Reports developed in
the media last month identifying suspected cases of ‘krokodil’ use in Utah, Arizona,
and Illinois. While the drug’s presence
has not officially been confirmed there is a significant health concern when
considering this new drug’s properties and what the results of its use are.
Background
‘Krokodil’ is the
street name given to a substance whose active ingredient is likely to be
desomorphine. Easily made at home from
codeine, this drug’s presence has increased in Russian in recent years where
more than 100,000 people are thought to be addicted and where 65 million doses
were seized in the first quarter of 2011.
‘Krokodil’ seems to be a fitting name as it refers to both a codeine
derivative step in its production (chlorocodide) and the adverse effects it
causes, namely the scale-like green-black skin of its users.
Pharmacokinetic/pharmacodynamic properties
While ‘krokodil’ is
relatively new, desomorphine is not. It
was first synthesized and patented in 1932 in the United States in an attempt
to find an alternative analgesic for morphine with a more favorable side effect
profile. Pharmacokinetically,
desomorphine differs from morphine in that it is a ten times more potent
analgesic, three times as toxic, and has a much shorter half life. Its quick onset and short half life
contribute to its increased addictive potential versus morphine. Users are left with little time for anything
other than the loop of acquiring, synthesizing, and administering the drug in
order to avoid withdrawal.
Production
‘Krokodil’ is produced
via various recipes with the most common being a reduction process to
desomorphine. It can be produced in as
quickly as 10 minutes with minimal laboratory equipment and easily available
chemicals. A strong alkali (household
cleaner), organic solvents (gasoline, paint thinner), iodine, red phosphorus
(heads of matches), and hydrochloric acid are combined with codeine in a way to
produce either dried desomorphine or a solution which can be intravenously
injected directly. Essentially there are two steps; first, extraction of
codeine from the starting medication form (in Russia, codeine is cheap and was not
restricted to pharmacies until mid-2012) and second, reduction of codeine to
desomorphine. Due to variations in
production and substrates used, the resultant product is likely a composition
that varies between users and probably contains desomorphine.
Risk
The adverse effects of
‘krokodil’ are those of opioids and opioid withdrawal in addition to
devastating systemic and injection-related injury. Localized damage includes serious venous
damage and skin and soft tissue damage which quickly advances to gangrene and
necrosis. This includes skin and soft
tissue infection, bone infection, open ulcers, large eschars, and veins that
rot from the inside requiring surgical removal.
Other systemic damage may include: kidney and liver problems; pneumonia;
sores and ulcers on the head, ears, nose, and lips; meningitis; rotting gums,
jaw, and facial bones; and thyroid disorders.
These systemic effects are not at traditional inject sites so they may
be the consequence of the chemicals and heavy metals used in the production in
‘krokodil’. The final product is a
suspension that is highly impure and likely not pH neutral, isotonic, or even
filtered prior to injection.
Management
Outcomes for users of
‘krokodil’ are very grim and have been sensationalized in the media. Abstinence of ‘krokodil’ use and minimizing
barriers of care is essential. A
coordinated surgical management plan (which often includes amputation) along
with infectious disease management is also recommended.
References:
1. Grund JP, Latypov A, Harris M. Breaking worse: The emergence of krokodil and
excessive injuries among people who inject drugs in Eurasia. Int J
Drug Policy 2013;24:265-74.
2. Gahr M, Freudenmann RW, Hiemke C, et al.
Desomorphine goes “Crocodile”. J Addict Dis 2012;31:407-12.
3. Micromedex.
Available at www.micromedexsolutions.com
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