Snapshot of narcotic drugs and psychoactive substances in Kuwait: a qualitative analysis of illicit drugs and their associated mortality in Kuwait from 2015 to 2018

Background: The misuse of illicit substances is associated with increased morbidity and mortality; thus, substance abuse is a global health concern. However, a lack of laboratory-based research has limited the scientic assessment of drug misuse in the Arabian Gulf region. Thus, the primary aim of this study was to assess the problem of illicit drugs in Kuwait using laboratory-based analyses. Methods: We investigated the type and quantity of detained narcotic drugs and psychotropic substances from 2015 to 2018, number of abusers, and mortality among abusers. In total, 6220 cases from the Narcotic and Psychotropic Laboratory and 17,755 cases from the Forensic Toxicology Laboratory were reviewed and analyzed. Substances were identied and documented using gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. Results: Cannabis, including marijuana, was the most seized substance, followed by heroin, opium, and cocaine. Amphetamines, including methamphetamine, in the form of powder or pills, were seized in larger quantities than other psychoactive substances. Benzodiazepines, tramadol, Khat, synthetic cannabinoids, and psilocin were also seized. The most consumed substances were, in order, amphetamines (including methamphetamine), benzodiazepines, cannabis, and heroin. Drug misuse was considerably higher among men than among women. We report the death rate associated with the abuse of various illegal drugs according to sex. The mortality rate associated with single-drug use was the highest among abusers of heroin, benzodiazepines, and methamphetamine. The mortality rate asscoaited with multiple-drug use was the highest among abusers of heroin–benzodiazepines, cannabis–benzodiazepines, and cannabis– amphetamines. Conclusions: Our study shows the changing trends in quantity and variety of substances illegally abused and marketed in Kuwait. Additionally, we report a direct gender-based association between mortality and consumption of certain substances. These ndings suggest that there is a growing need to conduct larger scale studies to implement new strategies, policies, and interventions in populations affected by illicit drugs. Our results show that many different narcotic drugs and psychotropic substances were abused. These include methamphetamine (MET), amphetamine (AMP), benzodiazepines (BEN), cannabinoids (CAN), heroin (HER), tramadol (TRA), and cocaine (COC). Our data shows that methamphetamine was the most abused illicit drug in Kuwait throughout 2015–2018, whereas cocaine had the least number of users. For the remaining illegal drugs, no dramatic changes were observed in terms of the number of abusers. Amphetamine, benzodiazepines, cannabis, and heroin were also highly abused. Generally, the number of male abusers were higher than the number of female abusers for all the illicit drugs. Moreover, the change in the number of abusers was inconsistent, and it uctuated throughout the four years of study (Figure 4).


Background
The use of illicit drugs is a global concern. These substances for which extra-medical uses have been prohibited and criminalized under international drug control treaties [1]. Despite international efforts to eliminate drug abuse, the global consumption trend of these substances increases continuously. In 2018, it was estimated that approximately 275 million people (~5.5% of world's population) have used illicit substances at least once, which is an increase of 30% compared with that in 2009 [2,3]. Thus, extra measures are needed to tackle this ongoing crisis.
Illicit substance abuse is a preventable and treatable condition that imposes enormous costs on the global health and economy [4]. The use of these substances carries risks of adverse health outcomes. Drug abuse is accountable for roughly 1.5% of the global disease burden and was responsible for more than 750,000 premature deaths in 2017 [3]. The use of these substances increases the risks of adverse health conditions, including but not limited to disability, viral infections, sepsis, thrombosis, and endocarditis [5]. Thus, the abuse of illicit drugs adds a severe nancial burden on the global economy. The International Narcotics Control Board [6] estimates that the cost of medical care associated with drug misuse is more than $200 billion annually.
The global market for drug tra cking continues to grow each year. The term "drug tra cking" used here refers to cultivation, production, distribution, and sale of illicit substances. In 2017, the United Nations O ce on Drugs and Crime (UNODC) estimated that the global market for drug tra cking is worth $426 to $652 billion [7].
The Middle East and North Africa (MENA) are considered a signi cant area for illicit substance tra cking. In terms of production, cannabis (Morocco and Lebanon), opiates (Egypt), Khat (Yemen to Somalia), and amphetamine-type stimulants (ATS) (Egypt and Lebanon) are the most produced substances [8]. Owing to its geographical location situated between different tra cking routes and its widespread borders, MENA is recognized as a major transit area for illicit substances. Indeed, MENA links the major drug producers to the vast markets in Europe and the Gulf countries. Illicit substances that ow through MENA include opiates (Golden Crescent to Europe), cannabis (Morocco to the Gulf Countries), cocaine (Latin America to Europe), and amphetamine-type stimulants (Western Africa to Europe) [9]. Because of its geographical location being a passage between continents, drug addiction and abuse in MENA countries are high. As a result, legislative authorities in these countries have imposed harsh penalties for drug-related offences to restrict and reduce the epidemic of recreational use of illicit drugs. However, such legislation only made illegal drug tra cking more lucrative [10].
Despite the importance of this topic, to our knowledge, the few studies published thus far concerning illicit substances that have been seized or consumed, or the associated-death rates, in the Middle East in general, and more speci cally in Kuwait (representing a population of approximately 4 million people), have not been comprehensive [11,12]. Additionally, most studies that have been previously conducted in Kuwait were outdated survey-based studies that did not rely on solid analytical data generated by laboratory-based experiments [13,14]. Moreover, the only previous analytical-based study is outdated [15].
A cross-sectional questionnaire conducted on Kuwaiti male students (n = 1587) reported that the most commonly used illicit substances were marijuana (11%), stimulants (7.1%), cocaine (2.2%), and heroin (1.3%) (13). Omu et al. (2017) performed a survey on illicit drug abuse among teenagers (15 to 18 years) between September 2012 and June 2013 [14]. The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. Hashish (marijuana) was the most commonly used illicit substance among both current users and previous users, 3.7% and 5.3%, respectively [14]. A Kuwaiti pilot study con rmed the association between levels of self-esteem and anxiety with drug user behavior [16]. Wilby and Wilbur assessed narcotic requirements in different Arabic-speaking countries in the Middle East region [17]. Bahrain and Kuwait had the highest estimated rate (364 and 352 de ned doses per million inhabitants per day, respectively), as well as the highest rates of growth (2008-2012). Radovanovic et al. assessed the prevalence and trend of different psychoactive substances in Kuwait from 1992 to 1997 by screening 3781 biological samples [15]. According to the study, the most used substances were as follows: cannabinoids, benzodiazepines, opiate, and amphetamine. Other drugs were also identi ed but at insigni cant levels; these included methadone, cocaine, and phencyclidine [15]. However, the information gained in that study was based only on a preliminary analysis (screening tests) of biological samples and is now outdated. Consequently, the current study is aimed to identify the types of narcotic drugs and psychotropic substances that were seized and consumed in Kuwait from 2015 to 2018 and their associated mortality. This was achieved using a Mass Spectrometric (MS) based approach for the analysis of drug (6220) and toxicological (17755) samples , providing a clear picture on the recent drug situation in Kuwait which provide local, regional and international public health workers and forensic analysts with data that are normally scarce in this region.

Receipt of Seized Narcotic Drugs and Psychotropic Substances
We have divided the received materials into two groups: (1) substances that can be weighed and thus reported in grams, including liquid materials (i.e. cannabis oil), powders (i.e. heroin and cocaine), vegetal materials (i.e. marijuana and damiana leaves containing synthetic cannabinoids), and solid blocks (such as cannabis and opium blocks), and (2) substances that can be counted, such as pills and capsules (i.e. tramadol, clonazepam, diazepam and alprazolam). Narcotic substances that were received by the NPL and are scheduled and documented in this report include cocaine, opium, heroin, cannabis (resin, oil and hashish), and marijuana ( Figure 1). Psychotropic substances that were received by the NPL and scheduled and documented in this report include methamphetamine, synthetic cannabinoids, Khat, and psilocybin mushrooms, which can all be weighed in grams (Figure 2), and methamphetamine, amphetamine, tramadol, and benzodiazepines (such as clonazepam, diazepam, unitrazepam, alprazolam, and bromazepam), which can all be counted as pills or capsules ( Figure 3). Photographic images were taken as representative examples for some of the seized substances (Additional le 1).
Seized narcotic drugs and psychotropic substances were received by the Narcotic and Psychotropic Laboratory (NPL) of Kuwait, a division of the Forensic Laboratories, General Department of Criminal Evidence. NPL is the only accredited laboratory in Kuwait that conducts drug-related investigations and routine drug testing to provide expert opinion (reports) for the court of law. Seized materials were sent to the NPL by several governmental agencies. Additionally, drug samples brought in for analysis included details of the origin of the sample e.g. place of seizure, date, physical appearance, name of suspect.
Toxicological samples data included the type of sample (blood, urine), date, name of suspect.
The current study reviews and analyses documented cases that were received by the NPL and the Forensic Toxicology Laboratory (FTL) from January 2015 to December 2018. It also highlights the protocols and the experimental procedures that were used by the laboratory specialists at the NPL to generate the reports.
Only reports that were generated from cases that were positive for the presence of at least one illicit drug (i.e., those listed in the schedules of narcotic drugs or psychotropic substances) were reviewed and analyzed.
Processing Seized Materials in the NPL All procedures were performed according to the required legal provisions and the chain of custody. Regarding the analysis of seized drugs, we followed the recommendations of the Scienti c Working Group for the Analysis of Seized Drugs (SWGDRUG) [18]. The mission of SWGDRUG is to recommend minimum standards for the forensic examination of seized drugs and to seek the international acceptance of these standards [18].

Color (Spot) Tests
Color (spot) is the most commonly used presumptive screening test in forensic laboratories. Speci c instructions and protocols described by Clarke's Analysis of Drugs and Poisons were used for the identi cation of the illicit drugs [19]. Marquis reagent was used for the detection of Opiates amphetamine, and methamphetamine, Duquenois-Levine and Fast Blue B reagent used for testing for cannabinoids in cannabis, and Scott's reagent for the detection of cocaine.

Macroscopic and Microscopic Examination for Cannabis
Macroscopic analysis (visual characterization) was used to document different cannabis species. The microscopic examination of leafy materials was performed using a stereomicroscope (Stemi DV4, Carl Zeiss, Jena, Germany), equipped with a cold light (Zeiss KL1500 LCD, Jena, Germany). Analysis included the identi cation of botanical characteristics such as cytolithic hairs (bear claw appearance), elongated hairs on the underside of the leaf, and resin glands (glandular hair).

Thin Layer Chromatography (TLC)
TLC was performed on pre-coated aluminum TLC-sheets (20 × 20), with a 0.25-mm silica gel layer thickness. Solid samples were dissolved in methanol (MeOH; HiPerSolv CHROMANORM, HPLC grade, BDH prolabo) (VWR International, Fonenay-sous-Bois, France) then spotted onto a TLC plate using capillary tubes (Terumo corporation, Tokyo, Japan). The mobile phases were prepared and used according to the recommendation of Clarke's Analysis of Drugs and Poisons [19]. Plates visualization was acheived using a short-wave ultraviolet (UV) light source and the ultraviolet uorescent indicator ALUGRAM® Xtra SIL G SIL UV254 (Macherey-Nagel Gmbh, Duren, Germany). Rf values were calculated for each sample, for comparison with standards.

Ultraviolet-visible Spectroscopy (UV-Vis)
Ultraviolet-visible spectroscopy technique used to identify a number of different compounds, including ketamine hydrochloride, cocaine hydrochloride, diazepam, phenobarbital, and barbital [21]. In our laboratory, a Cary 60 UV-Vis spectrophotometer (Agilent Technologies, Santa Clara, CA, USA) was used for these measurements, and the spectra were recorded using the Cary WinUV Scan software (Agilent Technologies, Santa Clara, CA, USA).

Attenuated Total Re ection-Fourier Transformed Infrared (ATR-FTIR) Spectroscopy
It is used as a con rmatory method for the detection of a variety of different drugs including benzodiazepines, amphetamine, methamphetamine, MDMA, lysergic acid diethylamide (LSD), cocaine, opium, heroin, morphine, synthetic cannabinoids, and cathinones. Most of the samples that were examined using this method in our laboratory are in a solid form. IR spectra were recorded using a Bruker ALPHA spectrometer (Bruker Optics, Ettlingen, Germany).

Gas Chromatography-Mass Spectrometry (GC-MS)
The method used for GC-MS analysis in this paper was adapted from our previous study [22]. GC-MS analysis was used exclusively for identi cation purposes in this study; no quanti cation was performed. Additionally, samples were analysed in triplicates (n=3).
GC-MS vials were analyzed in a GC 7693 Gas Chromatograph (Agilent Technologies, Santa Clara, CA, USA) with an autosampler, and mass spectroscopy was performed using a 5977B GC/MSD Mass Selective Detector (Agilent Technologies, Santa Clara, CA, USA). GC-vials, GC-vial lids, and GC-vial inserts were also purchased from Agilent Technologies (Santa Clara, CA, USA).
The GC-MS parameters were set as reported in the methodology from our previous study [22]. The injection port temperature was set to 250 °C, the splitless injection volume was 2.0 µL under a purge ow of helium gas at 3 mL/min, and the solvent delay was set to 3 min. The wash steps were: four pre-injection washes, four post-injection washes, two sample washes, and six sample pumps. The initial temperature was set to 100 °C for 4 min. Ramp 1 was set to 10 °C/min until reaching 280 °C, where it remained for 2 min. The°C /min rate for Ramp 2 was set to 6 °C until it reached 300 °C, where it remained for 5 min. An HP-5MS UI column of 30 m length, 0.25 mm inner diameter, and 0.25 μm lm thicknesses (Agilent, Waldbronn, Germany) was used with the ow rate set to 1 mL/min. The MS ionization mode was electron ionization (EI) set at −70 eV, with an ion-source temperature of 280 °C and an interface temperature of 290 °C. Ions were monitored using SCAN mode. Cayman Spectral, FORCHEM, and NIST 14 Libraries were used for comparative analysis.

Toxicology Laboratory Procedures
One of the job duties of the Forensic Toxicology Laboratory (FTL) in the General Department of Criminal Evidence is to analyze drug metabolites in biological matrices including urine and blood. Additionally, FTL is the only lab in the country authorized to analyse toxicological samples. Each toxicology analysis is then translated into an o cial report to con rm or deny drug abuse suspension, and to be used for subsequent legal actions.
This study only analyzes reports from specimens that yielded positive results for drug abuse. In addition, some positive cases were not reported herein, as the toxicants are irrelevant to the current study. All data Page 7/29 were collected with permission from the Ministry of Justice and the Ministry of Interior.

Urine Sample Collection from Deceased Cases
If available, urine was syringed from the bladder of deceased individuals, using a 10 mL syringe as soon as they were admitted to the Forensic Medicine Unit (FMU). The specimen was then stored at 20 °C until analysis. Living individuals (hospitalized or apprehended) provided 10 mL of urine samples in containers, which were sealed and taped to prevent adulteration.

Blood Sample Collection
Venous blood was taken from a cubital vein by a physician or registered nurse of living or deceased individuals, using 10 mL gray-stopper evacuated glass tubes containing sodium uoride (100 mg) and potassium oxalate (25 mg) as preservative agents.  [22]. Prior to analysis, solid phase extraction (SPE) was used to extract illicit drugs from urine and blood samples for testing. As with GC/MS analysis, samples were analysed in triplicates (n=3).

Screening of Urine and Blood Samples
CHROMABOND® C18 columns with a volume of 3 mL containing 500 mg sorbent (Macherey-Nagel, Düren, Germany) were used for solid-phase extraction of urine samples. The pH of the urine samples (10 mL) were adjusted according to Macherey-Nagel guidelines for speci c drugs of abuse and samples were then centrifuged.
The compound database used for analysis was the Forensic Database (Forensic DB). However, the identi cation of the unknown or examined samples by the library database in this step was only tentative. Therefore, reference standards were used following preliminary identi cation of the unknown sample using the library, and an LC-MS/MS procedure was developed. The LC-MS/MS procedure used in the current study was a two-step scheme that was performed after injecting 10 mg/mL of the standard in methanol and 100 ng/mL of the standard in blank urine (for urine samples) or blank blood (for blood samples). The standards were extracted from blank urine or blank blood using the SPE method and used as quality controls.

Data Analyses
Raw data visualization, analysis, and graph creation were conducted using GraphPad Prism version 6 (Prism Software Corporation) and Microsoft Excel 2016 (Microsoft Corporation).

Results
NPL received a total of 6,220 drug abuse cases from 2015 to 2018. In terms of cases per year, 1,832 cases were received in 2015; this decreased in 2016, 2017, and 2018, to 1,506, 1,356, and 1,526 cases, respectively For analytical purposes, the current study focused on cases with positive drug outcomes: the presence of at least one illicit drug listed in the narcotics or psychotropic substances schedules. Negative While cocaine was received mostly as a white powder (95% of cases), in a few cases (5%) it was received in its smokable form (crack cocaine); that is, processed with sodium bicarbonate (baking soda) and water. Heroin was received as a powder with a color that ranges from light to dark brown (and, in very rare cases, off-white). Opium in all cases was received as a sticky black solid block with a distinctive odor. Cannabis was mostly received as blocks of various sizes, and sometimes as "shatter" (concentrated cannabis sheets) or in an edible form (candies, brownies, and cookies). In very rare cases, tetrahydrocannabinol (THC), which is the principle psychoactive constituent of cannabis, was detected in some of the received pills. Marijuana was mostly received in dried plant materials or in herb form, but in very rare cases the two plant types (Cannabis sativa or indica) were received.

Amounts of Psychotropic Substances Seized in Kuwait from 2015 to 2018
The total quantities of psychotropic substances (grams), including methamphetamine, synthetic cannabinoids, Khat, and psilocybin mushrooms are presented in Figure 2. For the psychotropic substances, the quantity of methamphetamine (MET) decreased in the rst three years and then sharply increased in 2018. Similarly, the quantity of Khat (KHA) showed a relative pattern of decrease and increase. For synthetic cannabinoids (SYN CAN), no data was documented in 2015, and the quantity reported in 2016 was low. This is primarily because these substances were only listed and banned in October 2016. Thus, the data stated herein report the seized materials only after the banning legislation. In 2017, the quantity increased dramatically, and then the quantity sharply declined (approximately 800 times) in 2018. It is believed that the sharp decrease is due the criminalization of synthetic cannabinoids, leading drug users/abusers to revert back to classical cannabinoids products. Finally, the quantity of psilocybin mushrooms (PSY) seized throughout the four years was very low compared to other psychoactive substances. Although the quantity did increase in 2016, it dropped drastically to almost nothing in the following years ( Figure 2). Additional le 3 shows the exact seized quantities of psychoactive substances (grams).

Physical Characteristics of Psychoactive Substances Seized in Kuwait from 2015 to 2018
In the vast majority of cases, methamphetamine was received as crystal-like glass fragments or small, shiny, white rocks. In very few cases, seized amphetamine occurred in different colors (pink, light blue, and even dark blue). Methamphetamine was also seized in the form of tablets of different colors and sizes.
However, the data shown in Figure 2 do not include the tablet forms of methamphetamine. Descriptions of the physical characteristics of synthetic cannabinoids have been previously reviewed [22]. Khat usually comes in the form of dried plant materials or herbs, and the detected active stimulating compound in these materials are cathinone and/or cathine. Psilocin and/or psilocybin are the active psychoactive compounds in some mushrooms species (including Psilocybe mexicana and P. cubensis, formerly Stropharia cubensis) that are commonly known as magic mushrooms. NPL obtains these active compounds by extracting them from the mushroom plant except in the very rare cases that they are received as a liquid substance. Our data shows that methamphetamine was the most abused illicit drug in Kuwait throughout 2015-2018, whereas cocaine had the least number of users. For the remaining illegal drugs, no dramatic changes were observed in terms of the number of abusers. Amphetamine, benzodiazepines, cannabis, and heroin were also highly abused. Generally, the number of male abusers were higher than the number of female abusers for all the illicit drugs. Moreover, the change in the number of abusers was inconsistent, and it uctuated throughout the four years of study ( Figure 4).

Quantities of Psychotropic Tablets
The abovementioned abused substances were found to be abused alongside other combinations of illicit drugs ( Figure 5). For instance, heroin was frequently abused, along with amphetamine, methamphetamine, and benzodiazepines. Cannabis was abused with amphetamine, benzodiazepines, methamphetamine, and heroin. All these abused combinations are shown in Figure 5. Our four-year analysis shows that some of these combinations of abuse decreased, including heroin and amphetamine, heroin and benzodiazepines, and methamphetamine and cannabis. Consistently, the number of males who abused two substances was in all cases higher than the number of female abusers. More interestingly, some combinations, such as heroin and cannabis and amphetamine and cannabis were rarely No quantitative investigations were conducted in the present study, and thus abused drugs were not necessarily the causative agent for the death. The possibility that the deceased subjects may have received prescribed medication cannot be ignored. Thus, the data reposted herein represent only the number of illicit drugs users. Among the identi ed illicit drugs in the deceased samples were methamphetamine, amphetamine, cocaine, heroin, benzodiazepines, tramadol, and cannabis. The highest numbers of deaths were associated with benzodiazepine and heroin. Figure 6 shows that in the last three years, there was an increase in the number of deaths related to the abuse of methamphetamine, benzodiazepines, and heroin. The numbers of fatalities associated with the abuse of cocaine and tramadol were lower than any other illicit drugs. Additionally, no female deaths were associated with the illegal abuse of cocaine and tramadol.
In addition, we investigated the deaths associated with the abuse of two different illicit drugs (Figure 7).
Our results showed that the abuse of heroin combined with benzodiazepines and that of heroin combined with methamphetamine were associated with the highest number of deaths. Some combinations were only associated with mortality in some years but not The potential in uence of substance abuse on mortality among drug abusers was assessed by calculating the death rate associated with each misused substance ( Figure 8). The death percentage was high among those who abused heroin and benzodiazepines, whereas it was minimum for those who misused cocaine.
The four-year trend increased for the mortality associated with abuse of benzodiazepines and methamphetamine and decreased with the mortality associated with heroin misuse (Figure 8). Additional les 9 and 10 list the four-year cumulative mortality rates (2014-2018) associated with the abuse of one or two substances, respectively.

Discussion
Drug misuse is a prevalent long-lasting phenomenon affecting individuals in countries all over the world, and the state of Kuwait is not an exception. Therefore, this study was designed to address issues surrounding the abuse of illicit drugs in Kuwait. Our study investigated commonly smuggled types of drugs, the most misused substances based on gender, and mortality associated with abuse of each drug. We found that the most seized substances were cannabis (including marijuana), followed by heroin, opium, and cocaine. Among psychoactive substances, amphetamines (including methamphetamine) were received in large quantities in both powder and pill forms. Other substances seized included benzodiazepines, tramadol, Khat, synthetic cannabinoids, and psilocin. Additionally, amphetamines (including methamphetamine), benzodiazepines, cannabis, and heroin were the most abused substances in Kuwait. Finally, we were able to associate fatality rate with the abuse of different illegal drugs, with respect to both gender and the most lethal illicit substance combinations.

Tra cking and Marketing of Illicit Drugs in Kuwait
The initial objective of our study was to determine the different types of narcotic drugs and psychotropic substances that were seized and consumed in Kuwait from 2015 to 2018. In addition, the study aimed to identify gender-based differences and the mortalities associated with the consumption of these illicit substances. Our analysis reports the different types and quantities of illicit drugs that were seized in Kuwait from 2015 to 2018 (Figures 1 and 2). The variety of drugs seized is primarily associated with the geographical situation of Kuwait relative to major drug-producing countries, including Afghanistan, Pakistan, Iraq, and Iran [24]. However, the variety of drugs seized may also re ect the rapid nancial development of Kuwait; its economic prosperity may have made the country an excellent target for the illicit drugs market. The data revealed annual uctuations in the quantities of the same seized substances. These variations may be associated with the changes in 1) ow of the illicit drugs from the country of origin; 2) smuggling strategies (methods and routes); and 3) activities of Kuwaiti law enforcement.
Cannabis and marijuana were the most often seized substances among narcotic drugs (i.e., opium, heroin, and cocaine). These data are consistent with the International Narcotics Control Board (INCB) report (2018), which stated that cannabis tra cking into or through Kuwait increased by 233% from 2016 to 2017 [25]. Many countries neighboring Kuwait produce and tra c cannabis and marijuana to Kuwait through different routes. The relative accessibility of Kuwait for these smuggling operations may explain the increase in cannabis and marijuana seizures.
Morocco is most likely to be the origin of cannabis in the Kuwaiti market since it is the principal producer of cannabis resin globally (~ 47,000 hectares under cultivation). In addition, cannabis may originate from Lebanon and Afghanistan, which are the main suppliers for cannabis in the MENA market [10]. Afghanistan supplies the gulf countries with many illicit drugs, including opium, heroin, and cannabis; these pass through the Iranian docks of Chabahar and Bandar Abbas. According to the INCB report [25], there are indications that Iraq is becoming a key player for illicit drug cultivation and production, including heroin, opium poppy, and cannabis. This is especially prevalent in the Basra region of Iraq, which borders Iran and Kuwait. By late 2014, the number of arrests for drug tra cking and drug use nearly doubled in Basra (compared with that in the period 2011-2014). Large quantities of drugs have since been seized in containers at the Basra port and at border crossings. The INCB report stated that Kuwait had witnessed a substantial increase in cannabis tra cking into or through its territory during this period [25]. Indeed, 653 kg of cannabis were seized in 2015, and this increased to 970 kg in 2016.
Another important nding was that low quantities of cocaine were received during the four years of the study (Figure 2). These ndings agree with a previous DEA report, which revealed a weak association between the Arab world and the production or tra cking of cocaine. Nevertheless, there is some evidence for an increase in seizures of cocaine in the Middle East that are destined for distribution in Western Europe. The Kuwaiti market did show noticeable quantities of Khat, and this may have been smuggled from Ethiopia and Yemen. While Ethiopian Khat is smuggled by Ethiopian workers via air routes, Khat from Yemen is smuggled to Kuwait via land routes through the borders with Saudi Arabia. Even though Khat use is uncommon among Kuwaiti locals, there may be some in uence from neighboring countries with high Khat consumption, including Yemen, Oman, and Saudi Arabia [26].
The most obvious nding to emerge from our study is that illicit use of amphetamine-type stimulants (ATS), including methamphetamine and amphetamine, is highly prevalent in Kuwait (Figures 2 and 3). The NPL usually receives amphetamine as a component of Captagon pills smuggled in from Iraq. In November 2017, 599 bags of Captagon were seized by law enforcement o cers in the Basra region of Iraq, near the Kuwaiti border. This seizure was from what is believed to be one of the most signi cant smuggling operations in recent years. In addition, ATS precursors are lab-processed in Syria and Lebanon into ATS substances, and these are then transported into Kuwait through Iraq. Our data is consistent with the European Union Institute for Security Studies (EUISS) November 2017 report [10], which declared that the Gulf countries are facing an amphetamine-type stimulant (ATS) addiction crisis. The report showed that abuse of these stimulants accounted for more than 62% of the admissions into Saudi rehab facilities. According to the report, the increase in ATS addiction in the MENA area could be attributed to the impact of modernization, and exposure to modern Western cultures and lifestyles.
The illegal use of medically prescribed drugs is a worldwide health concern, and our data con rm that the state of Kuwait is not an exception. Several different psychoactive substances were seized by Kuwaiti law enforcement, including tramadol and drugs of the benzodiazepine family. Our data show that con rmed users of psychoactive substances also tested positive for other illicit drugs (i.e. heroin, cannabis, and methamphetamine). Thus, an assumption can be made that the abuse of these psychoactive drugs was associated with behavioral addictions rather than for medical purposes. These substances were abused for pleasure purposes to induce an altered state of consciousness through modifying the perceptions, feelings, and emotions of the user.
Tramadol is a synthetic opioid analgesic usually prescribed to manage moderate to severe levels of pain.
Tramadol misuse is a matter of genuine concern in the Gulf countries, as an overdose is associated with signi cant morbidity and mortality [6]. The abuse of tramadol in the United Arab Emirates has been previously reported [27]. According to the INCB [25], tramadol is used (non-medically) as a mood enhancer, to enhance sexual stamina, or to boost energy during physical activities. However, long-term use of tramadol results in psychological and physical dependence, increasing the risk of overdose [25]. In this study, we showed that large quantities of tramadol have been seized, and it is assumed that these are to be used illegally for non-medical purposes (Figure 1). Our results show that the quantity seized (in pill form) increased signi cantly from 40,050 in 2015 to 7,460,319 in 2016, before decreasing in the subsequent years (10,150 in 2017 and 42,213 in 2018). According to these data, tramadol has gained great popularity among abusers and the demand in the Kuwaiti market for this illicit drug is high.
Tranquillizers of the benzodiazepine family were among the most popular substances of abuse seized from the Kuwaiti market. These included clonazepam, diazepam, unitrazepam, alprazolam, and bromazepam ( Figure 3). Our data showed that the classes of benzodiazepines most commonly seized were clonazepam, diazepam, and alprazolam ( Figure 3). Benzodiazepines slow down bodily functions by enhancing the in uence of the inhibitory neurotransmitter γ-aminobutyric acid (GABA), which interacts with GABA A receptors to increase their sedative and anxiolytic actions. A previous survey reported that benzodiazepines were among the drugs most abused by youth in Saudi Arabia [28]. Benzodiazepines can be obtained in Kuwait either as smuggled substances from countries such as Iran, Saudi Arabia, the United Arab Emirates, and Egypt, or through illegal purchase from pharmacies without a prescription (or sometimes with a falsi ed prescription).

Abuse of Illicit Drugs in Kuwait Compared to Neighboring Countries
The misuse of intravenous illicit drugs has been reported in all MENA countries. Several studies estimate that the number of individuals that are injecting drugs in the region is 349,500-437,000. While 96.2% of abusers were reported to use opioids as their primary drug, 14.2% were abusing stimulants [29,30]. The most commonly misused substances in neighboring countries were heroin (63.9% in Egypt and Morocco), cannabis (46.2% in Lebanon, Tunisia, and Morocco), and cocaine (32.8% in Morocco and Lebanon) [29]. In this study, we investigated the number of illicit drug abusers in Kuwait from 2015 to 2018. Most of the abusers used methamphetamine, cannabis, amphetamine, or heroin. The abuse of benzodiazepine, tramadol, and cocaine was less common (Figure 4). The use of amphetamine-type stimulants has been well established in the Middle East [31].
The abuse of other types of drugs has also been reported [31,32], including methylenedioxymethamphetamine (MDMA) (predominantly in Lebanon), methamphetamine (mostly in Iran and Lebanon), and benzodiazepines (in Tunisia). In Egypt, the trend of Tramadol and Tamol use is continually rising [31]. Fenethylline (Captagon), a stimulant co-drug of amphetamine and theophylline, is consistently used in the Arabian Peninsula, speci cally among adolescent males in Saudi Arabia [33,34]. Captagon was reported to be an easily accessible drug that can be obtained by e-commerce via the darknet in the United Arab Emirates, Syria, Iraq, and Turkey [34].
Our study also highlighted gender-based differences among substance abusers ( Figure 4). In general, the number of female abusers was much lower than the number of male abusers (Figure 4). These differences can be explained in part by male dominance in the Kuwaiti culture. In addition, previous studies have shown that males abuse almost all kinds of illicit drugs and that they do so much more than females [17]. This extreme abuse by males increases their chances of a visit to the emergency department and of overdose associated mortality [17]. However, women are just as likely as men to develop a substance use disorder [35]. Moreover, studies suggest that females are more susceptible to craving and relapse, two critical phases of the addiction cycle [36][37][38][39][40][41].
Some abusers were addicted to combinations of multiple drugs, usually a combination of two substances ( Figure 5), but sometimes more (data not shown). Some combinations were more prevalent in a particular year than others. For instance, while the combination of methamphetamine and cannabis was commonplace in 2015, the popularity of this mixture decreased dramatically in subsequent years. This nding is consistent with a report that cannabis is the most common secondary illicit substance for methamphetamine users [42]. The number of individuals co-abusing heroin and benzodiazepines remained high throughout the four years. This observation is in agreement with that in a study by Jones et al. reported that co-abuse of opioids and benzodiazepines is ubiquitous worldwide [43]. According to Jones et al., co-abuse of benzodiazepine and opioids is primarily for recreational purposes, to enhance the opioid intoxication or "high" and to enable doses that exceed the therapeutic range [43]. A second explanation for the use of benzodiazepines is self-medication; i.e., the treatment of anxiety, mania, or insomnia. Globally, overdose is the leading cause of death among people who abuse intravenous illicit drugs. It accounts for 50% of fatalities among people who inject heroin, exceeding other related diseases [7]. In Europe, drug-related death has been rising for the last ve years, and drug overdoses account for the loss of 9,000 individuals [44]. In the United States of America, the 2018 annual surveillance report of drugrelated risks and outcomes announced that drug overdoses were responsible for the deaths of 63,632 individuals [45]. However, robust data regarding overdose associated mortality within the Gulf counties (and Kuwait, in particular) are not available. The risk of drug overdose depends on the nature of the misused substances. For example, opioid-dependent individuals and those who inject opioids are more likely to die from an overdose. In addition, the use of opioids with other central nervous system depressants (such as benzodiazepines) increases the risk factor for opioids overdose. Thus, our current study addresses these issues.
In the current study, we investigated the mortality rates among abusers of methamphetamine, amphetamine, benzodiazepines, cannabis, heroin, tramadol, and cocaine ( Figures 6 and 7). Our data showed that the highest mortality rate was among those who abuse heroin, with overall rising trends in those who abuse heroin, benzodiazepines, and methamphetamine ( Figure 6). In contrast, the mortality among tramadol and cocaine users in Kuwait was much less compared with that among the other illicit drugs abusers ( Figure 6). The low mortality among cocaine users may be due to the negligible amount of cocaine available in the Kuwaiti market for illegal substances. Although cannabis overdose is rare, it is still possible under certain circumstances. For example, the risk of cannabis overdose increases when it is abused with other substances (polysubstance abuse). A cannabis-alcohol combination is also considered as the most frequently encountered drug mixture implicated in tra c accidents [46]. These drug combinations may signi cantly increase the levels of THC in the blood.
Our data on mortality among multiple drugs abusers in Kuwait (2015-2018) showed that fatality is highest among those who abused heroin-benzodiazepines combinations. Other combinations associated with signi cant abuser mortality include cannabis-benzodiazepines and cannabis-amphetamines (including methamphetamine) (Figure 7). The data reported should be interpreted with caution due to the qualitative nature of the analyses. Thus, our mortality rates do not necessarily implicate illicit substance abuse as the primary cause of death.

Limitations of the Study
As with the majority of studies, the design of the current study is subject to limitations. The most critical aw lies in the fact that no quantitative analysis was conducted, and the results reported herein were obtained qualitatively. Consequently, we were unable to generalize from some of the research ndings with any con dence, including those of mortality rates among drug abusers. Fatality association with drug overdose cannot be established based on qualitative analysis of the drug pro le. Moreover, the possibility that the deceased subject used some of the identi ed drugs for medical purposes cannot be excluded (in which case these drugs may not be a causative agent for the death). Similarly, no quantitative con rmation was used for reporting drug concentrations in the biological samples obtained from living subjects. Only a simple "positive or negative" result was provided in the nal report for con rmation of drug abuse. Thus, further research should be undertaken, including a quantitative approach, to provide a comprehensive analysis of illicit drug abuse. Only then can we tackle the drug misuse crisis in Kuwait and actively promote our society as free of illicit substance addiction. An additional source of weakness is our generalization to drug families during drug abuse analysis of biological samples (without specifying the exact derivative). For example, while the existence of benzodiazepines in the samples may be con rmed, identi cation of the exact derivative was not performed.

Conclusions
In this paper we presented an MS based analytical platform that analysed 6220 drug samples and 17755 toxicological samples between the years 2015-2018. The data revealed that cannabis was the most seized illicit drug, while methamphetamine was the most abused. In the single drug category, deaths resulting from benzodiazepine and heroin were the highest, while in the multiple drug category, deaths from heroinbenzodiazepine combination were the highest. This study provides valuable data to local and international drug analyst, law enforcement and health o cials. Our ndings suggest that there is a growing need to conduct larger scale studies to implement new strategies, policies, and interventions for positive outcomes in populations affected by illicit drugs.       Deceased individuals (number) who were using two illicit drugs in Kuwait during 2015-2018. Males and females were differentiated by using different colors (light green for males and orange for females). MET, methamphetamine; AMP, amphetamine; BEN, benzodiazepine; CAN, cannabis; HER, heroin. The y-axis is discontinuous at one point due to the large variations in the data.