Reports of a “flesh-eating zombie drug” called krokodil, accompanied by lurid images first appeared in English during 2010. The drug serves as an excellent illustration of the havoc bad drug policies can wreak on communities.
Krokodil first emerged in provincial Russia during the early 2000s. It’s an illicit injectable drug, easily baked in home kitchens from codeine-containing medication, iodine, phosphorus, paint thinner, and lighter fuel.
Its active ingredient is intended to be desomorphine, a synthetic opiate, but most home-baked krokodil is impure. The impurities are what produce the horrific injuries characteristic of krokodil use, which include severe damage to skin and veins, leading to ulcers and gangrene.
Krokodil’s chemical instability and short high leads to binges of frequent injecting among users. This kind of use is regarded as a risk factor for blood-borne viruses such as HIV and hepatitis C. And, the stigma around drug use and strict drug laws in Russia mean krokodil users tend to avoid hospitals, exacerbating their injecting injuries.
A case of policy misadventure
The history of krokodil is a colourful case of health policy misadventure. To understand it, the drug needs to be examined in context.
Krokodil is just the latest home-baked illicit drug to affect Russia and surrounding countries. Moonshine vodka production had long been widespread. And across much of southern Russia, opium poppies have grown wild since time immemorial. These poppies were traditionally used in cooking and medicine. But after the USSR dissipated in 1991, they came increasingly to be used in home-made injectable drugs.
Alongside opiates, other injectable home-made drugs, such as the methamphetamine “vint” and the methcathinone “jeff”, have become increasingly popular.
Krokodil use increased dramatically from the mid-2000s; Russian seizures of the drug grew by 40 times from two kilograms in 2006 to 100 kilograms in 2011. By comparison, a mean of 2,922 kilograms of heroin was seized each year between 2006 and 2010.
Shortages of Afghan heroin and a police crackdown on dealers likely contributed to the rapid increases in krokodil use within Russia after 2010. The drug’s popularity was driven by the relative ease of legal access to codeine-containing medications compared to heroin. Indeed, the ease of access to cheap over-the-counter codeine-containing medications was perhaps the most important factor driving people towards krokodil use.
Access to codeine-containing medications in Russia was originally restricted. But pharmaceutical company lobbying in the early 2000s eased these restrictions, and the two-packets-per-customer guidance for pharmacists was routinely ignored at the point of purchase.
After 2006, concerns began to emerge about diversion of codeine-containing medications to krokodil from regional police and medical services. But Russian health bureaucrats didn’t respond. Russian media later suggested this lack of responsiveness may be attributable to inappropriately close links between the pharmaceutical company manufacturing popular codeine-containing medications, and the Russian federal health minister.
A little late
Understandably, Krokodil attracted considerable national media interest in Russia. At a national drug conference in 2011, then-president Dmitry Medvedev demonstrated the ease with which krokodil recipes could be found on the Internet.
Shortly thereafter, the first serious public debates about restricting access to codeine-containing medications started. Even then, health bureaucrats continued to resist change. One senior bureaucrat even suggested easy access to strong analgesics served as a legitimate policy response to managing demand for health services.
Finally, in June 2012 the Russian federal government restricted access to codeine-containing medications. Scientific and media reports suggest these bans slowed but didn’t stop their diversion to krokodil. And, of course, the bans didn’t stop injecting drug use.
Other injectable drugs such as methamphetamines and “bath salts” (cathinones) remain popular today, while Afghan heroin remains inaccessible.
Even though krokodil use has decreased, the problems facing Russian illicit drug policy remain. Krokodil was a Russian invention, but today, Russian decision makers associate both illicit drug use and the interventions to reduce injecting-related harms as unwelcome foreign ideas.
Senior addiction medicine specialists have publicly claimed “Western” health interventions, such as safe injecting advice, access to sterile equipment, and methadone increase drug use and rates of HIV infection.
And the story doesn’t end there. From 2011, reports of krokodil-related injection injuries began to appear in Western Europe and from late 2013, in the United States.
Nevertheless, the story of krokodil offers lessons for international decision makers about drug policy. It’s also a reminder of the need to find an appropriate balance between legitimate use of analgesics for pain control and diversion to recreational drug use.