Tuesday, December 31, 2013

Krokodil Redux

The Krokodil paper has resurfaced in the American Journal of Medicine. The abstract can be found here.

Comparing this Article in Press to the original accepted manuscript that we discussed, I see a much cleaner and coherent article.  BUT...

Not much has changed between the two versions (old and new).

The only real differences that I see are:

1. The terrible grammar, punctuation and sentence structure that was observed in the accepted manuscript has been corrected. The article in press is a much cleaner version.

2. In the original manuscript, the patient has been injecting [krokodil] for the past two months. Whereas, in the article in press, the patient has been injecting [krokodil] for the past 6-7 months.

3. In the original manuscript, the patient has a history of injecting heroin into the arms and thighs for the past 2 years.  Whereas, in the article in press, the patient has been injecting heroin into the arms and thighs for the past 7-8 years.

4. The last statement in the conclusion section has been removed. The original manuscript read, "All kinds of governmental and non governmental authorities must be aware and on the watch for preventing this devastating and fatal drug addiction from spreading in our society." This is a good change.

5. The article in press adds 2 additional references.  One reference is the paper from Grund et al. (2013) from the International Journal of Drug Policy and the second reference is from Thomas Roche and is a technology web blog posting from 2011 on the subject of krokodil. The Grund paper is truly fantastic - I recommend reading it. I'm not sure we should be referencing blog posts in scientific/medical case reports.

Some things we discussed earlier:

1. Regarding the highly unusual acceptance turnaround.  The manuscript was received on 9/19/13, revised on 9/24/13, accepted for publication on 9/24/13. Still  unusual to me.

2. In the article in press, the drug is described as “flesh eating", which is still not accurate. The drug, desomorphine or its derivatives, does not cause the necrotic effects. 

3. The article in press still states that the drug is spreading rapidly around Europe. There is no scientific evidence to this claim.

4. A TIME article is still cited as a scientific reference. And now a technology blog post is cited as well.

5. Still no mention of toxicology results. In 5 months of treatment, not even a urine drug screen (with confirmation) for opiates/opioids was completed? I would love to see urine/blood drug toxicology. What other things was this patient using? Diacetylmorphine? Fentanyl? Was there codeine present in his urine? Morphine? Also, there are toxicology laboratories in the USA that can and do test for desomorphine. So, it is a misrepresentation to state that chemical analysis is not available.

At the end of the day, I do agree that physicians (and other people) need to be aware of this drug. This article will make people aware, but I still await some real scientific evidence that krokodil is in the USA. Until we see evidence, it is illogical to be here and I remain a skeptic.

Be safe.



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