“Krokodil” paper reappears on American Journal of Medicine website

January 2, 2014, 4:02 pm

★★☆☆☆

‘Krokodil’ — A Designer Drug from Across the Atlantic, with Serious Consequences. Thekkemuriyi DV et al. Am J Med 2013 Oct 15 [Epub ahead of print]

Reference – no abstract available

This paper, which was posted in manuscript form and then temporarily withdrawn from the American Journal of Medicine website, has reappeared as a “Clinical Communication to the Editor” prior to publication. As @ForensicToxGuy points out in a thorough analysis on his blog, the journal, the new version of the case report has been edited to eliminate some of the horrendous grammar and sentence structure in the original manuscript, and some details have for some reason been changed.

I agree with the criticism that the extremely rapid acceptance and posting of the original manuscript was unusual, perhaps unprecedented. I also agree that the use of the term “flesh eating” is inappropriate for a scientific publication, and that the claim that use of “krokodil” is spreading rapidly across Europe is unsupported by any evidence.

However, I believe that @ForensicToxGuy, like many toxicologists who have written about “krokodil” since the manuscript of this communication was first posted by the journal, is remiss in not positing a clear definition specifying exactly what is meant by the term “krokodil.” As TPR has argued before, the term can not refer to desomorphine itself, which is simply an opiate and is not, to my knowledge, available anywhere in pure form. To my mind, “krokodil” refers more to a process in which users attempt to home-brew desomorphine using codeine and various caustic ingredients such as lighter fluid, gasoline, hydrochloric acid, and red phosphorous. There is not laboratory test that can confirm this process — the diagnosis depends on consistent soft-tissue injury and a history of using the home-brewed product. It laboratory tests fail to find desomorphine, this might just mean that the user was unsuccessful in manufacturing it, or that so much time has passed since last use that — although the soft tissue injury remains — the drug has been eliminated from the body.

Related posts:

“Krokodil” paper withdrawn by American Journal of Medicine

Case Report: extensive soft-tissue injury from homemade “krokodil”

Krokodil: a devastating homemade opiate

Krokodil: the flesh-eating designer opiate

Krokodil: a home-brewed designer opiate

 

 

 

2 Comments:

  1. Las Ambach Says:

    I’ve commented on the whole Krokodil craze before, here and on twitter. I can agree with you, that a lot of the discussion that has been going on, is due to different definitions of the term “Krokodil”.

    I think in the most narrow sense (as we’ve seen it in the Ukraine, Russia etc.), Krokodil is a rather contaminated desomorphine preparation, made from OTC codeine medication. I for myself would prefer to stick to that definition. If I understand you correctly, you propose to use a process-oriented definiton rather than a product-oriented one. Then question then would be: How is that process defined? Attempted synthesis of desomorphine from codeine with household chemicals? Synthesis of other opoids with the same household chemicals? Entirely other drug classes with contaminations that can cause necrosis/physical deterioration (methamphetamine from red phosphorous/hydroiodic acid route, levamisole-laced cocaine etc.)?

    The problem with the term “Krokodil” is that it has been so charged up with sensationalist connotations by its use in mainstream media, often only for the purpose (in my perception) of presenting disturbing images of extreme cases of necrosis. That’s why I personally would like to see the term “Krokodil” used as little as possible (which means in its most narrow definition), to keep these attention-begging, sensationalist news stories down to a minimum.

    So if a scientist claims to have a case of Krokodil and we can at least agree on the definition of it being a (attempted) preparation of desomorphine, there should be analytical data to back this up: desomorphine (might or might not be present, depending how well the synthesis went), desomorphine derivatives (synthesis byproducts), other opoids, crime scene investigation for precursors/educts etc. If you don’t have any of that, all you have is a patient who has injected something that has caused necrosis and something that seems more like yellow-press sensationalism than a scientific publication.

    N.B.: The Techyum blog entry that the Am J Med letter quotes (Ref. 2) regarding Krokodil cases in Germany is essentially a reblogging (the part about Krokodil, anyway) of a Worldcrunch.com post which in turn was re-reporting an article from German Newspaper “Die Welt”. Reading the original Die Welt article, it states there was no definitive evidence of Krokodil for the cases in Bochum and that the supposed appearance of Krokodil in Frankfurt could not be confirmed by police. As far as I am aware from talking with colleagues from the German Federal Criminal Police such cases usually turn out to be contaminated heroin or something similar (which again would lead to the question of where to draw the line of what counts as Krokodil). The article concludes with the statement that a wave of Krokodil cases in Germany is unlikely as codeine-containing preparations are available only by prescription.

  2. Leon Says:

    Las:

    Thank you for these excellent comments. I agree completely that — at least for the purposes of presentation in the medical literature — a good case definition is needed. Since a patient could present with soft tissue injury long after injection of the products of his or her attempt to manufacture desomorphine, neither laboratory tests or scene investigation could be definitive.

    I would propose that a history of following a recipe to make desomorphine, along with consistent soft tissue injury, is enough to define a case. Unfortunately, there are few details about these issues in the AJM letter.

    Thank you also for the additional information about ref 2 in the paper. Unfortunately, the habit of referencing a “source” that cites another source, etc, resulting in a statement not backed up by any real evidence, is rampant in the medical literature, even when all citations are peer-reviewed articles.