Wednesday, October 30, 2013

Doubts About Reported Krokodil Cases Within US

Suspected krokodil a false alarm
Negative tests lead to further skepticism
October 27, 2013|By Andy Grimm, Chicago Tribune reporter
The hunt for krokodil continues as tests conducted in recent days on a suspected sample of the so-called flesh-eating drug came back negative, federal officials said.

An announcement two weeks ago by a Joliet doctor who said he treated three patients who showed the telltale rotting flesh associated with the toxic, home-brewed opiate — made from mixing codeine tablets with solvents like gasoline or acids — has sparked media coverage. A week later, a Crystal Lake hospital reported treating a krokodil user, and reports have cropped up across the country.

In a sweep modeled after the agency's successful search for the source of deadly fentanyl-tainted heroin some six years ago, 200 DEA agents across five states have made finding krokodil a top priority, Riley said.

"We have run quite a few buys in the city and suburbs," Riley said "What the lab tells us is it's just heroin."

Some experts in law enforcement and public health say it's unlikely the drug will be widely used beyond the remote areas of Russia and eastern Europe where it became popular a decade ago.

The Tribune contacted health officials in nine states where reports of krokodil have surfaced in the media, but no agency, yet, has found conclusive proof that the drug is in use. The number of unverified cases recorded by poison control centers in states where krokodil has been reported in the media is barely into double digits.
 Most of the reported cases of krokodil use have come from people who thought they were buying heroin, public health officials said.
"For krokodil ... people think they are getting heroin, and they say, 'I was using heroin and I got these sores.'"

In the Joliet case at least, suspected krokodil victims reportedly were heroin users who began to develop sores where they injected the drugs.

And even the symptoms associated with krokodil use are not that unique, said Jane Maxwell, a researcher at the University of Texas who has studied drug trends and sits on a National Institute on Drug Abuse panel that has identified new drug variants.

Long-term users of injectable drugs like heroin can develop infections from reusing needles and exposing themselves to all sorts of bacteria, leading to staph infections or those that are resistant to methicillin, known as MRSA infections.

Maxwell said there have been outbreaks of infections among heroin users that point out a peril facing users of illegal drugs that is well known, and less insidious than a new concoction: quality control.

"In California once, there were these outbreaks of sores," she said. "It was because the heroin was coming across the border stuck up the rear ends of cows."

Desomorphine, questionably the main component of Krokodil

     I had my own doubts about the appearance of krokodil within the US. One reason krokodil is a thing in Russia is because codeine is available OTC. Combined with a high rate of opiate use and crushing poverty it's not surprising some people desperate to relieve their pain turn to this toxic, home-baked and short-acting opioid. I doubt there are very many recreational krokodil users, though I may be wrong.
     Codeine is not exactly rare in the US, but given how short-acting desomorphine is (duration around 90 minutes), it just does not seem economical. Most codeine pills are 15, 30 and 60 mg. No synthesis is 100% efficient and there is every reason to believe the amateurish attempts at synthesizing desomorphine from codeine would result in low yields. I personally have not done much in depth research on the specifics of the "krokodil" method, there are some on the opiophile forums that question whether the Russians are truly producing desomorphine. Anyway codeine is sold in Russia OTC and cheap, but that is not the case here in the US.
      So it's possible the recent krokodil-like effects seen in some heroin users may in fact be due to contaminated heroin. We have seen this before, in anthrax outbreaks in UK heroin users (caused by smuggling heroin in the stomachs of animals). You know what might stop people from sticking heroin up the rear end of cows and causing infections in users? Legalization. Drug users have rights, among them the right to the highest possible standard of health. Any regime which violates fundamental human rights is illegitimate and should be discarded. 

A Note about Krokodil Synthesis:

The Russian makers only get a low yield or an impure product BUT codeine phosphate capsules are about $1.50/50x25mg so the start material is cheap. The exact route varies from maker to maker but they all seem to do more or less this:

1-Codeine + SOCl2 ---> α-Chlorocodide + HCl + SO2

2-α-Chlorocodide + I2 ---> 7,8 diiodo α-Chlorocodide

3-7,8 diiodo α-Chlorocodide + HI ----> desomorphine

Basically steps 2 & 3 are done in 1 pot. The iodine adds across the 7,8 double-bond in the same way Br adds across a double bond. The chemist then adds P to make HI which is a reducing agent. It removes the Is. The HI also demethylates the 3-methoxy. Looking at a list of the stuff formed, 6 or 7 impurities are found in varying amounts. Yield of product is about 30% at best. Of course, the stuff is x10 morphine so about 4x heroin (the BNF directs doctors that diamorphine is x2.5 morphine in medical uses).
Now, the product has a bare phenol on it so it cannot be smoked. One can readily esterify this compound (acetyl ester, nicotinic ester and so on) so it's BP becomes sufficiently low.
I will do a full test including pictures if enough people ask me to. It's about £300 of stuff I will use and I have no interest in taking the product... or selling... or giving away.
-Borohydride on the Opiophile Forum


    It appears Russia has made codeine prescription-only. Apparently krokodil has become less common, a good thing. For people who used codeine medically, or for junkies trying to take the edge off the withdrawals, life is bound to get more difficult.
     Opiophilia was mentioned in Jacob Sullum's article on krokodil, Another Way Prohibition Makes People's Flesh Rot. I'm a huge fan of Sullum's work, he and Maia Szalavitz are two of the best writers in the mainstream press covering drugs and drug policy.


Tuesday, October 29, 2013

Thursday, October 24, 2013

Harm Reduction, the Ultimate Goal

In the United States harm reduction was followed three basic themes:
-Syringe Exchange
-"Good Samaritan" Laws which offer immunity for people who respond to overdoses by contacting emergency services (immunity may be limited and not cover those on probation, in drug court, nor possession or distribution charges)
-Naloxone (narcan) access for people who use opioids

Radley Balko has a recent post about a Wisconsin state Rep whose daughter is a heroin addict. It was her experience which motivated him to sponsor a series of bills that moved forward harm reduction in Wisconsin:
The Milwaukee Journal Sentinel has the story of Wisconsin Republican state Rep. John Nygren, who is sponsoring a series of bills aimed at addressing and minimizing the damage from heroin overdoses. Two of the policies he's pushing are somewhat controversial. The first would offer limited immunity for people who call 911 or bring overdose patients to an emergency room. The sensible theory behind the policy is that people are reluctant to report overdoses if doing so could subject them to criminal charges. The other would expand those with access to Narcan, a medication that reverses the effects of an overdose.

Nygren is sponsoring these laws after confronting his daughter's heroin habit, and her near fatal overdose in 2009. Unfortunately, that sort of brush with the drug war's collateral damage is sometimes what it takes to make politicians see the light. But good on Nygen for coming around.

The Good Samaritan policy is understandably controversial, although it's certainly a sound approach. You're sacrificing a possible low-level drug prosecution in order to save a life. You'd think that even an ardent drug warrior would find that to be a satisfactory trade.

Or perhaps not. Some drug policies over the years have reflected more of a "better dead than high" approach to addiction. Consider the Narcan policy. If there's a medication out there that can prevent heroin overdose deaths, you'd think policymakers would want it distributed far and wide. But that hasn't been the case. There's a history here in which both the federal government and state governments have tried to restrict Narcan's availability. Consider this quote from Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy during the George W. Bush administration.
    "Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services."
In other words, withholding lifesaving medication from overdose patients may be just what addicts need to kick the habit for good. Yes, it could also kill them. But at least at that point, they'll no longer be getting high.

Daughter's Heroin Habit Moves Wisconsin Lawmaker To Sponsor Good Samaritan Law

Offering immunity for people who try to save addicts lives and expanding access to naloxone are important measures. Yet these "controversial" measures (if it was saving the lives of any other population it wouldn't be controversial) are doing little more that chipping away some of the worst aspects of the drug war. Rep Nygren's daughter went through the stereotypical junkie experience:

Cassie Nygren's parents divorced when she was 3.

As a teen, she experimented with alcohol and marijuana. She also says she was sexually abused.

At 15, she became pregnant and later gave up her daughter for adoption.

"I had just turned 16 and for her to leave me and be put into a vehicle of somebody else's and driven away was the hardest thing that I've ever had to do," she says. "I know that it was best. I know that it was a selfless thing to do. I know that she's loved and safe, and I wouldn't ask for anything more. However, it affected me, and it was never dealt with."

Months after she gave birth, she says, she started using Oxycontin, a commonly abused prescription narcotic painkiller. A friend introduced her to the drug, she says.

"I loved it right away," she says. "It gave me a feeling of being numb, no pain. It filled a void of emptiness that I had had, and right away I was hooked. The way I started was snorting....By 18, I was shooting heroin."

To feed her drug habit, she stole from her family.

"I don't think even any dollar amount could answer how much I've stolen and robbed from them," she says. "Not just in expenses or valuable things but our trust."

She cries as she recalls stealing her dad's Jaycees ring and pawning it for $150.

"It breaks my heart and to have admitted that to him was extremely hard," she says.

Cassie Nygren confessed to her father about her drug problems during a dinner at a local pizza restaurant.

"She looked terrible," he says. "Face white, pale, sunken in. And she's a pretty girl. You could basically see it on her face."

The family got her into treatment, but it didn't stick. She was in and out of several programs.

"A smart kid with a bright future ended up not graduating from high school," John Nygren says. "She got her GED later."

And she spent time in jail. The prosecutor, Marinette County Assistant District Attorney Kent Hoffmann, says his approach in Cassie Nygren's case "was to send her to prison to save her life."

After serving her prison sentence, Cassie Nygren violated her extended supervision several times. The latest was over the summer when she left town with an ex-boyfriend. They went to Texas, where she was picked up during a routine traffic stop.

She says she was trying to break away so that she could live a clean life with a friend in Texas. She says she now knows it was a mistake to leave.

John Nygren and his ex-wife worry about what will happen to their daughter. Amy Harris says she has seen encouraging changes in recent weeks.
 Marinette lawmaker confronts daughter's heroin addiction, seeks new legislation

Cassie Nygren

A traumatized girl deals with her mental pain by self-medicating with opiates. Because real drug education on how to use drugs safely is nonexistent, and only the most concentrated and therefore dangerous formulations are available to users (oxycontin and heroin instead of opium or poppy pod tea), the chance of overdosing is high. Cassie Nygren's story, the overdosing, stealing, jail, the in-and-out of ineffective treatment programs, is far from unique. It could even be called the stereotypical junkie story, but it doesn't need to be.

If Cassie Nygren was offered heroin maintenance she could have been kept from overdosing, stealing from her family and out of jail. She might even go to school and become a productive member of society. Expanding opiate maintenance beyond methadone and buprenorphine to include the full spectrum of available opioids would probably do more to lessen the problems of opiate prohibition than any other measure (short of full legalization). The black market would be dramatically reduced and users would no longer be criminalized. Because heroin is relatively harmless in and of itself, most of the health problems that are common in heroin users would disappear. The acquisitive crime and prostitution that is so common among destitute addicts would be dramatically reduced. The hard working addicts who hold down a job only to see a sizable portion of their paycheck go to supporting their habit would keep that money, improving the quality of life of their families. Accidental overdoses would be rare, and would be promptly treated by clinic staff.

The cost of pharmaceutical heroin, morphine and the other semi-synthetic opiates is negligible. The savings in criminal justice costs, crime averted and health savings more than compensates for the cost of running opiate maintenance clinics. The only real cost to society is that we would have to stop persecuting addicts and give them the drugs they want.

Opiate maintenance using the individual's opioid of choice is the form of harm reduction that has the most benefit for the individual and society. I urge all drug reformers to move the discussion beyond (but not abandon!) clean syringes, safe injection facilities and "Good Samaritan" laws and adopt maintenance prescribing as the most important harm reduction goal.

Saturday, October 19, 2013

Opium Dens and Shooting Galleries

In the 19th century when opiates were legal, consumed as opium, morphine or patent medicines containing opium among other ingredients, there were two primary types of addicts. One was predominantly white, and had been introduced to opiates from a doctor (iatrogenic addiction). They took their opiates orally, or increasing through a syringe. Women outnumbered men, middle-class housewives were typical cases.
The second type of addict was the opium smoker. Opium smoking was a Chinese custom, one they brought with them upon mass immigration to the US in the latter part of the 19th century. 

The Chinese immigrant largely isolated themselves, in part due to racism and in part by choice. Most immigrants were young men hoping to earn enough money to return home a wealthy man, a dream few actually realized. Regardless most thought of themselves as temporary workers and saw no reason to assimilate with US society. Mass influx of Chinese labor willing to work cheap was seen by some as taking away jobs from white native Americans, when combined with racism and xenophobia, contributed to the exclusion of the Chinese.

One major exception was the opium den, which attracted the more deviant members of society. The opium den was more than just a place to get high. "More formally, the opium den had become the matrix of a deviant subculture, a tightly knit group of outsiders whose primary relations were restricted to themselves." (Courtwright, 1982) The den was one of the few places where Chinese and whites, of both sexes, mixed openly. Lurid charges were leveled at proprietors, charges that Chinese perverts were using opium to seduce young white women into a life of immorality. The labor leader Samuel Gompers excelled at using hysterical rhetoric, complete with anxieties over miscegenation, to drum up popular support against the opium den:

"...tiny lost souls...forced to yield up their virgin bodies to their maniacal yellow captors...What other crimes are committed in these dark fetid places when these innocent victims of the Chinaman's wiles were under the influence of the drug opium is too horrible to imagine. There are hundreds, aye thousands, of our American girls and boys who have acquired this deathly habit and are doomed, hopelessly doomed, beyond redemption.

They carry the curse of China, opium, as their weapon. They and their poison must be rooted out before they will decimate our youth and emasculate the coming generation of Americans."
Opium Dens from around the world, some are more affluent than others but the basic accommodations for those on the hip are the same.
The reality was quite different, as the historian David Courtwright documents:

"An opium den was more than a school, however; it was also a meeting place, a sanctuary, and a vagabonds' inn. Member's of the underworld could gather in relative safety, to enjoy a smoke with their friends and associates. One addict has left us a memorable portrait of life in the New York City dens. 'The people who frequent these places,' he recounted, 'are, with very few exceptions, thieves, sharpers and sporting men, and a few bad actors; the women, without exception, are immoral.' In spite of the desperate character of clientele, fights were practically unknown. Instead, the smokers passed the time between pipes by chatting, smoking tobacco, telling stories, cracking jokes, or even singing in low voices...Within the den a rigid code of honor prevailed: smokers would not take advantage of other smokers, or tolerate those who did. 'I have seen men and women come to the joints while under the influence of liquor,' continued the New York addict, 'lie down and go to sleep with jewelry exposed and money in their pockets, but no one would ever think of disturbing anything.' 'The joint,' confirmed an experienced Denver smoker, 'is considered a sacred sanctum, and to betray...any conversation between the fiends is considered an unpardonable offense, and a fiend who commits a second offense of this character is generally debarred from all the rights and privileges of the joint.'" (Courtwright, 1982)

In many ways the opium den represented the start of the drug subculture in the United States. Language still in use today originates from the opium den culture. "Hip", which is used by drug users to distinguish themselves from non-drug users ("squares", "straights"), originates from opium smokers lying on their hip while on the pipe. The word "dope" is adapted from the Dutch, originally meant a thick, viscous sauce, probably adapted during the process of preparing the opium for smoking. Today "dope" is a generic term for any illicit drug (though where I come from if you ask for dope on the street you are referring to heroin).

If the opium dens were left alone, perhaps by today they would be legitimate. People would be able to choose whether to frequent an alcohol bar, cannabis cafe or opium den. Because opium is smoked slowly, overdosing is more difficult than taking concentrated derivatives. Proprietors would be on hand to treat any cases of overdose.
"Needle Park" in Zurich, Switzerland (prior to heroin maintenance)

Unfortunately the War on (the people who use certain) Drugs has perverted this possible scenario. Opium smoking is almost unknown in the US, almost all the opium produced for the illicit market is manufactured into heroin. Because of prohibition, the cost of this inexpensive to produce, plant-based medicine is astronomical. This encourages methods of ingestion that maximize the effect: intravenous injection.

So instead of opium dens, we have shooting galleries. A shooting gallery is a place where addicts can inject together in relative safety, they are also synonymous with disease and degradation. In contrast to the opium den described by Courtwright, if someone nodded out in a shooting gallery their money and jewelery would almost certainly be stolen.

By ending the drug war and bringing back the opium den, the problems of accidental overdoses will be reduced. Diseases associated with injecting drugs of unknown purity and subject to no quality control (meaning they may be adulterated with other drugs or diluted with substances never meant to be injected), in addition to blood born infections from sharing syringes, will be reduced or eliminated altogether. Crime brought about by the poverty resulting from being dependent on an (artificially) expensive drug will disappear. Drug dealers and criminal cartels will be replaced by taxpaying opium den proprietors.

Further Reading and References:

Courtwright, David T. (1982) Dark Paradise Opiate Addiction in America before 1940. Cambridge, MA: Harvard University Press