desomorphine and Osteonecrosis

"Krokodil" is the street name for the homemade injectable mixture that has been used as a cheap substitute for heroin. Its use begun in Russia and Ukraine and nowadays is being spread over several other countries. Desomorphine is the semi-synthetic opioid claimed to be the main component of krokodil and considered to be responsible for its psychoactive characteristics. The starting materials for desomorphine synthesis are codeine tablets, alkali solutions, organic solvent, acidified water, iodine and red phosphorus, all of which are easily available in retail outlets, such as supermarkets, drugstores, etc. The resulting product is a light brown liquid that is called krokodil. People who inject krokodil present a great variety of serious signs and symptoms, including thrombophlebitis, ulcerations, gangrene, and necrosis, quickly evolving to limb amputation and death. These effects are thought to result from the toxic components produced as byproducts during the homemade drug synthesis. In this work, we reviewed several aspects of krokodil use, including its epidemiology, pharmacology and the chemical properties of the main active ingredient (desomorphine). To enhance our understanding of the clinical and toxic effects and to support the implementation of harm reduction measures, we also describe the "bathtub chemistry" of krokodil and the content of the final solution.

Topics: Amputation, Traumatic; Codeine; Gangrene; Humans; Illicit Drugs; Molecular Structure; Necrosis; Neurotoxicity Syndromes; Osteonecrosis; Skin; Substance Abuse, Intravenous

Topics: Amphetamine-Related Disorders; Codeine; Drug Users; Facial Bones; Humans; Methamphetamine; Morphine Dependence; Osteonecrosis; Phosphorus; Skull

The aim of this study is to show the effectiveness of the use of mylohyoid muscle flap in surgical treatment of stage 1 and 2 Krokodil drug-related ON of mandible. Retrospective study of patients with stage 2 Krokodil drug-related ON of distal mandible was performed. Regarding to the used surgical technique the patients were divided into two groups (groups 1 and 2). In group 1(control group) the wound was closed only by the local mucoperiosteal flaps, while in group 2 (experimental group) the wound was closed by combining mylohyoid muscle flap and local mucoperiosteal flaps. 24 patients were included in this study (15 patients in the group 1 and 9 patients in the group 2). In all patients of experimental group the postoperative period was uneventful and no recurrence occurred. In group 1 recurrence was found in 7 patients, which is significantly higher than in group 2 (χ

Topics: Codeine; Humans; Mandible; Neck Muscles; Osteonecrosis; Plastic Surgery Procedures; Retrospective Studies; Treatment Outcome

Topics: Codeine; Humans; Osteonecrosis; Skull Base

A 52-year-old man with a history of krokodil (desomorphine) use was admitted to the department of oral and maxillofacial surgery with drug intoxication and severe pain in his jaw. During clinical and radiological examination, several sites of exposed necrotic bone with purulent discharge were seen. In krokodil-using patients osteonecrosis of the jaw is a frequently occurring manifestation. Other oral aspects associated with the use of krokodil include mucosal changes, a high risk of caries and periodontitis. Systemic effects can interfere with dental and oral and maxillofacial treatment. Treatment consists of sequestrectomy of the necrotic bone under general anaesthesia. The clinical picture of osteonecrosis in krokodil users is similar to cases of 'phossy jaw' and Medication Related Osteonecrosis of the Jaw (MRONJ).. Een 52-jarige met een voorgeschiedenis met het gebruik van de drug krokodil (desomorfine) presenteerde zich op een afdeling Mond-, Kaak-, en Aangezichtschirurgie met een drugsintoxicatie en ernstige pijnklachten in de kaak. Na klinisch en röntgenologisch onderzoek werd op meerdere plaatsen in de mond necrotisch bot met een purulente afvloed gezien. Osteonecrose van de kaak is een frequent voorkomende manifestatie bij krokodilgebruikers. Andere orale aspecten geassocieerd met krokodilgebruik betreffen veranderingen van de orale mucosa, een hoog cariësrisico en parodontitis. Systemische effecten kunnen interfereren met tandheelkundige en mka-chirurgische behandeling. De behandeling bestaat uit een sekwestrectomie van het necrotische bot onder algehele anesthesie. Het klinisch beeld van osteonecrose van de kaak bij krokodilgebruikers is vergelijkbaar met casussen van de phossy jaw en medicatiegerelateerde osteonecrose van de kaak (MRONJ).

Topics: Codeine; Humans; Male; Middle Aged; Oral Health; Osteonecrosis

Krokodil is a cheap and effective home-made substitute for heroin. It is widely used over the territory of the former USSR (Russia, Ukraine, Armenia and others). Krokodil drug-related midface ON often occurs as a complication of maxillary ON. Treatment of Krokodil drug-related ON of the midface is challenging. It is difficult to determine the ON zone preoperatively and intraoperatively, due to the complex anatomy of the midface and the different periods of the disease onset in different areas. The aim of this study is to show variations of the clinical course and treatment options of Krokodil drug-related ON of the midface. In this study, 3 cases of Krokodil drug-related midface ON are reported. The main clinical feature of midface ON is extraoral fistula in the midfacial zone with purulent discharge or extraoral exposure of zygomatic bone. Surgery is the main treatment method for Krokodil drug-related midface osteonecrosis. Surgery includes necrotic bone removal and defect closure. Usually an extraoral approach is used to expose necrotic bone. Intraoral maxillary sinus floor defect is closed with the use of a buccal fat pad to prevent formation of oroantral communication. Drug withdrawal, radical necrectomy, and proper closure of formed defects are the main factors that lead to successful treatment of Krokodil drug-related midface ON patients.

Topics: Adult; Codeine; Humans; Illicit Drugs; Male; Maxilla; Middle Aged; Necrosis; Osteonecrosis; Sinus Floor Augmentation; Substance Abuse, Intravenous; Treatment Outcome

We report a case of a 48-year-old male patient with "krokodil" drug-related osteonecrosis of both jaws. Patient history included 1.5 years of "krokodil" use, with 8-month drug withdrawal prior to surgery. The patient was HCV positive. On the maxilla, sequestrectomy was performed. On the mandible, sequestrectomy was combined with bone resection. From ramus to ramus, segmental defect was formed, which was not reconstructed with any method. Post-operative follow-up period was 3 years and no disease recurrence was noted. On 3-year post-operative orthopantomogram, newly formed mandibular bone was found. This phenomenon shows that spontaneous bone formation is possible after mandible segmental resection in osteonecrosis patients.

Topics: Analgesics, Opioid; Armenia; Bone Regeneration; Codeine; Follow-Up Studies; Humans; Male; Mandible; Mandibular Diseases; Maxilla; Maxillary Diseases; Middle Aged; Narcotics; Osteonecrosis; Radiography, Panoramic

Retrospective study of jaw osteonecrosis treatment in patients using the "Krokodil" drug from 2009 to 2013. On the territory of the former USSR countries there is widespread use of a self-produced drug called "Krokodil". Codeine containing analgesics ("Sedalgin", "Pentalgin" etc), red phosphorus (from match boxes) and other easily acquired chemical components are used for synthesis of this drug, which used intravenously. Jaw osteonecrosis develops as a complication in patients who use "Krokodil". The main feature of this disease is jawbone exposure in the oral cavity. Surgery is the main method for the treatment of jaw osteonecrosis in patients using "Krokodil". 40 "Krokodil" drug addict patients with jaw osteonecrosis were treated. Involvement of maxilla was found in 11 patients (27.5%), mandible in 21 (52.5%), both jaws in 8 (20%) patients. 35 Lesions were found in 29 mandibles and 21 lesions in 19 maxillas. Main factors of treatment success are: cessation of "Krokodil" use in the pre- (minimum 1 month) and postoperative period and osteonecrosis area resection of a minimum of 0.5 cm beyond the visible borders of osteonecrosis towards the healthy tissues. Surgery was not delayed until sequestrum formation. In the mandible marginal or segmental resection (with or without TMJ exarticulation) was performed. After surgery recurrence of disease was seen in 8 (23%) cases in the mandible, with no cases of recurrence in the maxilla. According to our experience in this case series, surgery is the main method for the treatment of jaw osteonecrosis in patients using "Krokodil". Cessation of drug use and jaw resection minimize the rate of recurrences in such patients.

Topics: Adult; Alveolectomy; Codeine; Cutaneous Fistula; Female; Follow-Up Studies; Humans; Illicit Drugs; Male; Mandibular Diseases; Maxillary Diseases; Middle Aged; Opioid-Related Disorders; Oral Fistula; Osteonecrosis; Osteotomy; Recurrence; Temporomandibular Joint; Tooth Socket; Treatment Outcome