should discuss with their patients about tapering the dose of methadone and improving their attendance if they want to switch from methadone to buprenorphine. Further studies are necessary to verify whether our findings generalize to other populations.

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.

Association of benzodiazepine and Z-drug use with the risk of hospitalisation for fall-related injuries among older people: a nationwide nested case-control study in Taiwan

Background

Non-benzodiazepine hypnotics (Z-drugs) are advocated to be safer than benzodiazepines (BZDs). This study comprehensively investigated the association of BZD and Z-drug usage with the risk of hospitalisation for fall-related injuries in older people.

Methods

This study used the Taiwan National Health Insurance Database with a nested matched case-control design. We identified 2238 elderly patients who had been hospitalised for fall-related injuries between 2003 and 2012. They were individually matched (1:4) with a comparison group by age, sex, and index year. Conditional logistic regression was used to determine independent effects of drug characteristics (type of exposure, dosage, half-life, and polypharmacy) on older people.

Results

Older people hospitalisation for fall-related injuries were significantly associated with current use of BZDs (adjusted odds ratio [AOR] = 1.32, 95% confidential interval [CI] = 1.17–1.50) and Z-drugs (AOR = 1.24, 95%CI = 1.05–1.48). At all dose levels of BZDs, high dose levels of Z-drugs, long-acting BZD, and short-acting BZD use were all significantly increased the risk of fall-related injuries requiring hospitalisation. Polypharmacy, the use of two or more kinds of BZDs, one kind of BZD plus Z-drugs and two or more kinds of BZDs plus Z-drugs, also significantly increased the risk (AOR = 1.61, 95% CI = 1.38–1.89; AOR = 1.65, 95% CI = 1.08–2.50, and AOR = 1.58, 95% CI = 1.21–2.07).

Conclusions

Different dose levels and half-lives of BZDs, a high dose of Z-drugs, and polypharmacy with BZDs and Z-drugs were associated with an increased risk of fall-related injury requiring hospitalisation in older people. Physicians should balance the risks and benefits when prescribing these drug regimens to older people considering the risk of falls.

Sleep disturbance and its associations with severity of dependence, depression and quality of life among heroin-dependent patients: a cross-sectional descriptive study

BACKGROUND

Sleep disturbance is common and may adversely affect treatment outcome, mental health, and quality of life in heroin-dependent patients. Previous studies have focused upon patients receiving treatment. We conducted a cross-sectional descriptive study to explore the 1-month prevalence of sleep disturbance and its associations with socio-demographic, substance-related characteristics, severity of dependence, severity of depression, and quality of life among heroin-dependent patients before entering treatment program.

METHODS

The sample (n = 514) comprised individuals with heroin dependence attending the methadone maintenance treatment program and the therapeutic community at a psychiatric center in Nantou, Taiwan between 2008 and 2014. Sleep quality was measured using Pittsburgh Sleep Quality Index (PSQI) with a global score greater than 5 indicating sleep disturbance. Centre for Epidemiologic Studies Depression Scale, Severity of Dependence Scale, and World Health Organization Quality of Life-BREF were also approached. T-test, chi-square tests, and multivariate logistic regression were performed to measure associations between variables and sleep disturbance.

RESULTS

The 1-month prevalence of sleep disturbance (PSQI > 5) was 76.3% among 514 subjects with heroin dependence. Heroin users with sleep disturbance had significantly more life events in the previous year, higher rate of unemployment, greater cigarette consumption, more substance related criminal convictions, longer length of heroin use, higher rate of injectors, greater severity of dependence, greater severity of depression, and lower quality of life compared to those without sleep disturbance. Severity of dependence, severity of depression, and physical health domain of quality of life remained significantly associated with sleep disturbance after adjusting for other variables.

CONCLUSION

Heroin-dependent patients had a high 1-month prevalence of sleep disturbance, and this was associated with greater severity of dependence, greater severity of depression, and poorer physical health-related quality of life. Early assessments and interventions for sleep disturbance among patients with heroin dependence are recommended.

Comparison of socio-demographic characteristics, substance, and depression among male heroin users attending therapeutic community and methadone maintenance treatment program in Nantou, Taiwan

Background

Little is known about differences between the characteristics and psychopathological symptoms of heroin users attending TC or MMT in Asia. This study aimed to compare characteristics and prevalence of depressive disorders among male heroin users in TC and MMT program in Nantou, Taiwan.

Methods

The study sample (n = 705) comprised male heroin users with heroin dependence recruited from the MMT program and TC program at a psychiatric center in Nantou, Taiwan between 2006 and 2014. Socio-demographic and heroin-related characteristics were obtained from self-report questionnaires. DSM-IV diagnoses of heroin dependence, major depressive disorder, and dysthymic disorder were evaluated by trained interviewers. T-test and chi-square test and multivariate logistic regression were performed to measure the differences on variables between samples of TC and MMT.

Results

Compared to MMT, TC participants had poorer family support, higher rate of unmarried, higher rate of unemployment, earlier onset of heroin use, longer length of heroin use, and lower daily dosage of heron. MMT heroin users had higher 1-month prevalence of major depressive disorder than TC participants. We found the distribution of current major depression disorder differed between heroin users choosing different treatment models even controlling for other demographic factors, substance related factors and psychosocial factors. The underlying explanations require further investigation.

Conclusions

This study found differences in the characteristics and prevalence of psychopathology. Further study to explore the effect of these differences on the outcome between MMT and TC is warranted.

Global patterns of methamphetamine use

PURPOSE OF REVIEW

As the most popular psychostimulant in the world, methamphetamine use has reached epidemic proportions. Its enormous popularity has created subcultures of methamphetamine users all over the globe. The purpose of this review is to describe the geographic availability of different types of methamphetamine, the characteristics of each user population, and the psychosocial impact the two have on society.

RECENT FINDINGS

Methamphetamine has diversified immensely from the early days of its use. Different forms of methamphetamine - ICE, powder, and pills - have different pharmacokinetic characteristics that make them popular among certain types of users. New studies have shown that addiction to methamphetamine results in a very characteristic loss of inhibition that augments various risk-taking behaviors in its users. Also, recent seizure data suggest that its production and trafficking is spreading into new areas of the globe.

SUMMARY

From recreational use to addiction, methamphetamine use represents a serious risk to health and wellbeing of the community. Recognizing the pattern of abuse in specific populations is the key to assessing the risk, implementing prevention, and harm reduction measures, as well as making public policies.