Editors’ choice
Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia

https://doi.org/10.1016/j.drugpo.2013.04.007Get rights and content

Abstract

Background

Krokodil, a homemade injectable opioid, gained its moniker from the excessive harms associated with its use, such as ulcerations, amputations and discolored scale-like skin. While a relatively new phenomenon, krokodil use is prevalent in Russia and the Ukraine, with at least 100,000 and around 20,000 people respectively estimated to have injected the drug in 2011. In this paper we review the existing information on the production and use of krokodil, within the context of the region's recent social history.

Methods

We searched PubMed, Google Advanced Search, Google Scholar, YouTube and the media search engine www.Mool.com for peer reviewed or media reports, grey literature and video reports. Survey data from HIV prevention and treatment NGOs was consulted, as well as regional experts and NGO representatives.

Findings

Krokodil production emerged in an atypical homemade drug production and injecting risk environment that predates the fall of communism. Made from codeine, the active ingredient is reportedly desomorphine, but – given the rudimentary ‘laboratory’ conditions – the solution injected may include various opioid alkaloids as well as high concentrations of processing chemicals, responsible for the localized and systemic injuries reported here. Links between health care and law enforcement, stigma and maltreatment by medical providers are likely to thwart users seeking timely medical help.

Conclusion

A comprehensive response to the emergence of krokodil and associated harms should focus both on the substance itself and its rudimentary production methods, as well as on its micro and macro risk environments – that of the on-going syndemic of drug injecting, HIV, HCV, TB and STIs in the region and the recent upheaval in local and international heroin supply. The feasibility of harm reduction strategies for people who inject krokodil may depend more on political will than on the practical implementation of interventions. The legal status of opioid substitution treatment in Russia is a point in case.

Section snippets

Introduction: the wheel of history

Russia, Ukraine and all other former Soviet countries share a long history of injection of home produced opioid and stimulant drugs that dates back to before the demise of the Soviet Union. Researchers have documented a lively and regionally varied pattern of small scale production and injection of home-made heroin (called Cheornaya in Russia and Himiya in Ukraine), methamphetamine (Vint) and methcathinone (Jeff) (e.g. Booth et al., 2008, Grund, 2002, Heimer et al., 2007a, Platt et al., 2008).

Methods

Our research strategy comprised: 1. Literature searches (search terms “krokodil,” “crocodile”, “desomorphine”,“desoxymorphine”) of PubMed, Google Scholar, Google, and the media search engine Mool.com (krokodil, desomorphine) for grey, media and academic literature pertaining to krokodil use, production and effects; 2. Consultations with relevant researchers and NGO representatives in the region to ascertain a variety of perspectives and gain access to grey and unpublished literature; 3. A video

Krokodil production

In considering the drug krokodil, two aspects are of importance, its pharmacology and its chemistry. The short half-life, limited high after the impact effect and, in particular the need for frequent administration may narrow the attention of users on the (circular) process of acquiring, preparing and administering the drug, leaving little time for matters other than avoiding withdrawal and chasing high, as reported in several popular magazines (e.g. Shuster, 2011, Walker, 2011). However, when

Discussion

A number of factors appear to have precipitated and exacerbated the use of krokodil in Russia and the Ukraine. These include changes to heroin availability, purity and price due to heroin ‘droughts’ and increased police interdiction; legislative changes targeting poppy straw and rising poverty levels in Russia since the start of the 2008 global economic crisis (Rapoza, 2012). In 2010 the total opium production in Afghanistan (the source of most of the heroin used in the Eurasian region) was 48%

Conclusion

As detailed, krokodil use is situated within a multifaceted high risk environment. This environment is comprised of a multitude of macro and micro risk factors, such as the poor chemical synthesis of the drug itself and the resulting contaminants in the drug solution injected; the home-based production environment; drug manufacture and distribution practices; the frequency of production and injection; the poverty, social marginalization and stigma experienced by many PWID; rising heroin prices;

Acknowledgements

We thank Dasha Ocheret (Eurasian Harm Reduction Network, Vilnius); Anya Sarang (Andrey Rylkov Foundation, Moscow, Russia); Natalia Dvinskykh, Liudmyla Shulga, Inna Shvab & Oksana Matiyash (ICF “International HIV/AIDS Alliance in Ukraine,” Kiev, Ukraine); David Otiashvili (Alternative Georgia, Tbilisi, Georgia); and Jana Javakhishvili (Global Initiative on Psychiatry, Tbilisi, Georgia) for their input, valuable comments and providing data on the extent and geographic spread of krokodil use in

References (91)

  • M. Akhmedova

    Snap goes the crocodile. openDemocracy

    (2012)
  • P. Alcabes et al.

    Needle and syringe exchange in Poland and the former Soviet Union: A new approach to community-impact studies

    Journal of Drug Issues

    (1999)
  • F. Altice et al.

    Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users

    Journal of Urban Health

    (2003)
  • Andrey Rylkov Foundation

    Drug scene in Russia–2010. Results of the internet survey on the heroin situation in Russia in 2010

    (2011)
  • M.D. Anglin et al.

    History of the methamphetamine problem

    Journal of Psychoactive Drugs

    (2000)
  • A.V. Asaeva et al.

    Russia: New trends in drug use lead to severe health consequences and death among IDUs

  • O.M. Balakireva et al.

    Risk and protective factors in the initiation of injecting drug use: Report of a respondent driven sampling study & strategy paper on preventing the initiation of injecting drug use among vulnerable adolescents and young people

    (2006)
  • O.M. Balakireva et al.

    Analytical report: Behaviour monitoring and HIV prevalence among injecting drug users as a component of second generation sentinel surveillance (Results of the 2011 bio-behavioural survey)

    (2012)
  • K. Beardsley et al.

    Policy analysis and advocacy decision model for services for people who inject drugs

    (2012)
  • R.E. Booth et al.

    Drug injectors and dealers in Odessa, Ukraine

    Journal of Psychoactive Drugs

    (2003)
  • R.E. Booth et al.

    Stimulant injectors in Ukraine: The next wave of the epidemic?

    AIDS and Behaviour

    (2008)
  • R.E. Booth et al.

    Predictors of self-reported HIV infection among drug injectors in Ukraine

    Journal of Acquired Immune Deficiency Syndromes

    (2004)
  • P. Bourgois et al.

    Righteous dopefiend

    (2009)
  • R. Broadhead et al.

    Harnessing peer networks as an instrument for AIDS prevention: Results from a peer-driven intervention

    Public Health Reports

    (1998)
  • M.C. Clatts et al.

    HIV-1 transmission in injection paraphernalia: Heating drug solutions may inactivate HIV-1

    Journal of Acquired Immune Deficiency Syndromes

    (1999)
  • R. de Bie et al.

    Manganese-induce Parkinsonism associated with methcathinone (ephedrine) abuse

    Archives of Neurology

    (2007)
  • K.L. Dehne et al.

    The HIV/AIDS epidemic among drug injectors in Eastern Europe: Patterns, trends and determinants

    Journal of Drug Issues

    (1999)
  • Der Spiegel

    Todesdroge Krokodil erreicht Deutschland. Der Spiegel Online

    (2011)
  • D.C. Des Jarlais et al.

    Doing harm reduction better: Syringe exchange in the United States

    Addiction

    (2009)
  • K.V. Dumchev et al.

    HIV and hepatitis C virus infections among hanka injection drug users in central Ukraine: A cross-sectional survey

    Harm Reduction Journal

    (2009)
  • N.B. Eddy et al.

    Studies of morphine, codeine and their derivatives X. Desoxymorphine-C, desoxycodeine-C and their hydrogenated derivatives

    Journal of Pharmacology and Experimental Therapeutics

    (1935)
  • R. Elovich et al.

    On drug treatment and social control: Russian narcology's great leap backwards

    Harm Reduction Journal

    (2008)
  • M. Gahr et al.

    “Crocodile”: A new drug?

    Nervenheilkunde

    (2012)
  • M. Gahr et al.

    Desomorphine goes “crocodile”

    Journal of Addictive Diseases

    (2012)
  • M. Gahr et al.

    “Krokodil”: Revival of an old drug with new problems

    Substance Use and Misuse

    (2012)
  • J.K. Galbraith

    The affluent society

    (1958)
  • L.E. Grau et al.

    Expanding harm reduction services through a wound and abscess clinic

    American Journal of Public Health

    (2002)
  • J.-P.C. Grund

    A candle lit from both sides: The epidemic of HIV infection in Central and Eastern Europe

  • J.-P.C. Grund

    The eye of the needle: An ethno-epidemiological analysis of injecting drug use

  • J.-P.C. Grund et al.

    Drug sharing and HIV transmission risks: The practice of “frontloading” in the Dutch injecting drug user population

    Journal of Psychoactive Drugs

    (1991)
  • J.-P.C. Grund et al.

    Stimulant use in Central and Eastern Europe: How recent social history shaped current drug consumption patterns

  • R. Haemmig

    Krokodil” frisst Löcher in den Verstand. dgs-info Extra. 13th October 2011 – Bochum: Info über Desomorphin/Krokodil für Drogenkonsumenten. Deutsche Gesellschaft für Suchtmedizin e.V.

    (2011)
  • H. Hagan et al.

    Sharing of drug preparation equipment as a risk factor for hepatitis C

    American Journal of Public Health

    (2001)
  • M. Harris

    The ‘do-it-yourself’ New Zealand injecting scene: Implications for harm reduction

    The International Journal of Drug Policy

    (2013)
  • Cited by (81)

    • Soft Tissue, Bone, and Joint Infections in People Who Inject Drugs

      2020, Infectious Disease Clinics of North America
    • New Synthetic Opioids: Part of a new addiction landscape

      2019, Neuroscience and Biobehavioral Reviews
    • Osteonecrosis of the jaw unrelated to medication or radiotherapy

      2018, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
    View all citing articles on Scopus
    View full text