Application of Wastewater-Based Epidemiology in China—From Wastewater Monitoring to Drug Control Efforts. In: Subedi B, Burgard DA, Loganathan BG, editors. Wastewater-Based Epidemiology: Estimation of Community Consumption of Drugs and Diets. Washington: American Chemical Society; 2019. pp. 119-35. [DOI: 10.1021/bk-2019-1319.ch006]

Contribution of Illicit Drug Use to Pharmaceutical Load in the Environment: A Focus on Sub-Saharan Africa

Illicit drug abuse and addiction are universal issues requiring international cooperation and interdisciplinary and multisectoral solutions. These addictive substances are utilized for recreational purposes worldwide, including in sub-Saharan Africa. On the other hand, conventional wastewater treatment facilities such as waste stabilization ponds lack the design to remove the most recent classes of pollutants such as illicit drug abuse. As a result, effluents from these treatment schemes contaminate the entire ecosystem. Public health officials are concerned about detecting these pollutants at alarming levels in some countries, with potential undesirable effects on aquatic species and increased health hazards through exposure to contaminated waters or recycling treated or untreated effluents in agriculture. Contaminants including illicit substances enter the environment by human excreta following illegal intake, spills, or through direct dumping, such as from clandestine laboratories, when their manufacturer does not follow accepted production processes. These substances, like other pharmaceuticals, have biological activity and range from pseudopersistent to highly persistent compounds; hence, they persist in the environment while causing harm to the ecosystem. The presence of powerful pharmacological agents such as cocaine, morphine, and amphetamine in water as complex combinations can impair aquatic organisms and human health. These compounds can harm human beings and ecosystem health apart from their low environmental levels. Therefore, this article examines the presence and levels of illicit substances in ecological compartments such as wastewater, surface and ground waters in sub-Saharan Africa, and their latent impact on the ecosystem. The information on the occurrences of illicit drugs and their metabolic products in the sub-Saharan Africa environment and their contribution to pharmaceutical load is missing. In this case, it is important to research further the presence, levels, distribution, and environmental risks of exposure to human beings and the entire ecosystem.

Tracing consumption patterns of stimulants, opioids, and ketamine in China by wastewater-based epidemiology

Illicit drug use has long been a key issue of international concern, and the true situation is unknown to the relevant authorities. To develop a profile of comprehensive consumption patterns of illicit drugs in China, data from 34 wastewater treatment plants in 25 cities were collected to analyze four classes of drugs, including amphetamine-type stimulants, opioids, ketamine, and cocaine. They were identified and quantified in samples using methods based on gas chromatography coupled to mass spectrometry. According to the wastewater-based epidemiology (WBE) approach, an analysis of the consumption pattern was performed regarding per inhabitant consumption based on the revised metabolic rate. The consumption quantity of illicit drug and precursor was divided into four categories based on statistical difference analyses: methamphetamine and ephedrine (precursor) were the predominant drugs in the first category, followed by ketamine and heroin in the second category, methcathinone and 3,4-methylenedioxymethamphetamine (MDMA) in the third category, and cocaine and methadone in the fourth category. There were distinctive spatial patterns: heroin and cocaine consumption was higher in Southern China than in Northern China, heroin consumption was higher in Western China than in Eastern China, and the consumption of each drug differed across seven regions of China, especially with ephedrine and methcathinone consumption higher in North China; heroin consumption higher in Southwest, Central, and Northwest China; and ketamine and MDMA consumption higher in East, South, and Central China. Compared with findings in previous studies, there were temporal patterns, in which ketamine consumption presented a downward trend but heroin remained stable. Based on correlation analyses, there were the polydrug abuse patterns between heroin and cocaine, methcathinone and ketamine, and cocaine and MDMA. In general, this study based on WBE provides a comprehensive evaluation of drug consumption in China.

A revised excretion factor for estimating ketamine consumption by wastewater-based epidemiology - Utilising wastewater and seizure data

The rate of drug excretion (excretion factor) is a critical parameter for monitoring drug consumption in the population by wastewater-based epidemiology (WBE). Previous studies have refined excretion factors for common illicit drugs, such as cocaine, amphetamine, methamphetamine, heroin, to improve the accuracy and reduce uncertainty in back-calculating consumption. Nevertheless, for ketamine, one of the most prevalent psychoactive substances, a careful review of its excretion factors has not been performed due to limited pharmacokinetic data. Here we review WBE studies and seizure data to refine and validate the excretion factors for ketamine and norketamine. The average ketamine/norketamine ratio in wastewater (5.36) was much higher than that found in urine (0.64), which means that the excretion factors derived only from pharmacokinetics data are not appropriate. Based on the comparison of the ratio between estimated consumptions of ketamine and methamphetamine by WBE with their corresponding ratio in official seizure data, a revised WBE excretion factor of 20% was proposed for ketamine following this review and applied to estimate the ketamine consumption in China. The revised estimates of ketamine consumption corresponded well with drug statistics. This suggests that the revised ketamine excretion factor is appropriate for estimating ketamine consumption by WBE. Systematic review of WBE studies is a suitable approach to refine the excretion factors for substances with inadequate pharmacokinetic data.

Prevalence of illicit and prescribed neuropsychiatric drugs in three communities in Kentucky using wastewater-based epidemiology and Monte Carlo simulation for the estimation of associated uncertainties

A cost-effective alternative approach capable of determining the prevalence of substance use in communities can complement the existing efforts of combating drug abuse and addiction. In this study, the prevalence of 10 illicit and 19 prescribed psychoactive drugs of potential abuse was determined utilizing wastewater-based epidemiology, and compared in two adjoined urban communities and a rural community. This is the first application of the Monte Carlo simulation method to account multiple uncertainties and propagation of errors associated with the individual parameter of wastewater based epidemiological estimations in the U.S. A significantly higher prevalence of cocaine [3830 (mean difference, MD: 2960) mg/d/1000 people] was found in the central business district while the per-capita consumption rates of amphetamine [738 (MD: 338) mg/d/1000 people] and methamphetamine [1660 (MD: 629) mg/d/1000 people] were higher in a rural community. Among narcotics, the per-capita consumption rate of fentanyl and morphine was significantly higher in urban communities while codeine, hydrocodone, hydromorphone, and buprenorphine were dominant in a rural community. The significantly higher prevalence of buprenorphine (˜20-30 folds), oxycodone (˜2-3 folds), and alprazolam (˜2-3 folds) determined in these communities compared to the conventional estimates based on the electronically reported prescriptions and drug-related inpatient hospitalizations suggest the abuse of these drugs.