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Ramishvili N, Chachua I, Zurmukhtashvili M, Abiatari I, Marks L, Dugashvili G. Progression of primarily untreated desomorphine drug induced jaw osteonecrosis: A case report. Spec Care Dentist 2023; 43:685-688. [PMID: 36482761 DOI: 10.1111/scd.12807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022]
Abstract
Desomorphine is a composite of the self-made illicit drug "krokodil", which is popular in Eastern Europe and other parts of the world. It causes toxic damage of different organs including bones. In this paper, a clinical portrait of the patient with drug-induced osteonecrosis of mandible who refused surgical treatment in the early stages of the disease, is presented. At the time of first presentation, the patient displayed swelling of oral soft tissues and purulent discharge in the molar area of the right mandible. Radiographic examination demonstrated several small radiolucent lesions in the body of the mandible. The patient gave consent for surgical treatment and rehabilitation only after 12 months of the diagnosis. During this period of time, the necrosis of the mandibular bone progressed and a pathological fracture of the jaw was developed. Patient underwent surgical treatment - resection of the mandible. Management of drug-induced jaw osteonecrosis is challenging as the necessity of dental and surgical treatment as well as treatment and rehabilitation of substance use disorder arises. Involvement of a multidisciplinary healthcare professionals team is essential in successful treatment of this pathology. The latter includes early surgical intervention/medical treatment and rehabilitation from drug addiction.
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Affiliation(s)
- Nata Ramishvili
- Institute, of Medical and Public Health Research, Ilia State University, Tbilisi, Georgia
| | - Irakli Chachua
- School of Medicine, New Vision University, Tbilisi, Georgia
| | | | - Ivane Abiatari
- Institute, of Medical and Public Health Research, Ilia State University, Tbilisi, Georgia
| | - Luc Marks
- Special Care in Dentistry, Department of Cranio - Maxillofacial Surgery, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine & Health Science, University of Antwerp, Belgium
- Special Care in Dentistry, Ghent University Hospital, Gent, Belgium
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Ispiryan DH, Hakobyan G, Li A, Diachkova EY, Vasil'ev Y, Kheygetyan A, Ivanova E, Zhandarov K, Kireeva N, Safronov R, Serikov A, Medvedev YA. Surgical Treatment in Patients with Toxic Phosphorus Osteonecrosis of Facial Skull Middle Zone. Dent J (Basel) 2023; 11:dj11050108. [PMID: 37232759 DOI: 10.3390/dj11050108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
During the last few years, in the territory of the Russian Federation, the number of cases of toxic phosphoric osteonecrosis of the jaws has increased against the background of taking drugs of "artisanal" production (pervitin, desomorphin). The aim of our study was to increase the effectiveness of surgical treatment of patients with a diagnosis of toxic phosphorus necrosis of the maxilla. We performed a comprehensive treatment of patients with a history of drug addiction and the above diagnosis. Surgical intervention in the volume of complete resection of pathologically altered tissues and reconstructive techniques using local tissues and a replaced flap made it possible to achieve good aesthetic and functional results in the early and late postoperative period. Thus, our proposed method of surgical treatment can be used in similar clinical situations.
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Affiliation(s)
- Davit H Ispiryan
- Department of Maxillofacial Surgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), 121059 Moscow, Russia
| | - Gagik Hakobyan
- Department of Oral and Maxillofacial Surgery, Yerevan State Medical University, Yerevan 0025, Armenia
| | - Anastasia Li
- Department of Oral Surgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), 121059 Moscow, Russia
| | - Ekaterina Yu Diachkova
- Department of Oral Surgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), 121059 Moscow, Russia
- Department of Operative Surgery and Topographic Anatomy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Yuriy Vasil'ev
- Department of Operative Surgery and Topographic Anatomy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Artur Kheygetyan
- Dentistry Department No.1, Rostov State Medical University, 344022 Rostov-on-Don, Russia
| | - Elena Ivanova
- Department of Oral Surgery and Implantology, Vladimirsky Moscow Regional Research Clinical Institute, 129110 Moscow, Russia
- Department of Therapeutic Dentistry, FGBOU DPO RMANPO of the Ministry of Health of Russia, 125993 Moscow, Russia
| | - Kirill Zhandarov
- Department of Operative Surgery and Topographic Anatomy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Natalia Kireeva
- Department of Outpatient Therapy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119333 Moscow, Russia
| | - Roman Safronov
- Department of Physical Education, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119121 Moscow, Russia
| | - Alexey Serikov
- Department of Physical Education, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119121 Moscow, Russia
| | - Yuri A Medvedev
- Department of Maxillofacial Surgery and Traumatology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
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Abstract
Krokodil is the street name for a homemade mixture that has been used as a cheap substitute for heroin. The main active substance in krokodil is desomorphine, an opioid that is 10 times more potent than morphine. Krokodil use began in Russia and Ukraine but has spread throughout several countries in Europe and North America. Krokodil is produced from codeine tablets in a bootleg reaction performed under clandestine and unsanitary conditions. The toxicity of krokodil is characterized by devastating symptoms that start as black ulcers at the injection site and evolve to gangrene and limb amputation. The dangerous effects of krokodil are associated with its homemade nature and lack of purification prior to use. In this review, we discuss the chemical and pharmacological properties and the metabolism of desomorphine, the preparation of krokodil, and how its homemade nature contributes to its toxicity. The synthesis of krokodil produces several other morphinans in addition to desomorphine that warrant further study as possible analgesic alternatives to morphine.
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Affiliation(s)
- Emanuele Amorim Alves
- Department of Forensic Science, College of Humanities and Sciences, Virginia Commonwealth University 1015 Floyd Avenue, Richmond, Virginia 23284, United States
- Oswaldo Cruz Foundation, 21040-900 Rio de Janeiro-RJ, Brazil
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Abstract
Opioids are arguably one of the most important pharmacologic classes, mainly due to their rich history, their useful and potent analgesic effects, and also, just as importantly, their "Dark Side", constituted by their reinforcing properties that have led countless of users to a spiral of addiction, biological dependence, tolerance, withdrawal syndromes, and death. Among the most significant abused and addictive known opioids are heroin and desomorphine, both synthetic derivatives of morphine that belong to the 4,5-epoxymorphinan structural chemical group of the opioid family drugs. These agents share not only structural, pharmacological, and epidemiological features but also a common geographical distribution. A drop in Afghan heroin production and its "exports" to Russia gave rise to widespread consumption of desomorphine in ex-Soviet republics during the first decade of the 21st century, representing an economical and accessible alternative for misusers to this sort of derivative. Herein we review the state of the art of history, chemistry and synthesis, pharmacology, and impact on society of these "cursed cousins".
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Affiliation(s)
- Jaime Mella-Raipán
- Instituto de Quı́mica y Bioquı́mica, Facultad de Ciencias, Universidad de Valparaı́so, Av. Gran Bretaña 1111, Valparaı́so 2360102, Chile
- Facultad de Farmacia, Centro de Investigación Farmacopea Chilena, Universidad de Valparaı́so,, Av. Gran Bretaña 1093, Valparaı́so 2360102, Chile
| | - Javier Romero-Parra
- Departamento de Quı́mica Orgánica y Fisicoquı́mica, Facultad de Ciencias Quı́micas y Farmacéuticas, Universidad de Chile, Sergio Livingstone 1007, Casilla
233, 8380492 Santiago, Chile
| | - Gonzalo Recabarren-Gajardo
- Bioactive Heterocycles Synthesis Laboratory, BHSL, Departamento de Farmacia, Facultad de Quı́mica y de Farmacia, Pontificia Universidad Católica de Chile, Casilla 306, Avda. Vicuña Mackenna 4860, Macul, 7820436 Santiago, Chile
- Centro Interdisciplinario de Neurociencias, Pontificia Universidad Católica de Chile,, Marcoleta 391, 8330024 Santiago, Chile
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Ventura L, Carvalho F, Dinis-Oliveira RJ. Opioids in the Frame of New Psychoactive Substances Network: A Complex Pharmacological and Toxicological Issue. Curr Mol Pharmacol 2019; 11:97-108. [PMID: 28676005 DOI: 10.2174/1874467210666170704110146] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND New psychoactive substances (NPS), often referred to as "legal highs" or "designer drugs", are derivatives and analogues of existing psychoactive drugs that are introduced in the recreational market to circumvent existing legislation on drugs of abuse. OBJECTIVE This systematic review aims to gather the state of the art regarding chemical, molecular pharmacology and toxicological information of opioid class of NPS. METHODS Chemical, pharmacological, toxicological and clinical effects of opioid class of NPS were searched in books and in PubMed (U.S. National Library of Medicine) without a limiting period. RESULTS Within this class, fentanyl analogues are among the most frequently abused and pose several clinical concerns and therefore will be thoroughly discussed. Other opioid sub-categories of NPS frequently misused include AH-7921, MT-45, U-47700, U-50488, desomorphine, mitragynine, tramadol, tapentadol, salvinorin A and its analogue herkinorin. CONCLUSION Due to inefficient monitoring techniques, as well as limited knowledge regarding the acute and long-term effects of opioids NPS, further clinical and forensic toxicological studies are required.
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Affiliation(s)
- Ludovic Ventura
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Felix Carvalho
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Ricardo Jorge Dinis-Oliveira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal.,UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.,IINFACTS - Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal
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Hearne E, Alves EA, Van Hout MC, Grund JPC. Home Manufacture of Drugs: An Online Investigation and a Toxicological Reality Check of Online Discussions on Drug Chemistry. J Psychoactive Drugs 2017; 49:279-288. [PMID: 28535130 DOI: 10.1080/02791072.2017.1320735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Emerging trends in market dynamics and the use of new psychoactive substances are both a public health concern and a complex regulatory issue. One novel area of investigation is the availability of homemade opioids, amphetamines and dissociatives, and the potential fueling of interest in clandestine home manufacture of drugs via the Internet. We illustrate here how online communal folk pharmacology of homemade drugs on drug website forums may actually inform home manufacture practices or contribute to the reduction of harms associated with this practice. Discrepancies between online information around purification and making homemade drugs safer, and the synthesis of the same substances in a proper laboratory environment, exist. Moderation and shutdown of synthesis queries and discussions online are grounded in drug websites adhering to harm-reduction principles by facilitating discussions around purification of homemade drugs only. Drug discussion forums should consider reevaluating their policies on chemistry discussions in aiming to reach people who cannot or will not refrain from cooking their own drugs with credible information that may contribute to reductions in the harms associated with this practice.
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Affiliation(s)
- Evelyn Hearne
- a MSc Public Health (Addictions) Student, The Public Health Institute , Liverpool John Moore's University , Liverpool , UK
| | - Emanuele Amorim Alves
- b Ph.D. Student,Department of Legal Medicine and Forensic Sciences, Faculty of Medicine , University of Porto , Porto , Portugal.,c Ph.D. Student,UCIBIO-REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy , University of Porto , Porto , Portugal.,d Technician in Public Health, EPSJV-Polytechnical School of Health Joaquim Venâncio , Oswaldo Cruz Foundation , Rio de Janeiro , Brazil
| | - Marie Claire Van Hout
- e Professor of Public Health Policy, The Public Health Institute , Liverpool John Moore's University , Liverpool , UK
| | - Jean-Paul C Grund
- f Director of Research CVO , Addiction Research Centre , Utrecht , Netherlands.,g Senior Researcher, Department of Addictology, 1st Faculty of Medicine , Charles University, Prague, and General University Hospital , Prague , Czech Republic.,h Guest Researcher, Freudenthal Institute for Science and Mathematics Education , Utrecht University , Utrecht , Netherlands
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Alves EA, Brandão P, Neves JF, Cravo SM, Soares JX, Grund JPC, Duarte JA, Afonso CMM, Pereira Netto AD, Carvalho F, Dinis-Oliveira RJ. Repeated subcutaneous administrations of krokodil causes skin necrosis and internal organs toxicity in Wistar rats: putative human implications. Hum Psychopharmacol 2017; 32. [PMID: 28657190 DOI: 10.1002/hup.2572] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/11/2016] [Accepted: 01/06/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE "Krokodil" is the street name for an impure homemade drug mixture used as a cheap substitute for heroin, containing desomorphine as the main opioid. Abscesses, gangrene, thrombophlebitis, limb ulceration and amputations, jaw osteonecrosis, skin discoloration, ulcers, skin infections, and bleeding are some of the typical reported signs in humans. This study aimed to understand the toxicity of krokodil using Wistar male rats as experimental model. METHODS Animals were divided into seven groups and exposed subcutaneously to NaCl 0.9% (control), krokodil mixture free of psychotropic substances (blank krokodil), pharmaceutical grade desomorphine 1 mg/kg, and four different concentrations of krokodil (containing 0.125, 0.25, 0.5, and 1 mg/kg of desomorphine) synthesized accordingly to a "domestic" protocol followed by people who inject krokodil (PWIK). Daily injections for five consecutive days were performed, and animals were sacrificed 24 hr after the last administration. Biochemical and histological analysis were carried out. RESULTS It was shown that the continuous use of krokodil may cause injury at the injection area, with formation of necrotic zones. The biochemical results evidenced alterations on cardiac and renal biomarkers of toxicity, namely, creatine kinase, creatine kinase-MB, and uric acid. Significant alteration in levels of reduced and oxidized glutathione on kidney and heart suggested that oxidative stress may be involved in krokodil-mediated toxicity. Cardiac congestion was the most relevant finding of continuous krokodil administration. CONCLUSIONS These findings contribute notably to comprehension of the local and systemic toxicological impact of this complex drug mixture on major organs and will hopefully be useful for the development of appropriate treatment strategies towards the human toxicological effects of krokodil.
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Affiliation(s)
- Emanuele Amorim Alves
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.,IINFACTS-Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal.,EPSJV-Joaquim Venâncio Polytechnic School of Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Pedro Brandão
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - João Filipe Neves
- Department of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Sara Manuela Cravo
- Department of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - José Xavier Soares
- LAQV, REQUIMTE, Department of Chemical Sciences, Laboratory of Applied Chemistry, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Jean-Paul C Grund
- CVO-Addiction Research Centre, Utrecht, The Netherlands.,Department of Addictology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic.,Freudenthal Institute for Science and Mathematics Education, Utrecht University, Utrecht, The Netherlands
| | | | - Carlos M M Afonso
- Department of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry, Faculty of Pharmacy, University of Porto, Porto, Portugal.,Interdisciplinary Center of Marine and Environmental Investigation (CIIMAR/CIMAR), Porto, Portugal
| | | | - Félix Carvalho
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Ricardo Jorge Dinis-Oliveira
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.,IINFACTS-Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
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Affiliation(s)
| | - Noori Kim
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Crystal Aguh
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland
- Correspondence to: Crystal Aguh, MD, Johns Hopkins Bayview Medical Center, Mason F. Lord Bldg Center Tower Suite 2500, 5200 Eastern Ave, Baltimore, MD 21224.Johns Hopkins Bayview Medical CenterMason F. Lord Bldg Center Tower Suite 25005200 Eastern AveBaltimoreMD21224
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Abstract
Drug abuse is a common problem and growing concern in the United States, and over the past decade, novel or atypical drugs have emerged and have become increasingly popular. Recognition and treatment of new drugs of abuse pose many challenges for health care providers due to lack of quantitative reporting and routine surveillance, and the difficulty of detection in routine blood and urine analyses. Furthermore, street manufacturers are able to rapidly adapt and develop new synthetic isolates of older drugs as soon as law enforcement agencies render them illegal. In this article, we describe the clinical and adverse effects and purported pharmacology of several new classes of drugs of abuse including synthetic cannabinoids, synthetic cathinones, salvia, desomorphine, and kratom. Because many of these substances can have severe or life-threatening adverse effects, knowledge of general toxicology is key in recognizing acute intoxication and overdose; however, typical toxidromes (e.g., cholinergic, sympathomimetic, opioid, etc.) are not precipitated by many of these agents. Medical management of patients who abuse or overdose on these drugs largely consists of supportive care, although naloxone may be used as an antidote for desomorphine overdose. Symptoms of aggression and psychosis may be treated with sedation (benzodiazepines, propofol) and antipsychotics (haloperidol or atypical agents such as quetiapine or ziprasidone). Other facets of management to consider include treatment for withdrawal or addiction, nutrition support, and potential for transmission of infectious diseases.
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Affiliation(s)
- Megan A Rech
- Department of Pharmacy Services, Loyola University Medical Center, Maywood, Illinois; Department of Emergency Medicine, Loyola University Medical Center, Maywood, Illinois
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