Emergency department visits due to new psychoactive substances and other illicit drugs in Taiwan: preliminary results of the Taiwan Emergency Department Drug Abuse Surveillance (TEDAS) project

Determination of Arylcyclohexylamines in Biological Specimens: Sensors and Sample Pre-Treatment Approaches

Arylcyclohexylamine (ACH) compounds represent a predominant faction within new psychoactive substances. Due to their powerful dissociative effects, they are used in recreational contexts but also in situations of drug-facilitated sexual assault, and therefore, they are a constant target of analysis by forensic experts. In recent years, their consumption has been notably high, especially the use of ketamine, presenting daily challenges for laboratories in the determination of this and other ACH analogues. This review comprises the recent strategies that forensic specialists use to identify and quantify ACH compounds in the laboratory with more traditional analytical techniques and technology, and on the point-of-care testing via sensor technology. The study focuses on analogues of phencyclidine (PCP), ketamine, and eticyclidine, highlighting the consistent need for higher sensitivity in the analysis of various samples collected from real cases and simulations of possible matrices. The review also emphasises the ongoing research to develop more sensitive, quicker, and more capable sensors.

Mephedrone concentrations in clinical intoxications and fatal cases: a systematic review

BACKGROUND/PURPOSE

Mephedrone, a ring-substituted synthetic cathinone derivative, gained popularity as a recreational drug in the late 2000s. Reports of fatalities related to mephedrone use have emerged with varying concentrations of blood mephedrone upon forensic investigations. This study aims to evaluate the existing literature on mephedrone concentrations in instances of clinical intoxication and fatal cases.

METHODS

We comprehensively searched electronic databases, including Web of Science, PubMed, Embase, and the Cochrane Library, from inception to July 26, 2023. We selected case reports or case series of mephedrone intoxication presented with individual blood mephedrone concentration. Patient demographics, clinical characteristics, blood mephedrone concentrations, and outcomes were extracted for analysis.

RESULTS

77 cases from 14 case reports and 6 case series were identified for review. There were 34 deaths and 43 non-fatal intoxication cases. The median patient's age was 24 years (IQR: 10), and 91.4% were male. Forty-five of the 63 cases (71.4%) were reported with alcohol or other illicit drugs detected. The median blood mephedrone concentration was 0.37 mg/L (IQR: 1.09 mg/L). Death cases were older than non-fatal cases (median = 30 vs. 22 years, p = 0.029). The median blood mephedrone concentration was higher in death cases (1.30 mg/L vs. 0.12 mg/L, p < 0.0001).

CONCLUSIONS

Blood mephedrone concentration in dead patients is approximately 11 times higher than in non-fatal cases. This finding could serve as a stepping stone to the diagnosis of concentrations in clinical poisoning cases and deaths, especially in the treatment of poisoning patients. In more extensive prospective studies, further research is necessary to establish a standardized, real-time available methodology and validate the predictive value of mephedrone concentrations in the prognostic value of mephedrone concentrations.

Evaluation of spatial and temporal changes in illicit drug use in the Taipei metropolitan area via wastewater-based epidemiology

Taiwan, identified as pivotal in the Asian drug trafficking chain, has been experiencing a surge in illicit drug-related issues. Wastewater-based epidemiology (WBE) has emerged as a promising approach for comprehensive evaluation of actual illicit drug usage. This study presents the first WBE investigation of illicit drug consumption in Taiwan based on the analysis of wastewater from four wastewater treatment plants (WWTPs) in the Taipei metropolitan area. Additionally, it demonstrates a high correlation between the amounts of illicit drugs seized and influent concentrations over an extended period of time. The reliability of solid-phase extraction and analysis via high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) was validated for 16 illicit drugs (methamphetamine, ketamine, cocaine, codeine, methadone, morphine, meperidine, fentanyl, sufentanil, para-methoxyamphetamine (PMA), para-methoxymethamphetamine (PMMA), 3,4-methylenedioxymethamphetamine (MDMA), cathinone, methcathinone, mephedrone (MEPH), and 4-methylethcathinone (4-MEC)). Methamphetamine, ketamine, and 4-MEC were consistently detected in all wastewater samples, underscoring their prevalence in the Taipei metropolitan area. Biochemical oxygen demand (BOD) and ammonia nitrogen (ammonia N) were employed to reduce uncertainty in estimations of population size during back-calculation of illicit drug consumption. The results indicate that methamphetamine was the most consumed drug (175-740 mg day-1 1000 people-1), followed by ketamine (22-280 mg day-1 1000 people-1). In addition, urban-related WWTPs exhibited higher consumption of methamphetamine and ketamine than did the suburban-related WWTP, indicating distinct illicit drug usage patterns between suburban and urban regions. Moreover, an examination of temporal trends in wastewater from the Dihua WWTP revealed a persistent predominance of ketamine and methamphetamine, consistent with statistical data pertaining to seizure quantities and urine test results. The study provides encouraging insight into spatial and temporal variations in illicit drug usage in the Taipei metropolitan area, emphasizing the complementary role of WBE in understanding trends in illicit drug abuse.

A comparative study of old versus novel psychoactive substances on craving, perceived stigma and suicidal risk among rural-dwelling patients with substance abuse

WHAT IS KNOWN ON THE SUBJECT?: According to recent estimates, 10.4% of adults are patients with substance abuse, which is almost double the global rate. Rural areas are typically marginalized, compounded by a lack of access to mental health care, creating a startling disparity in suffering from drug use issues among rural cohorts. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Drawing on data from a descriptive comparative design would provide a distinctive picture related to the similarities and/or differences in relation to craving and how it affects perceived stigma and suicidal risk among patients using old versus novel psychoactive substances. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Substance abuse is a leading public health concern that forces nurses to encompass it into their agendas to tackle this looming problem. Addiction rehabilitation services are frequently run by nurses. They are well-versed in supporting patients during their journey to recovery and enabling them to adjust to a new lifestyle.

ABSTRACT

INTRODUCTION: Substance use disorder is a leading public health concern that currently, nations regulatory agencies are grappled with. The noticeable difference in the chemical structures between old and novel psychoactive substances can result in significant clinical complications among patients with substance abuse.

AIM

The study aims to compare substance craving, perceived stigma and suicidal risk among patients addicted to old and novel psychoactive substances (NPS).

METHOD

A descriptive comparative design was adopted on a sample of 105 patients with substance use who completed The Penn Alcohol Craving Scale (PACS), The Perceived Stigma of Addiction Scale (PSAS) and Suicide Probability Scale (SPS).

DISCUSSION

Most participants were male, with 89.5% in the old addictive substance group and 93.8% in the new addictive substance group. A statistically significant difference in the NPS groups' perceptions of stigma (23.4 ± 5.3) compared to the old addictive substance group (20.6 ± 4.2), (t = 3.037, p = .003).

IMPLICATION FOR PRACTICE

Participants in the new substance group report more suicidal ideation, negative self-evaluation and hostility than those in the old substance group. Policies and practices should be tailored to the type of drug used and potential risk factors to avoid suicide among patients with substance abuse.

GxE interaction effects of HCRTR2 single nucleotide polymorphism and adverse childhood experiences on methamphetamine use disorder

Background: Methamphetamine use disorder (MUD) is a worldwide health concern. The hypothalamic orexin system regulates stress response and addictive behaviors. The genetic variation in the hypocretin receptor 2 (HCRTR2), rs2653349, is associated with substance use disorder.Objectives: We explored the gene-environment (GxE) interaction of rs2653349 and adverse childhood experiences (ACEs) associated with MUD susceptibility.Methods: Four hundred and one individuals (336 males, 65 females) with MUD and 348 healthy controls (288 males, 60 females) completed a self-report questionnaire evaluating ACEs, encompassing childhood abuse and household dysfunction categories, and were genotyped for SNP rs2653349. Methamphetamine use variables were collected using the Diagnostic Interview for Genetic Studies. We used regression analyses to assess the GxE effect on MUD risk.Results: The MUD group had a comparable genotypic distribution for rs2653349 to the control group, albeit with a higher prevalence and number of types of ACEs, correlating with an increased MUD risk (p < .05). No significant genetic impact of rs2653349 on MUD risk was found. However, we observed a GxE interaction effect between the minor allele of rs2653349 and the number of childhood abuse or household dysfunction types, correlating with a reduced MUD risk (OR = -0.71, p = .04, Benjamini-Hochberg adjusted p = .08 and OR = -0.59, p = .045, Benjamini-Hochberg adjusted p = .09, respectively).Conclusion: HCRTR2 SNP rs2653349 has no significant impact on MUD risk, but ACEs may increase this risk. GxE results suggest that rs2653349 could offer protection against developing MUD in individuals experiencing multiple types of ACEs.

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.

Current state-of-the-art approaches for mass spectrometry in clinical toxicology: an overview

INTRODUCTION

Hyphenated mass spectrometry (MS) has evolved into a very powerful analytical technique of high sensitivity and specificity. It is used to analyze a very wide spectrum of analytes in classical and alternative matrices. The presented paper will provide an overview of the current state-of-the-art of hyphenated MS applications in clinical toxicology primarily based on review articles indexed in PubMed (1990 to April 2023).

AREAS COVERED

A general overview of matrices, sample preparation, analytical systems, detection modes, and validation and quality control is given. Moreover, selected applications are discussed.

EXPERT OPINION

A more widespread use of hyphenated MS techniques, especially in systematic toxicological analysis and drugs of abuse testing, would help overcome limitations of immunoassay-based screening strategies. This is currently hampered by high instrument cost, qualification requirements for personnel, and less favorable turnaround times, which could be overcome by more user-friendly, ideally fully automated MS instruments. This would help making hyphenated MS-based analysis available in more laboratories and expanding analysis to a large number of organic drugs, poisons, and/or metabolites. Even the most recent novel psychoactive substances (NPS) could be presumptively identified by high-resolution MS methods, their likely presence be communicated to treating physicians, and be confirmed later on.

Defective determination of synthetic cathinones in blood for forensic investigation

Antemortem specimens are sometimes the sole sources available for forensic investigation, and samples collected in nonideal ways are inevitably employed to achieve toxicological analysis. It is essential to assess the effects of blood collection tubes on the recoveries of emerging synthetic cathinones (SC) to estimate actual drug concentrations, and no such systematic investigations have been previously carried out. Seventy-one SC with various LogP values were employed to examine commonly used blood collection tubes, including plasma tubes, serum tubes and gel-containing tubes in recoveries which determined by a reliable LC-MS/MS method. Significantly poor recoveries for hydrophobic SC were obtained using serum separating tubes (SST). Notably, the suppressed recoveries in SST can be reversed by adding anticoagulants. Adding a procoagulant to a plasma separating tube (PST) considerably reduced recoveries, which indicated that clotting processes in the presence of polymeric gels contributed to poor recoveries of these hydrophobic drugs. In this study, we find that clotting formation in the presence of polymeric gels could significantly affect the determination of hydrophobic drugs. However, in real-world scenarios, nonideal collection methods are inevitably employed for antemortem specimens. Thus, it is important to rigorously interpret forensic toxicological results, especially for susceptible species.

Clinical Presentations and Predictors of In-Hospital Mortality in Illicit Drug Users in the New Psychoactive Substances (NPS) Endemic Era in Taiwan

Predictors of mortality in illicit drug users involving Novel Psychoactive Substances (NPS) and multiple substances have not been elucidated. We aimed to define predictors of mortality in the NPS endemic era’s illicit drug users to strengthen patient care in emergency treatment. This was a retrospective study. LC-MS/MS-confirmed positive illicit drug users who visited the emergency departments (ED) of six medical systems were enrolled. Demographic information, physical examinations, and laboratory data were abstracted for mortality analysis. There were 16 fatalities in 355 enrolled patients. The most frequently used illicit drugs were amphetamines, followed by opioids, cathinones, and ketamine. The most frequently detected cathinones among the 16 synthetic cathinones were eutylone, followed by mephedrone. The combined use of cathinones and ketamine was most commonly observed in our results. Univariate analysis revealed that the mortality patients were older, with deep coma, faster heart rate and respiratory rate, lower blood pressures and O2 room air saturation, more seizures, abnormal breath sounds, and had urine incontinence compared to the survivor patients. The mortality patients also had acute kidney injury, higher potassium, blood sugar, liver function test, and lactate level. The results of multiple logistic regression demonstrated that SBP < 90 mmHg, dyspnea, blood sugar > 140 mg/dl, and HCO3 < 20.6 mmHg were independent predictors of in-hospital mortality. Regardless of the pattern of the use of illicit drugs, the predictors allow for risk stratification and determining the optimal treatment.

Comparison of clinical characteristics between meth/amphetamine and synthetic cathinone users presented to the emergency department

BACKGROUND

Synthetic cathinones (SC) are popular new psychoactive substances that produce sympathomimetic toxicity. Meth/amphetamine and SC have similar chemical structures and pharmacological effects. We aimed to compare the clinical characteristics between meth/amphetamine and SC users presenting to the emergency department (ED).

METHODS

This retrospective observational cohort study included patients who presented to six EDs from May 2017 to April 2021 with symptoms that related to recreational drug use and whose urine toxicology tests were positive only for meth/amphetamine or SC through liquid chromatography-tandem mass spectrometry.

RESULTS

There were 379 patients who tested positive only for meth/amphetamine (MA group), and 87 patients tested positive only for SC (SC groups). Patients in the MA group were older than those in the SC group (median (IQR); MA: 37.0 (30-43.7), SC: 25.0 (21.0-32.7), p < 0.001). There were no significant between-group differences in the sex distribution and initial chief complaints. Compared with the MA group, the SC group had more cases of tachycardia (≥ 135/min; MA: 29 (8.2%), SC:16 (19.0%), p = 0.0031) and hyperthermia (≥ 38 °C; MA: 31 (8.2%), SC:18 (20.7%), p = 0.001). Besides, the SC group had significantly higher levels of creatinine kinase (CK, IU/L; MA: 263 (115-601), SC: 497 (206-9216), p = 0.008) as well as a higher risk of rhabdomyolysis (CK > 1000; MA:32 (8.4%), SC: 16 (18.4%), p = 0.006) and severe rhabdomyolysis (CK > 10,000; MA:10 (2.6%), SC:10 (11.5%), p = 001). Multivariable logistic regression analyses indicated SC group in comparison with the MA group (adjusted odds ratio: 2.732, 95% confidence interval: 1. 250-5.972, p = 0.012) was an association with the risk of rhabdomyolysis.

CONCLUSION

Our findings demonstrate that tachycardia, hyperthermia, and rhabdomyolysis were more common among cathinone users than among meth/amphetamine users presented to EDs.