Friday, January 3, 2014

More musings on the "krokodil" communication letter...


From a drug toxicology perspective, what compounds would I expect to be present in blood or urine in a true “krokodil” case?  Ultimately, the answer is I don’t know. I have never seen a confirmed “krokodil” case published with toxicology results. Grund et al. (2013) reviewed the reported synthetic pathways and manufacture of desomorphine and/or “krokodil”. Desomorphine may be the product that is sought, but with the different crude processes used, it may or may not be produced during the reaction. Savchuk et al. (2008) identified other desomorphine derivatives and codeine in actual “desomorphine” samples. In these samples, the desomorphine ranged from trace amounts to 75%. 
Are toxicology laboratory tests able to identify "krokodil"? This issue has been raised over at The Poison Review.  No. We wouldn't identify "krokodil", but the best that we can do (currently) is to attempt identification of desomorphine or codeine or possibly some other desomorphine derivatives in the samples.  My main criticism with the paper (or clarified as a "communication to the editor" by @infectiouschris) is that absolutely no toxicology was discussed AT ALL. Not a urine drug screen. Not a blood drug screen. No opiates analysis. No fentanyl analysis. Nothing. They had multiple patient visits over 5 months to interview the patient and collect biological samples.  And, as far as the reader knows, they did NOTHING.
When was the last administration of the drug in relation to the patient’s visits to the hospital? Opiates typically have a detection window of 1-4 days in urine post-administration. If drug use was recent, then biological samples could have been viable - at least it would have given more of an insight into the patient's substance use history. Was the patient not asked this question by the physicians? Is this not relevant to the case? It wasn't reported in the article.
Other than the patient's word, how do we know this case was or was not diacetylmorphine-related? We do not know. We have no toxicology results that show either the presence or absence of 6-acetylmorphine, morphine and/or codeine in the patient’s blood or urine.  How do we know this case was or was not fentanyl-related? We do not know. We have no toxicology results that show either the presence or absence of fentanyl and/or norfentanyl in the patient’s blood or urine.  How do we know this case was or was not “krokodil”-related? We do not know. We have no toxicology results that show either the presence or absence of desomorphine, desomorphine derivatives and/or codeine in the patient’s blood or urine. We also have no chemical analysis of any products used by the patient.
If I was the editor of the journal, what would I have required for calling this a confirmed “krokodil” case? I don’t know. But using common sense, I would have required the drug toxicology results be published along with the opinion that the reported case was “krokodil”. I find it highly dubious that either no attempt was made to run drug toxicology or no attempt was made to publish the drug toxicology results and expound on them (whether positive or negative). Maybe this is a difference of perspectives between clinical toxicology and forensic toxicology? I am looking at this from purely a forensic toxicology view, similar to the "reasonable degree of scientific certainty" that we testify to in a court of law and/or while rendering an expert opinion.

Ultimately, I'm not saying this is or is not a "krokodil" case.  No evidence exists to say it is or isn't.  We simply do not know.  And therein lies the rub.


Cheers,

ForensicToxGuy

PS. Thanks to The Poison Review for making this a discussion.  It is very much needed.



Related Posts:

Krokodil...not so fast my friends!

Krokodil, 7 Days Post-Withdrawal

Krokodil Redux




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