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Nogueira D, Caldas IM, Dinis-Oliveira RJ. Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects. Arch Oral Biol 2023; 155:105792. [PMID: 37611492 DOI: 10.1016/j.archoralbio.2023.105792] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/30/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis. DESIGN An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject. RESULTS MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered. CONCLUSIONS Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.
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Affiliation(s)
- Diana Nogueira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal.
| | - Inês Morais Caldas
- Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; Centre for Functional Ecology (CFE), Department of Life Sciences, University of Coimbra, Calçada Martim de Freitas, 3000-456 Coimbra, Portugal.
| | - Ricardo Jorge Dinis-Oliveira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; UCIBIO/REQUIMTE, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, R. Jorge Viterbo Ferreira, No 228, 4050-313 Porto, Portugal.
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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. SPECIAL CARE IN DENTISTRY 2023; 43:685-688. [PMID: 36482761 DOI: 10.1111/scd.12807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [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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Dinis-Oliveira RJ. One image is worth more than a thousand words: producing an atlas of medical signs for teaching clinical and forensic toxicology. Forensic Sci Res 2023; 7:815-822. [PMID: 36817238 PMCID: PMC9930749 DOI: 10.1080/20961790.2022.2059837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Clinical and forensic toxicology are critically involved in the acquisition of basic skills to correctly suspect intoxication, collect biological and non-biological materials for toxicological analysis, comprehend the complexities inherent to laboratory activity, and understand the fundamentals of toxicokinetics and toxicodynamics that underlie the interpretation of results. This works presents a pedagogical innovation proposal for the teaching of clinical and forensic toxicology based on a compilation of more than 3 000 cases where the image was fulcra for suspicion. The experience in this article follows the model practiced in bachelors, masters, and PhD degrees, as well as in other continuing training courses, where we are teaching toxicology for more than 15 years. All these levels of education are considered fundamental to the sound development of this science. This approach aims also to offer strength to the intervention of the true toxicologist in all the toxicological phases, besides the classic analytical chemistry. Indeed, it is impossible to provide effective clinical and forensic toxicological interpretations without a proper and broad education, and not thinking exclusively in terms of laboratory techniques. In the future, it will be interesting to evaluate knowledge retention and to propose a database of videos of signs related to intoxications.
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Affiliation(s)
- Ricardo Jorge Dinis-Oliveira
- TOXRUN – Toxicology Research Unit, University Institute of Health Sciences, Advanced Polytechnic and University Cooperative (CESPU), CRL, Gandra, Portugal,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,CONTACT Ricardo Jorge Dinis-Oliveira ;
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Toxic desomorphine encephalopathy due to the use of “Krokodil”: clinical and neuroimaging features. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract96475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Toxic desomorphine encephalopathy (TDE) is a pathological condition that develops as a result of the intravenous use of a drug called Krokodil containing desomorphine, made in the artisanal conditions using codeine-containing drugs, organic solvents (gasoline), iodine and red phosphorus. This disease is more often observed in the CIS countries. In addition to the acute and chronic pathological conditions with the damage to various organs, the use of Krokodil is characterized by pronounced extrapyramidal manifestations in the form of dystonia, parkinsonism, postural disorders, as well as the occurrence of cognitive and affective disorders.
Aims: To find the clinical and neuroimaging features of toxic desomorphine encephalopathy, as well as possible methods of its treatment.
Methods: A clinical analysis of the medical documentation of 21 TDE patients (11 women and 10 men) with a history of the use of Krokodil was carried out, the patients had been under observation from 2014 to 2021. All the patients underwent a clinical physical and neurological examination, 14 of them underwent neuroimaging (brain MRI and/or MSCT). The observation of these patients revealed a number of characteristic clinical and neuroimaging features inherent in the majority of drug addicts.
Results: The clinical picture of patients with TDE was dominated by movement disorders. All the patients had pronounced postural disorders and gait disturbance. Parkinsonism was observed in 20 of 21 patients. The hyperkinetic syndrome was presented in 17 patients (80.9%) and was manifested by dystonia of various localization with polymorphic manifestations. The brain MRI data taken from the Krokodil users for 3 years were characterized by symmetrical focal changes in the basal ganglia, brainstem, cerebellum and internal capsule of the thalamus in the form of an increase in the intensity of the MR signal in the T1 mode and attenuation in the T2-weighted images mode (7 of 11 cases), with the subsequent regression of these characteristics based on the results of the subsequent MRI studies.
Conclusion: The study results have revealed the clinical manifestations characteristic of TDE polymorphic extrapyramidal disorders, as well as neuroimaging changes reflecting these data.
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Walker S, Dietze P, Poznyak V, Campello G, Kashino W, Dzhonbekov D, Kiriazova T, Nikitin D, Terlikbayeva A, Nevendorff L, Busse A, Krupchanka D. More than saving lives: Qualitative findings of the UNODC/WHO Stop Overdose Safely (S-O-S) project. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 100:103482. [PMID: 35042142 DOI: 10.1016/j.drugpo.2021.103482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Stop Overdose Safely (S-O-S) initiative-developed in compliance with WHO guidelines-aims to prevent opioid overdose deaths. Under the umbrella of this initiative a multi-country project was implemented in Kazakhstan, Kyrgyzstan, Tajikistan, and Ukraine, that involved overdose recognition and response training, including the provision of take-home naloxone (THN). More than 14,000 potential overdose witnesses were trained and more than 16,000 THN kits were distributed across the participating countries. This paper reports on the qualitative component of an evaluation aiming to understand the views and experiences of S-O-S project participants. METHODS Data were drawn from focus group discussions with 257 project participants from across all four countries, including people who use and inject drugs, and others likely to witness an opioid overdose. Data were analysed thematically. RESULTS Findings revealed how past experiences of trauma and loss related to overdose death were common, as was appreciation and gratitude for the opportunity to participate in the S-O-S training. Participants described how they shared knowledge and skills with others. Empowerment and destigmatising narratives featured prominently, and highlighted how for people who use drugs, feeling valued and cared about-not only by families and friends, but by health care providers, and sometimes police-was a positive outcome of their participation. Nevertheless, findings also revealed how real experiences of fear regarding police intervention was a barrier to carrying naloxone and intervening when faced with an overdose situation. CONCLUSION Our analysis found that the S-O-S project produced positive outcomes that go well beyond saving lives. Despite identifying barriers to THN uptake, our findings support a growing body of evidence that broad access to THN as part of a continuum of care can enhance the health and wellbeing of people who use drugs and their communities, in low- to middle-income countries.
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Affiliation(s)
- Shelley Walker
- Burnet Institute, Behaviours and Health Risks Program, 85 Commercial Road, GPO Box 2284, Melbourne, Victoria, 3004, Australia; National Drug Research Institute, Faculty of Health Sciences, Curtin University, 85 Commercial Road, GPO Box 2284, Melbourne, Victoria, 3004, Australia.
| | - Paul Dietze
- Burnet Institute, Behaviours and Health Risks Program, 85 Commercial Road, GPO Box 2284, Melbourne, Victoria, 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne Victoria, 3004, Australia; National Drug Research Institute, Faculty of Health Sciences, Curtin University, 85 Commercial Road, GPO Box 2284, Melbourne, Victoria, 3004, Australia
| | - Vladimir Poznyak
- Alcohol, Drugs and Addictive Behaviours Unit, Department of Mental Health and Substance Use, World Health Organization, Avenue Appia 20, 1202, Geneva, Switzerland
| | - Giovanna Campello
- Prevention, Treatment and Rehabilitation Section, Drug Prevention and Health Branch, United Nations Office on Drugs and Crime, P.O. Box 500, A-1400 Vienna, Austria
| | - Wataru Kashino
- Prevention, Treatment and Rehabilitation Section, Drug Prevention and Health Branch, United Nations Office on Drugs and Crime, P.O. Box 500, A-1400 Vienna, Austria
| | | | - Tetiana Kiriazova
- Ukrainian Institute on Public Health Policy, 5 Biloruska Street, Office 20, 27, Kyiv, 04050, Ukraine
| | - Danil Nikitin
- Global Research Institute (GLORI) Foundation, 125 Suyumbaev Street Bishkek, 720011, Kyrgyzstan
| | - Assel Terlikbayeva
- Global Health Research Center of Central Asia (GHRCCA), 38B Shashkina Street, Almaty, Kazakhstan
| | - Laura Nevendorff
- Burnet Institute, Behaviours and Health Risks Program, 85 Commercial Road, GPO Box 2284, Melbourne, Victoria, 3004, Australia
| | - Anja Busse
- Prevention, Treatment and Rehabilitation Section, Drug Prevention and Health Branch, United Nations Office on Drugs and Crime, P.O. Box 500, A-1400 Vienna, Austria
| | - Dzmitry Krupchanka
- Alcohol, Drugs and Addictive Behaviours Unit, Department of Mental Health and Substance Use, World Health Organization, Avenue Appia 20, 1202, Geneva, Switzerland
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Vearrier D, Grundmann O. Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids. J Clin Pharmacol 2021; 61 Suppl 2:S70-S88. [PMID: 34396552 DOI: 10.1002/jcph.1923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022]
Abstract
Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.
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Affiliation(s)
- David Vearrier
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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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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Pharmacological Aspects of Over-the-Counter Opioid Drugs Misuse. Molecules 2020; 25:molecules25173905. [PMID: 32867117 PMCID: PMC7504308 DOI: 10.3390/molecules25173905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
Several over-the-counter (OTC) drugs are known to be misused. Among them are opioids such as codeine, dihydrocodeine, and loperamide. This work elucidates their pharmacology, interactions, safety profiles, and how pharmacology is being manipulated to misuse these common medications, with the aim to expand on the subject outlined by the authors focusing on abuse prevention and prevalence rates. The reviewed literature was identified in several online databases through searches conducted with phrases created by combining the international non-proprietary names of the drugs with terms related to drug misuse. The results show that OTC opioids are misused as an alternative for illicit narcotics, or prescription-only opioids. The potency of codeine and loperamide is strongly dependent on the individual enzymatic activity of CYP2D6 and CYP3A4, as well as P-glycoprotein function. Codeine can also be utilized as a substrate for clandestine syntheses of more potent drugs of abuse, namely desomorphine (“Krokodil”), and morphine. The dangerous methods used to prepare these substances can result in poisoning from toxic chemicals and impurities originating from the synthesis procedure. OTC opioids are generally safe when consumed in accordance with medical guidelines. However, the intake of supratherapeutic amounts of these substances may reveal surprising traits of common medications.
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10
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Sacco R, Ball R, Barry E, Akintola O. The role of illicit drugs in developing medication-related osteonecrosis (MRONJ): a systematic review. Br J Oral Maxillofac Surg 2020; 59:398-406. [PMID: 33789811 DOI: 10.1016/j.bjoms.2020.08.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/10/2020] [Indexed: 11/25/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a challenging condition to treat. It has primarily been associated with anti-resorptive and anti-angiogenic drugs, which are increasingly being used to prevent adverse skeletally-related complications in patients with cancer and bone pathologies. Although these medications have been proven to cause osteonecrosis of the jaws (ONJ) there are also a number of other drugs that could potentially cause this condition. The aim of this systematic review is to ascertain whether there is an associated risk of osteonecrosis of the jaw (ONJ) in recreational drug users (RDU). Three authors independently searched PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials for published reports of osteonecrosis of the jaw (ONJ) in recreational drug users (RDU) or illicit drug users (IDU) who had no history of treatment with anti-angiogenic or anti-resorptive agents. Only 30 studies were eligible for analysis, and all were independently assessed for risk of bias. There was a total of 101 patients with ONJ attributed solely to illicit drug consumption. The most common site of ONJ was the maxilla (n=54). The most common illicit drug related to ONJ was desmorphine, known as 'Krokodil', this was followed by cocaine, methamphetamine, anabolic steroids, and hydrocodone/acetaminophen. In 52 of the cases, the ONJ resolved following treatment, however, eight showed a recurrence. Although all the studies were judged to be at a high risk of bias, the limited data suggest that some patients are at risk of developing ONJ as a result of illicit drug usage. Studies of higher quality are needed to establish the relative risk of ONJ in this patient group.
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Affiliation(s)
- R Sacco
- Oral Surgery Department, King's College Hospital, London, SE5 9RW, UK; Oral Surgery Department, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK; Oral and Craniofacial Science, King's College London, London, WC2R 2LS, UK; Eastman Dental Institute - University College of London, London, WC1X 8LT, UK; Oral Surgery Department, Division of Dentistry, School of Medical Science - The University of Manchester, Manchester, M13 9PL, UK.
| | - R Ball
- Oral Surgery Department, King's College Hospital, London, SE5 9RW, UK
| | - E Barry
- Oral Surgery Department, King's College Hospital, London, SE5 9RW, UK
| | - O Akintola
- Oral Surgery Department, King's College Hospital, London, SE5 9RW, UK
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Mella-Raipán J, Romero-Parra J, Recabarren-Gajardo G. DARK Classics in Chemical Neuroscience: Heroin and Desomorphine. ACS Chem Neurosci 2020; 11:3905-3927. [PMID: 32568519 DOI: 10.1021/acschemneuro.0c00262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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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12
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Arenbergerova M, Arenberger P, Gkalpakiotis S, Sticova E, Hulkova H, Trhlikova O, Sikora J. Palladium causes bizarre skin hyperpigmentation in long-term dihydrocodeinone 'Braun' abusers. J Eur Acad Dermatol Venereol 2019; 34:188-191. [PMID: 31494978 DOI: 10.1111/jdv.15930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/25/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND 'Braun' is an illegal injectable dihydrocodeinone-enriched drug mixture of semi-synthetic opioids. It is prepared by palladium-catalysed hydrogenation from codeine-containing tablets. OBJECTIVE We aimed to characterize the dermatologic consequences of long-term abuse of 'Braun'. METHODS Skin biopsies of two long-term 'Braun' abusers were evaluated histopathologically, immunohistochemically and ultrastructurally. Palladium skin content was assessed by X-ray fluorescence (XRF) spectrometry. RESULTS Both patients showed generalized diffuse dark blue-grey hyperpigmentation of the skin. In both, an abnormal population of cells containing intracytoplasmic brownish granular material was identified in the papillary dermis by light microscopy. Electron microscopy revealed a dense and minimally structured material that predominantly accumulated in macrophages, fibroblasts and vascular endothelial cells. XRF analysis confirmed elevated levels of palladium in the patient's skin in comparison to healthy controls. CONCLUSION Long-term abuse of palladium-contaminated dihydrocodeinone ('Braun') results in excessive accumulation of granular material in various dermal cell types and causes generalized diffuse skin hyperpigmentation.
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Affiliation(s)
- M Arenbergerova
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - P Arenberger
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - S Gkalpakiotis
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - E Sticova
- Department of Pathology, Third Faculty of Medicine, Charles University, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - H Hulkova
- Department of Pediatrics and Adolescent Medicine, Research Unit for Rare Diseases, First Faculty of Medicine, General University Hospital, Prague, Czech Republic.,Institute of Pathology, First Faculty of Medicine, General University Hospital, Prague, Czech Republic
| | - O Trhlikova
- Institute of Macromolecular Chemistry, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - J Sikora
- Department of Pediatrics and Adolescent Medicine, Research Unit for Rare Diseases, First Faculty of Medicine, General University Hospital, Prague, Czech Republic.,Institute of Pathology, First Faculty of Medicine, General University Hospital, Prague, Czech Republic
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13
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LaMonaca K, Dumchev K, Dvoriak S, Azbel L, Morozova O, Altice FL. HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy. Curr Psychiatry Rep 2019; 21:47. [PMID: 31161306 PMCID: PMC6685549 DOI: 10.1007/s11920-019-1038-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing. RECENT FINDINGS Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.
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Affiliation(s)
- Katherine LaMonaca
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street Suite 323, New Haven, CT, 06510, USA
| | | | - Sergii Dvoriak
- Academy of Labour, Social Relations and Tourism, Kyiv, Ukraine
| | - Lyuba Azbel
- London School of Hygiene & Tropical Medicine, London, UK
| | - Olga Morozova
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street Suite 323, New Haven, CT, 06510, USA.
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14
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Winborn J, Kerrigan S. Quantitative analysis of desomorphine in blood and urine using solid phase extraction and gas chromatography-mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2019; 1106-1107:43-49. [DOI: 10.1016/j.jchromb.2018.12.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/11/2018] [Accepted: 12/16/2018] [Indexed: 01/24/2023]
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15
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Winborn J, Kerrigan S. Analysis of Desomorphine in Urine Using Liquid Chromatography–Tandem Mass Spectrometry. J Anal Toxicol 2018; 43:340-345. [DOI: 10.1093/jat/bky103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/20/2018] [Indexed: 01/11/2023] Open
Affiliation(s)
- Jessica Winborn
- Department of Forensic Science, Sam Houston State University, 1003 Bowers Blvd, Huntsville, TX, USA
| | - Sarah Kerrigan
- Department of Forensic Science, Sam Houston State University, 1003 Bowers Blvd, Huntsville, TX, USA
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16
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In vitro metabolism of desomorphine. Forensic Sci Int 2018; 289:140-149. [DOI: 10.1016/j.forsciint.2018.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 12/19/2022]
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17
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Sorrentino A, Trotta S, Colucci AP, Aventaggiato L, Marzullo A, Solarino B. Lethal endomyocarditis caused by chronic “Krokodil” intoxication. Forensic Sci Med Pathol 2018; 14:229-235. [DOI: 10.1007/s12024-018-9967-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 01/10/2023]
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18
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McMillin GA. Pharmacogenetics of Opioid Use and Implications for Pain Management-Are We Ready? J Appl Lab Med 2018; 2:481-484. [PMID: 33636887 DOI: 10.1373/jalm.2017.024968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/16/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Gwendolyn A McMillin
- Department of Pathology, University of Utah, Salt Lake City, UT.,ARUP Laboratories, Salt Lake City, UT
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19
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McGrew H, Ruble M. Updates on Novel Illicit Drugs: What Practitioners Should Be Aware Of. J Emerg Nurs 2017; 43:591-592. [PMID: 29100577 DOI: 10.1016/j.jen.2017.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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An analytical method to identify traces of white phosphorus on burned victim clothes. Forensic Sci Int 2017; 280:224-227. [PMID: 29080522 DOI: 10.1016/j.forsciint.2017.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/27/2017] [Accepted: 10/12/2017] [Indexed: 11/22/2022]
Abstract
We report for the first time, the chemical identification of phosphorus on the remains of burned clothes taken from an injured woman. The woman was accidentally burned as a result of spontaneous combustion of a "stone" pebble-like material her daughter picked up innocently on a beach. The remains of the woman's clothes were analyzed by gas chromatograph mass spectrometer (GCMS) after headspace adsorption using solid phase microextraction (SPME). The results of this test showed that the injuries were due to phosphorus, leading to the understanding that the "stone" was actually white phosphorus. This method can help both forensic investigators in a crime scene investigation and physicians that need this information in order to give the correct treatment to their patient.
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21
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Soares JX, Alves EA, Silva AMN, de Figueiredo NG, Neves JF, Cravo SM, Rangel M, Netto ADP, Carvalho F, Dinis-Oliveira RJ, Afonso CM. Street-Like Synthesis of Krokodil Results in the Formation of an Enlarged Cluster of Known and New Morphinans. Chem Res Toxicol 2017; 30:1609-1621. [PMID: 28708940 DOI: 10.1021/acs.chemrestox.7b00126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- José Xavier Soares
- LAQV, REQUIMTE,
Department of Chemical Sciences, Laboratory of Applied Chemistry,
Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Street
No. 228, 4050-313 Porto, Portugal
| | - Emanuele Amorim Alves
- UCIBIO, REQUIMTE, Laboratory
of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Street No. 228 4050-313 Porto, Portugal
- Department of Public Health and Forensic Sciences, and Medical Education,
Faculty of Medicine, University of Porto, Prof. Hernâni Monteiro Alameda, 4200-319 Porto, Portugal
- EPSJV−Polytechnic School of Health Joaquim Venâncio,
Oswaldo Cruz Foundation, Brazil 4.365
Avenue, Manguinhos, 21.040-900 Rio de Janeiro, Brazil
- IINFACTS-Institute
of Research and Advanced Training in Health Sciences and Technologies,
Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, Central de Gandra Street, 1317, 4585-116 Gandra, Portugal
| | - André M. N. Silva
- LAQV, REQUIMTE, Department of Chemistry and Biochemistry,
Faculty of Sciences, University of Porto, Campo Alegre Street, 4169-007 Porto, Portugal
| | - Natália Guimarães de Figueiredo
- Laboratory of Tobacco and Derivatives, Analytical Chemistry
Division, National Institute of Technology, Venezuela Avenue, 82, Praça
Mauá, 20081-312 Rio de Janeiro, Brazil
| | - João F. Neves
- Department
of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry,
Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Stree
No. 228, 4050-313 Porto, Portugal
| | - Sara Manuela Cravo
- Department
of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry,
Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Stree
No. 228, 4050-313 Porto, Portugal
| | - Maria Rangel
- LAQV, REQUIMTE, Institute
of Science Abel Salazar, University of Porto, José Viterbo Ferreira Street
No. 228, 4050-313 Porto, Portugal
| | - Annibal Duarte Pereira Netto
- Department of Analytical
Chemistry, Chemistry Institute, Fluminense Federal University, Outeiro de São João Batista, Valonguinho Campus, Centro,
Niterói, 24020-150, Rio de
Janeiro, Brazil
| | - Félix Carvalho
- UCIBIO, REQUIMTE, Laboratory
of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Street No. 228 4050-313 Porto, Portugal
| | - Ricardo Jorge Dinis-Oliveira
- UCIBIO, REQUIMTE, Laboratory
of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Street No. 228 4050-313 Porto, Portugal
- Department of Public Health and Forensic Sciences, and Medical Education,
Faculty of Medicine, University of Porto, Prof. Hernâni Monteiro Alameda, 4200-319 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, Central de Gandra Street, 1317, 4585-116 Gandra, Portugal
| | - Carlos Manuel Afonso
- Department
of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry,
Faculty of Pharmacy, University of Porto, José Viterbo Ferreira Stree
No. 228, 4050-313 Porto, Portugal
- Interdisciplinary Center of Marine and Environmental Investigation (CIIMAR/CIMAR), General Norton de Matos Avenue, 4450-208 Matosinhos, Portugal
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22
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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] [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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23
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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] [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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24
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Desomorphine (Krokodil): An overview of its chemistry, pharmacology, metabolism, toxicology and analysis. Drug Alcohol Depend 2017; 173:59-68. [PMID: 28199917 DOI: 10.1016/j.drugalcdep.2016.12.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/09/2016] [Accepted: 12/13/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND "Krokodil" or "Crocodile" is an illegal homemade desomorphine drug obtained from chemical reactions of commercial codeine drugs with several other powerful and highly toxic chemical agents increasing its addiction and hallucinogenic effects when compared with other morphine analogues. METHODS This paper summarizes a complete review about an old drug called desomorphine (Krokodil), presenting its chemistry, pharmacology, metabolism, toxicology and analysis. RESULTS It is of particular interest and concern because this cheaper injectable semisynthetic opioid drug has been largely used in recent years for recreational purposes in several Eastern European as well as North and South American countries, despite known damage to health that continuous use might induce. These injuries are much stronger and more aggressive than morphine's, infecting and rotting skin and soft tissue to the bone of addicts at the point of injection in less than three years, which, in most cases, evolves to death. On this basis, it is imperative that literature reviews focus on the chemistry, pharmacology, toxicology and analysis of dangerous Krokodil to find strategies for rapid and effective determination to mitigate its adverse effects on addicts and prevent consumption. CONCLUSIONS It is crucial to know the symptoms and consequences of the use of Krokodil, as well as METHODS: for identification and quantification of desomorphine, contaminants and metabolites, which can help the forensic work of diagnosis and propose actions to control and eradicate this great danger to public health around the world.
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25
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Winborn J, Kerrigan S. Desomorphine Screening Using Commercial Enzyme-Linked Immunosorbent Assays. J Anal Toxicol 2017; 41:455-460. [DOI: 10.1093/jat/bkx024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/01/2017] [Indexed: 11/12/2022] Open
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26
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Pourmand A, Mazer-Amirshahi M, Chistov S, Li A, Park M. Designer drugs: Review and implications for emergency management. Hum Exp Toxicol 2017; 37:94-101. [PMID: 28764574 DOI: 10.1177/0960327117698542] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the past 10 years, "designer drugs" such as synthetic cannabinoids and cathinones have emerged and come into widespread use, resulting in more overdose cases involving these new drugs in the United States. Emergency departments regularly treat a diverse array of drug intoxications, and providers must be cognizant of novel drugs of abuse and the associated clinical presentations in order to provide the most appropriate care. This review aims to describe the epidemiology, mechanism of action, clinical presentation, and treatment of intoxication for both the common and newest drugs of abuse.
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Affiliation(s)
- A Pourmand
- 1 Emergency Medicine Department, George Washington University, Washington, DC, USA
| | - M Mazer-Amirshahi
- 2 Emergency Medicine Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - S Chistov
- 1 Emergency Medicine Department, George Washington University, Washington, DC, USA
| | - A Li
- 1 Emergency Medicine Department, George Washington University, Washington, DC, USA
| | - M Park
- 1 Emergency Medicine Department, George Washington University, Washington, DC, USA
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27
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Trace-Level Screening of Chemicals Related to Clandestine Desomorphine Production with Ambient Sampling, Portable Mass Spectrometry. J CHEM-NY 2017. [DOI: 10.1155/2017/8571928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Desomorphine is a semisynthetic opioid that is responsible for the psychoactive effects of a dangerous homemade injectable mixture that goes by street name “Krokodil.” Desorption electrospray ionization (DESI) and paper spray ionization (PSI) are implemented on a portable mass spectrometer for the direct analysis of desomorphine and precursor reagent codeine from multiple substrates of potential relevance to clandestine drug laboratory synthesis and paraphernalia seizure. Minimal sample preparation required for analysis and portability of the instrument suggest the potential for rapid, on-site analysis of evidence, a highly desired benefit for forensic science and law enforcement practitioners. Both DESI-MS and PSI-MS can generate spectra consistent with preceding data obtained using traditional ionization methods, while demonstrating detection limits in the low- to sub-ng levels.
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28
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Osteomyelitis of the ulna secondary to krokodil injection requiring extensive bony resection. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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30
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Haskin A, Kim N, Aguh C. A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user. JAAD Case Rep 2016; 2:174-6. [PMID: 27222881 PMCID: PMC4864092 DOI: 10.1016/j.jdcr.2016.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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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31
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Hearne E, Grund JPC, Van Hout MC, McVeigh J. A scoping review of home-produced heroin and amphetamine-type stimulant substitutes: implications for prevention, treatment, and policy. Harm Reduct J 2016; 13:14. [PMID: 27094257 PMCID: PMC4837500 DOI: 10.1186/s12954-016-0105-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 03/24/2016] [Indexed: 11/23/2022] Open
Abstract
Several home-produced substances such as krokodil and boltushka are prevalent in many Eastern European countries. Anecdotal reports of its use have been circulating in Germany and Norway; however, this has not been confirmed. Its use has also been reported by the media in the USA, although only one confirmed report of its use exists. Home-produced drugs are associated with high levels of morbidity and a number of complex health issues such as the spread of blood borne viruses, gangrene, and internal organ damage. The high incidence of HIV rates amongst people who inject home-produced substances is a public health concern. The resulting physical health consequences of injecting these crude substances are very severe in comparison to heroin or amphetamine acquired in black markets. Due to this fact and the increased mortality associated with these substances, professionals in the area of prevention, treatment, and policy development need to be cognisant of the presentation, harms, and the dangers associated with home-produced substances globally. This scoping review aimed to examine existing literature on the subject of home-produced heroin and amphetamine-type stimulant substitutes. The review discussed the many implications such research may have in the areas of policy and practice. Data were gathered through the use of qualitative secondary resources such as journal articles, reports, reviews, case studies, and media reports. The home production of these substances relies on the utilisation of precursor drugs such as less potent stimulants, tranquillizers, analgesics, and sedatives or natural plant ingredients. The Internet underpins the facilitation of this practice as recipes, and diverted pharmaceutical sales are available widely online, and currently, ease of access to the Internet is evident worldwide. This review highlights the necessity of prevention, education, and also harm reduction related to home-produced drugs and also recommends consistent monitoring of online drug fora, online drug marketplaces, and unregulated pharmacies.
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Affiliation(s)
- Evelyn Hearne
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland.
| | - Jean-Paul Cornelius Grund
- Department of Addictology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic.,CVO - Addiction Research Centre, Utrecht, The Netherlands.,Freudenthal Institute for Science and Mathematics Education, Utrecht University, Utrecht, The Netherlands
| | | | - Jim McVeigh
- Centre for Public Health, Liverpool John Moores University, Liverpool, UK
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32
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Otiashvili D, Tabatadze M, Balanchivadze N, Kirtadze I. Policing, massive street drug testing and poly-substance use chaos in Georgia - a policy case study. Subst Abuse Treat Prev Policy 2016; 11:4. [PMID: 26772817 PMCID: PMC4715284 DOI: 10.1186/s13011-016-0049-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 01/10/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since early 2000, intensive policing, wide scale street drug testing, and actions aimed at limiting the availability of specific drugs have been implemented in Georgia. Supporters of this approach argue that fear of drug testing and resulting punishment compels drug users to stop using and prevents youth from initiating drug use. It has been also stated that reduction in the availability of specific drugs should be seen as an indication of the overall success of counter-drug efforts. The aim of the current review is to describe the drug-related law enforcement response in Georgia and its impact on illicit drug consumption and drug-related harm. METHOD We reviewed relevant literature that included peer-reviewed scientific articles, stand-alone research reports, annual drug situation reports, technical reports and program data. This was also supplemented by the review of relevant legislation and judicial practices for the twelve year period between 2002 and 2014. RESULTS Every episode of reduced availability of any "traditional" injection drug was followed by the discovery/introduction of a new injection preparation. The pattern of drug consumption was normally driven by users' attempts to substitute their drug of choice through mixing together available alternative substances. Chaotic poly-substance use and extensive utilization of home-made injection drugs, prepared from toxic precursors, became common. Massive random street drug testing had little or no effect on the prevalence of problem drug use. CONCLUSIONS Intensive harassment of drug users and exclusive focus on reducing the availability of specific drugs did not result in reduction of the prevalence of injecting drug use. Repressive response of Georgian anti-drug authorities relied heavily on consumer sanctions, which led to shifts in drug users' behavior. In most cases, these shifts were associated with the introduction and use of new toxic preparations and subsequent harm to the physical and mental health of drug consumers.
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Affiliation(s)
- David Otiashvili
- Addiction Research Centre - Alternative Georgia, 14a Nutsubidze Str., Office 2, 0177, Tbilisi, Georgia.
| | - Mzia Tabatadze
- Addiction Research Centre - Alternative Georgia, 14a Nutsubidze Str., Office 2, 0177, Tbilisi, Georgia.
- Business School, Ilia State University, Tbilisi, Georgia.
| | | | - Irma Kirtadze
- Addiction Research Centre - Alternative Georgia, 14a Nutsubidze Str., Office 2, 0177, Tbilisi, Georgia.
- Business School, Ilia State University, Tbilisi, Georgia.
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Alves EA, Soares JX, Afonso CM, Grund JPC, Agonia AS, Cravo SM, Netto ADP, Carvalho F, Dinis-Oliveira RJ. The harmful chemistry behind “krokodil”: Street-like synthesis and product analysis. Forensic Sci Int 2015; 257:76-82. [PMID: 26282512 DOI: 10.1016/j.forsciint.2015.07.042] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/22/2015] [Accepted: 07/26/2015] [Indexed: 11/26/2022]
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Neves JF, Alves EA, Soares JX, Cravo SM, Silva AMS, Pereira Netto AD, Carvalho F, Dinis-Oliveira RJ, Afonso CM. Data analysis of "krokodil" samples obtained by street-like synthesis. Data Brief 2015; 6:83-8. [PMID: 26958624 PMCID: PMC4773373 DOI: 10.1016/j.dib.2015.11.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 11/09/2022] Open
Abstract
The data described in this work is related to be the subject of an article in the Forensic Science International, titled: “The harmful chemistry behind “krokodil”: street-like synthesis and product analysis” (http://dx.doi.org/10.1016/j.forsciint.2015.07.042) [1]. The data presented here provides additional description of the chemical profile of “krokodil”. Physicochemical and organoleptic characteristics, TLC profile, UV/Vis, 1H NMR and FTIR spectrum are presented. These data validate the proposed synthetic procedure and pathway and give further information about the contaminants present in “krokodil”.
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Affiliation(s)
- João Filipe Neves
- Department of Chemical Sciences, Laboratory of Organic and Pharmaceutical Chemistry, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Emanuele Amorim Alves
- UCIBIO-REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal; Department of Legal Medicine and Forensic Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; EPSJV - Polytechnic School of Health Joaquim Venâncio, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - José Xavier Soares
- LAQV-REQUIMTE, Department of Chemical Sciences, Laboratory of Applied 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
| | - Artur M S Silva
- Department of Chemistry and QOPNA, University of Aveiro, Campus Universitário de Santiago, Aveiro, 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; Department of Legal Medicine and Forensic Sciences, Faculty of Medicine, 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
| | - Carlos Manuel 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
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