Written by Theresa Kim MD 

Outline

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• Introduction of the podcast
  
• Summary of American Journal of Medicine’s published case report on krokodil
  
• Hypotheses as to the cause of the disappearance this article
  
• Review of the current literature on krokodil
  
• Overview of krokodil history, production, and its chemical profile
  
• Confirmatory testing for krokodil?
  

Introduction

Podcast presenters:

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• Dr. Leon Gussow-medical editor of the Poison Review
  
• Dr. Steve Aks-Toxikon Director, fellowship director and faculty at Cook County Emergency Medicine
  
• Dr. Jenny Lu-Toxikon Consortium and Cook County Emergency Medicine faculty
  
• Dr. Theresa Kim-Cook County Emergency Medicine Resident & Producer of the podcast
  

Goals:

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• Resurrect the cassette tape days of Leon Gussow and Steve Aks.
  
• Produce a podcast monthly that covers toxicology related topics currently under review by the media, scholarly journals, or that are just interesting.
  

Summary of the Ghost Case Report

30 year old male from St. Louis area presents with left arm pain after injecting a “cheaper homemade [heroin] substitute prepared from codeine†presumed to be krokodil.

Hypotheses regarding disappearance of the American Journal of Medicine Article

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• According to the American Journal of Medicine, “The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated.â€
  
• Unedited manuscript filled with grammar errors, sensationalized terms, and false claims such as the statement that krokodil is rapidly spreading across Europe when it is in fact decreasing
  
• Accepted for publication within a week
  
• Competing publication?
  
• HIPAA violation?
  
• The drug exposure itself was not confirmed
  

Review of the current literature

2 articles briefly discussed:

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• ‘Krokodil’ and other home-produced drugs for injection: A perspective from Ukraine by Dr. Robert Booth
  
• Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia by Dr. Jean-Paul C. Grund
  

Overview of krokodil

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• Desormophine is homemade from a combination of codeine, with hydrochloric acid, red phosphorus, iodine, lighter fluid
  
• Metabolic pathway: Codeine > a-Chlorocodide > Desocodeine > Desormorphine
  
• Name derives from the grey-green, scaly skin resulting from local tissue destruction
  
• No confirmed cases yet in the US according to DEA
  
• Use primarily localized to European countries such as Ukraine and Russia when poppy straw and other narcotics are not readily available, but rarely in the US where heroine is quite cheap in comparison
  

Is there confirmatory testing?

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• No lab confirmatory testing exists to date
  
• The question still remains if the diagnosis can be made by history and clinical judgment alone
  

Links to topics discussed in this month’s podcast:

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• Original American Journal of Medicine post of “Article in Pressâ€
  
• Breaking worse: The emergency of krokodil and excessive injuries among people who inject drugs in Eurasia
  
• ‘Krokodil’ and other home-produced drugs for injection: a perspective from Ukraine
  
• The Dose Makes the Poison blog
  
• @forensictoxguy on Twitter
  
• Retraction Watch
  
• Huffington Post Krokodil coverage
  
• Russia’s Flesh-Eating Krokodil drug an Urban Legend in UK, US and Canada (International Business Times)
  

Quizzler

The first correct response will receive a $10 itunes gift card! The Quizzler question can be found near the end of the podcast. E-mail responses to toxtrivia@gmail.com

Bibliography

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• Booth, R. (2013). ‘krokodil’ and other home-produced drugs for injection: A perspective from ukraine.Internal Journal of Drug Policy, 24(4), 277-278. Retrieved from http://www.ijdp.org/article/S0955-3959(13)00083-2/references
  
• Grund, J., Latypov, A., & Harris, M. (2013). Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in eurasia.Internal Journal of Drug Policy, 24(4), 265-274. Retrieved from http://www.ijdp.org/article/S0955-3959(13)00051-0/abstract
  
• Forensictoxguy. (2013, 12 02). [Web log message]. Retrieved from http://dosemakespoison.blogspot.com/search?q=krokodil