Chronic pain and use of analgesics in the elderly: a nationwide population-based study.

INTRODUCTION: Chronic pain may cause many comorbidities in the elderly; however, nationwide data about this issue remain insufficient. We conducted this study to address the data gap. MATERIAL AND METHODS: We identified geriatric participants (≥ 65 years) with chronic pain between 2000 and 2013 from the Taiwan National Health Insurance Research Database. The causes of chronic pain and use of analgesics between two sexes and among three age subgroups were compared. RESULTS: A total of 21,018 participants were identified with the mean age (standard deviation) of 72.7 years (5.6) and the female percentage of 50.8%. The prevalence of chronic pain in the elderly was 21.5%, and it was higher in the females than males. The proportions of each age subgroup were 65-74 (66.8%), 75-84 (29.4%), and ≥ 85 years (3.8%). Common causes of chronic pain were osteoarthritis (21.9%), spinal disorders (19.0%), peripheral vascular diseases (12.4%), and osteoporosis (11.4%). Non-steroidal anti-inflammatory drugs were the most common medication, followed by acetaminophen and opioids. The most commonly used opioid was morphine. The use of opioids increased with age. CONCLUSIONS: This study delineated the causes of chronic pain and use of analgesics in a geriatric population, which may help further studies about this issue in the future.

Effect of Chronic Pancreatitis on Complications and Mortality in DM Patients: A 10-year Nationwide Cohort Study.

CONTEXT: Chronic pancreatitis (CP), is a long-term inflammation of the pancreatic parenchyma, and might increase risk of a hyperglycemia crisis or hypoglycemia in patients with diabetes mellitus (DM); however, the relationship has not been previously investigated. OBJECTIVE: To investigate the risk of diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), hypoglycemia, and long-term outcomes in DM patients with CP. DESIGN: A population-based cohort study. SETTING AND PARTICIPANTS: Tapping Taiwan's National Health Insurance Research Database, we identified 506 DM patients with newly diagnosed CP from 1999 to 2010 and created a control cohort consisting of 5060 age- and sex-matched DM patients without CP from the same time period. We followed those 2 cohorts from the index date to occurrence of outcomes, the date of death or 31 December 2012. MAIN OUTCOME MEASURES: DKA, HHS, hypoglycemia and mortality. RESULTS: DM patients with CP, who were predominantly male (88%) and younger (60% < 45 years old), had a 9.5-, 5.0-, and 3.0-fold higher risk for DKA (95% confidence interval [CI]: 6.51-13.91), HHS (95% CI: 2.85-8.62), and hypoglycemia (95% CI: 2.23-4.08), respectively. They also had lower 1-, 5-, and 10-year cumulative survival rates (98.4% vs 99.0%, 87.7% vs 96.6%, and 78.7% vs 93.6%, respectively) (log-rank test: P < .001), and a 2.43-fold higher risk for death (HR: 2.43, 95% CI: 1.82-3.27). CONCLUSIONS: In Taiwan, DM patients with CP have a higher incidence of DKA, HHS, hypoglycemia, and mortality. More attention is needed for preventing hyperglycemia crisis and hypoglycemia prevention in this population.

Nonmedical prescription drug use of analgesics and sedatives/hypnotics in Taiwan: Results from the 2014 National Survey of Substance Use.

Nonmedical prescription drug use (NMPDU) has become a major public health issue but little is known in Asian populations. This study aimed to investigate the prevalence and correlates of NMPDU in Taiwan. Participants from the 2014 national survey of 17,837 individuals, aged 12 to 64 year, completed anonymously a computer-assisted self-interview. Past-year prescription drug use was divided into medical use only (MUO) and nonmedical use (NMU), defined as using the drug without a prescription, or more frequently, or in larger doses than prescribed. Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT), problematic drug use using the 20-item Drug Abuse Screening Test (DAST), and depressive symptoms using the Center for Epidemiological Study-Depression (CES-D). The prevalence of past-year NMU was 3.02% for analgesics, 0.71% for sedatives/hypnotics, and 3.66% for either drug, with a very small overlap of NMU between analgesics and sedatives/hypnotics (0.07%). When individuals with NMU were compared to those without NMU (Non-NMU) and those with MUO, respectively, some correlates consistently identified, including young adulthood, tobacco smoking, alcohol drinking, and greater AUDIT's scores for analgesics, as well as hard drug use and greater DAST's scores for sedatives/hypnotics. NMU was associated with greater CES-D's scores for both analgesics and sedatives/hypnotics when compared to Non-NMU but not to MUO. Robust correlates of NMPDU could offer implications for development of prevention strategies of NMPDU.

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.

Long-term mortality in older adults with chronic pain: a nationwide population-based study in Taiwan.

PURPOSE: This study was conducted to clarify the long-term mortality in the older population with chronic pain (CP), which is still unclear. METHODS: We identified 17,568 older participants (aged ≥ 65 years) with CP and an identical number of comparison cohort without CP matched 1:1 by age and sex between 1996 and 2000 from the Taiwan National Health Insurance Research Database. Causes of CP, underlying comorbidities, living areas, and mortality were collected for analyses. The long-term mortality and the causes of mortality were compared between the two cohorts through follow-up since 2000 until 2015. RESULTS: The mean age (± standard deviation) was 73.5 ± 5.7 years, and female participants comprised 55.1% in both cohorts. The most common causes of CP were osteoarthritis (24.2%), spinal disorders (22.4%), peripheral vascular diseases (14.0%), and osteoporosis (9.5%). Older participants with CP had an increased rate of long-term mortality compared to that among their counterparts without CP after adjusting for the underlying comorbidities and the causes of CP (adjusted hazard ratio [AHR]: 1.18; 95% confidence interval [CI] 1.14-1.21). The increased mortality rate was observed even after the follow-up of 6 years (AHR 1.15; 95% CI 1.10-1.20). No significant difference was observed in the causes of mortality between the two cohorts. The most common cause of mortality was malignancy, followed by cardiovascular and cerebrovascular diseases. CONCLUSIONS: Chronic pain was associated with an increased rate of long-term mortality in the older population. Early detection and intervention for treating CP are suggested for this population.

Differences in prevalence, socio-behavioral correlates, and psychosocial distress between club drug and hard drug use in Taiwan: Results from the 2014 National Survey of Substance Use.

BACKGROUND: This study examined variation between users of 'club' and 'hard' drugs in Taiwan in terms of prevalence of use and demographics and psychosocial characteristics. METHODS: Data were derived from a survey of 17,837 Taiwanese civilians, aged 12-64 years, using stratified, multi-stage, random sampling. Participants completed a computer-assisted self-interview on tablet computers which covered use of legal substances, sedatives/hypnotics and prescription analgesics; use of illicit drugs/inhalants, risky sexual experiences; expectations of drugs; and psychological distress. FINDINGS: Approximately 1.29% of respondents reported ever using an illicit drug in their lifetime; prevalence estimates of club drugs (mainly ketamine, marijuana, and ecstasy) were slightly higher than hard drugs (mainly methamphetamine and heroin). Concurrent use of legal substances, particularly problematic use of alcohol and tobacco, as well as non-medical use of prescription drugs, were strong correlates of illicit drug use in general, with club drug use exhibiting an extremely strong association with alcohol use. Club drug users were demographically different from hard drug users, including in terms of their gender, age, and level of educational attainment. They were also more likely to be divorced or widowed, to report risky sexual partnerships and more depressive symptoms than hard drug users. CONCLUSIONS: Our findings indicate drug type specific distinct psychosocial characteristics, which may warrant further attention in the design of treatment and intervention programs.

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.

Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: a 10-year national cohort study.

BACKGROUND: The objective of this study is to determine the incidence and severity of acute pancreatitis (AP) in patients with end-stage renal disease (ESRD) on dialysis and whether the dialysis modality [hemodialysis (HD) versus peritoneal dialysis (PD)] confers a higher risk for AP as well as complications or mortality related to AP. METHODS: We analyzed national health insurance claims data of 67 078 ESRD patients initiating dialysis between 1999 and 2007 in Taiwan. All patients were followed up from the start of their dialysis to first AP diagnosis, death, end of dialysis or 31 December 2008. Cox proportional hazards models were used to identify risk factors. RESULTS: The cumulative incidence rates of AP were 0.6, 1.7, 2.6, 3.4 and 4% at 1, 3, 5, 7 and 9 years, respectively. ESRD patients on HD and PD had an AP incidence of 5.11 and 5.86 per 1000 person-years, respectively. Independent risk factors for AP in this population were being elderly, being female, having biliary stones or liver disease, and being on PD. Severe AP occurred in 44.9% of the HD patients and in 36% of the PD patients. Patients with AP on HD had a higher incidence of upper gastrointestinal (UGI) bleeding than those on PD (P = 0.002). In contrast, those with AP on PD had a higher incidence of need for total parenteral nutrition (TPN) support than those on HD (P = 0.072). Overall in-hospital mortality was 8.1%. The risk factors for mortality after an AP attack were male gender, increased age, AP severity, and the presence of diabetes mellitus or liver disease. CONCLUSIONS: ESRD patients on PD were at higher risk for AP than those on HD. HD patients with AP attacks had a greater incidence of UGI bleeding and PD patients with AP attacks a more frequent need for TPN support.

Trends in major opioid analgesic consumption in Taiwan, 2002-2014.

BACKGROUND/PURPOSE: According to WHO guideline, the consumption of opioids is an important sign of national progress in cancer pain relief. However, precise data on the consumption of opioid analgesics consumption in Taiwan has not been published. We investigate opioid analgesic consumption in Taiwan between 2002 and 2014 compare the results with those in other countries to see what we could learn about other methods of pain management. To find out the different patterns between Taiwan and other country, improves the quality of pain management. METHODS: We extracted from the Controlled Drugs Management Information System (CDMIS) database, the consumption data of morphine, fentanyl, and pethidine, three strong opioids, and of codeine and buprenorphine, two weak ones. Data were presented as defined daily doses for statistical purposes per million inhabitants per day (S-DDD/m/d). The number of inhabitants was extracted from the Taiwan Ministry of Interior Statistics population database. RESULTS: During the thirteen studied years, the total consumption of opioids markedly increased in Taiwan. By category, the consumption of morphine, fentanyl and buprenorphine increased, but the use of pethidine and codeine decreased. Compared with the selected regions and countries, the use of opioid in Taiwan progressed in Asia, but it was still lower than in Western countries. CONCLUSION: Opioid analgesics are probable addictive; however, they can improve a patients' quality of life if properly used. The Taiwan FDA continuously introduces new opioid analgesics and educates physicians on how to use them correctly. These measures will improve the quality of pain management in Taiwan.

A Smartphone Application Supporting Recovery from Heroin Addiction: Perspectives of Patients and Providers in China, Taiwan, and the USA.

Smartphone-based interventions are increasingly used to support self-monitoring, self-management, and treatment and medication compliance in order to improve overall functioning and well-being. In attempting to develop a smartphone application (S-Health) that assists heroin-dependent patients in recovery, a series of focus groups (72 patients, 22 providers) were conducted in China, Taiwan, and the USA to obtain their perspectives on its acceptance and potential adoption. Data were analyzed according to the Diffusion of Innovation (DOI) theory of characteristics important to the adoption of innovation. Important to Relative Advantage, USA participants cited S-Health's potential ability to overcome logistical barriers, while those in China and Taiwan valued its potential to supplement currently limited services. In terms of Compatibility, participants across sites reported recovery needs and goals that such an application could be helpful in supporting; however, its utility during strong craving was questioned in China and Taiwan. Important factors relevant to Complexity included concerns about smartphone access and familiarity, individualization of content, and particularly in China and Taiwan, participants wanted assurance of privacy and security. The study results suggest a general acceptance, but also indicate cultural variations in access to therapeutic and other social support systems, legal repercussions of substance use, societal perceptions of addiction, and the role of family and other social support in recovery. Taking these factors into consideration is likely to increase diffusion as well as effectiveness of these smartphone-based interventions.

Long-term usage of narcotic analgesics by chronic intractable noncancer pain patients in Taiwan from 2003 to 2012.

BACKGROUND/PURPOSE: Chronic pain is a common and important medical problem worldwide. Patients with chronic intractable noncancer pain (CINCP) are treated primarily with narcotics. We analyzed the characteristics of patients with CINCP and the pain prescriptions of Taiwan's physicians. METHODS: We enrolled 644 patients from 66 hospitals approved by the Taiwan Food and Drug Administration to use long-term narcotics for CINCP between 2003 and 2012. RESULTS: The majority (61.8%) of patients were 40-49-year-old men who had been treated with pethidine more often than with fentanyl in the 20-49 years age group. More than 50% of CINCP patients live in northern Taiwan, and most were treated in the department of pain; the major diagnosis (men 28.9%; women 27.7%) was neuropathy. The most frequently prescribed single analgesic was morphine (52.2%); the most frequently prescribed two-drug combination was morphine plus fentanyl (50.8%). Pethidine, however, was the most frequently prescribed analgesic in the neurology (78.0%) and plastic surgery (50.0%) departments. CONCLUSION: To decrease malaise and addiction in patients with CINCP, Taiwan's physicians need more education on narcotic analgesics, and greater professional cooperation to develop therapeutic guidelines that will improve pain care for patients with CINCP.

Current controlled drug regulation in Taiwan.

In order to strengthen the management system of medical and scientific use of controlled drugs, Taiwan government referred to the three major drug control treaties of United Nation to formulate the "Controlled Drugs Act" in 1999. There are three kinds of system to manage controlled drugs, including (1) Schedule Management, (2) Licensing Regulation Management and (3) Diversion Control Management, such as the reporting and auditing systems. In this article, the management system of controlled drugs will be discussed thoroughly. Under the "Controlled Drugs Act", the controlled drugs are scheduled by the tendency of their habitual use, drug dependency, abuse, and social hazard. If violating the rule, the administrative sanction is applied. Cases of violations will also be given in this article.

Dinosaur girls, candy girls, and Trinity: voices of Taiwanese club drug users.

Research among Asian users of methylenedioxy methamphetamine (MDMA), also known as Ecstasy, is rare. To evaluate the feasibility of a study on the abuse of and dependence on Ecstasy, two focus groups of users (n= 12) and health professionals (n=7) were conducted in Taiwan. Major results included blatant human testing with "candy and dinosaur girls" and a specific sequence of drugs called a "Trinity" (Ecstasy, ketamine, and marijuana). "Head-shaked bars" and "KTVs" were public places where illegal behaviors were implicitly allowed. Depression after Ecstasy use was not reported. For future studies, participants suggested that magnetic resonance imaging could be a strong incentive for young users to enhance willingness to participate. Cultural issues of Ecstasy use are also discussed.

Performance characteristics of DRI, CEDIA, and REMEDi systems for preliminary tests of amphetamines and opiates in human urine.

Arrestee urine specimens (930) were tested with DRI, CEDIA, and REMEDi; those that tested positive for amphetamines and opiates (616 and 414, respectively) were then confirmed by gas chromatography-mass spectrometry. The performance characteristics of these three preliminary systems were evaluated using the following commonly used parameters: true positive, true negative, false positive, and false negative. The sensitivity, specificity, and efficiency of these methods were also calculated. Data derived from this study indicated DRI and CEDIA adapted by this study generated acceptable preliminary test results for amphetamine/methamphetamine and morphine/codeine, but not for MDA/MDMA and REMEDi has lower sensitivity than DRI and CEDIA, but with better specificity and efficiency, supporting its use under emergency room settings where drug concentrations in overdose cases are expectedly at high levels.

Performance characteristics of selected immunoassays for preliminary test of 3,4-methylenedioxymethamphetamine, methamphetamine, and related drugs in urine specimens.

Eight commercially available immunoassays for amphetamines (DRI Amphetamines, CEDIA DAU Amphetamines-Semiquantitative, EMIT d.a.u. Monoclonal Amphetamine/Methamphetamine, Synchron CX Systems AMPH, TDx/TDxFLx Amphetamine/Methamphetamine II, CEDIA Amphetamines/Ecstasy, COBAS INTEGRA Amphetamines, and Abuscreen((R)) OnLine HS Amphetamine/MDMA) are evaluated for their effectiveness in serving as the preliminary test methodology for the analysis of 3,4-methylenedioxymethamphetamine/3,4-methylenedioxyamphetamine (MDMA/MDA) and methamphetamine/amphetamine (MA/AM). Standard solutions (in urine matrix) of MDMA, MDA, MA, and AM are used to determine these immunoassays' reactivities (or cross-reactivities) toward these compounds of interest. Case specimens containing MDMA/MDA and MA/AM are also used to study the correlations of the apparent immunoassay MDMA (or MA) concentrations and the gas chromatographic-mass spectrometric concentrations of these compounds. Data resulting from this study suggest that CEDIA Amphetamines/Ecstasy can best predict the concentrations of MDMA and MA in case specimens and can also detect the presence of MDMA at low levels, whereas Abuscreen OnLine HS Amphetamine/MDMA can detect both MDMA and MA at low concentrations.

Improved screen and confirmation test of 7-aminoflunitrazepam in urine specimens for monitoring flunitrazepam (Rohypnol) exposure.

Confirmed and alleged misuses of flunitrazepam (FM2, Rohypnol) have brought about serious interest in the development of an analytical methodology that can be effectively used for preliminary screen and confirmatory test of FM2 (or its metabolites) in urine specimens under high-volume settings. Reported methods do not serve this need well for the following reasons: (1) common benzodiazepine (BZ) immunoassays (IAs) have broad cross-reactivities toward widely prescribed BZs (and their metabolites) and are therefore likely to generate an unacceptable number of false positives and (2) because FM2 is typically used at low doses (1-4 mg), IAs with low cross-reactivities toward FM2 (and its metabolites) are likely to generate false-negative results. In this current study, a familiar and effective two-step IA/gas chromatography-mass spectrometry (GC-MS) approach is successfully developed and applied to clinical specimens. Cross-reacting characteristics of the following BZ IAs toward various BZs (and their metabolites) are evaluated focusing on their effectiveness in serving as the preliminary test reagent in a two-step testing protocol: TDx, Beckman, CEDIA, Roche Cobas Integra, Emit II Plus, and Cozart ELISA. Although other IAs show broad cross-reactivities toward various BZs and their metabolites, diazepam is the only non-FM2 derived compound that exhibits noticeable cross-reactivity toward Cozart ELISA reagent. Cross-reactivity data and data derived from studies conducted on a limited number of clinical specimens demonstrate that, when used to monitor FM2 exposure in a large population group (including those exposed to other BZs), Cozart ELISA has the potential of being as effective as (or better than) those currently used in various workplace drug-testing programs for monitoring respectively targeted drugs. Data derived from this study further suggest that 50 ng/mL apparent 7-aminoflunitrazepam (Cozart ELISA) and 30 ng/mL free 7-aminoflunitrazepam (GC-MS) are potentially effective preliminary test and confirmation test cut-offs. To maximize efficiency, it is further suggested that urine specimens are first diluted by a factor of 5 for the preliminary test in which a 10-ng/mL 7-aminoflunitrazepam standard is used as the assay's cut-off standard.