Written by Kevin Jennings
As advances in medical science are made, there are bound to be a few missteps, especially when it comes to prescription drugs. While drugs undergo a rigorous testing process, these tests remain limited in a few ways. First, long term effects are often unable to be determined as it is unlikely that a pharmaceutical company would be willing to endure decades of clinical trials per drug. Second, initial testing is mostly done under controlled settings.
The result of these limitations is that sometimes a drug slips through that should not have. Well over 100 medications have been withdrawn from use for causing problems such as addiction and withdrawal, organ failure, toxicity, or even death. One such drug was desomorphine, a semi-synthetic opioid that was first discovered in Germany in 1920, but not commercialized until the 1930s by a pharmaceutical company in Switzerland.
Desomorphine was designed as an alternative to morphine. It was more potent and faster acting, and was also was mostly free of the nausea associated with morphine. The only immediately apparent downside was that the pain relief did not last as long, so more doses would need to be administered.
At first it seemed like this could be a great replacement for morphine in medicinal pain relief, but it didn’t take long for the serious side effects to kick in. Negative side effects such as low blood pressure, urinary retention, and severe breathing problems were occurring at an extremely high rate. The medication had only made it as far as Switzerland and Russia before being shelved completely in 1981. Commercially manufactured desomorphine way have gone away, but unfortunately the existence of the chemical compound was already known.
Origins of Krokodil
Russia’s illicit opioid scene was largely dominated by heroin imported from Afghanistan. There was a severe drop in the amount of heroin being exported to Russia between 2002 and 2003, likely related to the United States invasion of Afghanistan. With the decrease of actual heroin on the streets, the Russian drug users began turning to homemade options for their opioid usage instead.
The first reports of homemade desomorphine came out of Siberia in 2002, where the homemade version had acquired the colourful name of krokodil. The most widely accepted origin for this name comes from the effects seen at the injection site of the drug. The injection size is often covered in sores, gangrene, and necrosis that take on the visual appearance of a crocodile’s scales. The necrosis can become so severe that the skin and flesh will fall off revealing exposed bone, which gives krokodil its other nickname: the flesh eating drug. These symptoms sound nothing like that of the medicinal grade desomorphine, which was already dangerous enough, but it is the homemade nature of krokodil that makes it much more deadly than the purer, medicinal version.
While most countries required a prescription for medications containing codeine, in Russia codeine was available over the counter until 2012 when it was made prescription only in response to the high usage of krokodil among its citizens. These codeine tablets were the key ingredient in manufacturing homemade desomorphine, which was incredible cheap and easy to do. It was so easy that the process could be done in under an hour.
The other ingredients used in the manufacturing of krokodil were also cheap and readily available. Ingredients like paint thinner, gasoline, iodine, and red phosphorous from match tips were used to perform the chemical reactions. Not only do these reactants contain dangerous and toxic impurities, but the byproducts of the chemical reactions do as well. It also caused krokodil to have a pH of 3, something roughly as acidic as orange juice or vinegar. Drinking orange juice is obvious fine as your stomach is well equipped to deal with acid, but injecting something of the pH into your body completely unfiltered is much more dangerous.
Removing all of the impurities from the resulting solution would take time and thus increase prices, and most people manufacturing krokodil were unlikely to have the knowledge or skills required to do so anyway. They were aware of the issues with the substances pH, so to try to decrease the acidity they would often add things like cigarette ash or bicarbonate salt to the formula. While those are both alkaline, neither is strong enough to raise the pH above 3 so the manufacturers were just needlessly adding more impurities into the formula. With how quickly the effects of krokodil wear off, many addicts also take to cooking it themselves because of how easy the process is. Given the increased sense of urgency in a person trying to avoid withdrawal, taking time to remove toxic impurities becomes even less of a priority.
Studies of krokodil samples purchased on the streets of Russia showed that, at best, they were only 75% desomorphine with some samples containing only trace amounts of the synthetic drug. The other 25% or more that the users were injecting themselves with was nothing but a cocktail of various toxins with severe effects on the body.
These effects were not limited to just the injection site, either. Not only could the obvious effects to the skin occur on parts of the body far away from the injection, but krokodil can also cause damage to the entire system of blood vessels, muscle damage, bone damage, and multiple organ failure.
Two Years to Live
All opioids are obviously dangerous and lead to dramatically shortened life spans, but the average life span of a person after taking their first dose of krokodil is only two years. There are a number of factors contributing to this beyond just the toxic impurities from shoddy manufacturing.
The overwhelming majority of krokodil addicts in Russia identified themselves as having been former heroin addicts. When the supply of Afghan heroin dried up, prices for genuine heroin increased dramatically while krokodil was available for dramatically cheaper. This made it an extremely attractive alternative for addicts trying to avoid becoming dope sick. A big problem with this is both the increased potency and shorter lasting effects of krokodil.
Addicts tend to know their dosage pretty well. When introduced to a replacement drug like krokodil, they would be inclined to start with their normal dose, despite the fact that krokodil is 4-5 times more potent than heroin. It’s similar to what is causing so many deaths from fentanyl, which is up to 50 times more potent than heroin, although in the case of fentanyl the problem is made even worse as many users aren’t even aware that’s the drug they have been given instead of heroin.
Though krokodil users seem to be aware of what they’re taking, they may not be aware of the increased potency. Even if they are, the shorter duration means they will need to take krokodil more often to avoid withdrawal. Higher potency plus more frequent injections is a guaranteed recipe for an increase in levels of addiction. And when the addiction is to a substance that is at least 25% paint thinner and gasoline, it’s also a guaranteed recipe for death.
The high levels of iodine can cause thyroid disorders. The heavy metals cause damage to the central nervous system and can impede speech and motor skills. The contaminated red phosphorous can cause damage to cartilage and bones. And of course, there’s the necrosis where the drug was injected.
What makes this particularly deadly is that those in active addiction are often hesitant to seek medical attention until things are extremely serious. In the case of krokodil, by the time things are serious it is usually already in the late stages of tissue damage and will almost certainly end with severe mutilation, amputation, or even death.
Spread of the Drug
As we stated earlier, production of krokodil began in Russia in response to a shortage of heroin and because of the easy availability of over the counter codeine. In the 20 years since its production began, it fortunately hasn’t spread too far. The majority of krokodil users are in Russia and Ukraine, though it has been making its way west across Europe. Countries like Kazakhstan, the Czech Republic, Germany, Georgia, and France have reported the use of krokodil and the associated injuries that result.
To date there have not been any confirmed cases of krokodil use making it to North America. There are several reports of people admitted to the hospital who claimed to have been using krokodil, but their injuries have been more consistent with heroin use so it is unknown whether or not the deadly drug has made landfall in North America yet.
Worldwide it is estimated that there are between 100,000 and 200,000 krokodil users. One of the biggest hurdles to eliminating its use entirely is that Russia, the main source of krokodil, has banned opioid substitution treatment. Though harm reduction approaches may not be a perfect solution, and they remain controversial in many parts of the world, the extremely addictive and deadly nature of krokodil is going to require attention sooner rather than later.