From the Experts
 DOI: 10.1176/appi.pn.2013.3a23
Krokodil: ‘Zombie Drug’ Scare Hits U.S.
Psychiatric News
Volume 49 Number 5 page 1

Krokodil, the so called “flesh-eating zombie drug,” is the newest addictive drug to reportedly hit the United States. Scary photographs showing deep wounds on people’s extremities abound on the Internet. Television news programs have given us a number of interviews with emergency room physicians who have alerted the public on the dangers of this latest drug menace. How much of this is true, and how much is simply hype?

Krokodil (Russian: крокодил, crocodile) takes its name either from the green scale-like appearance of the skin of its users or from its derivation from alpha-chlorocodide, an intermediate compound during its production from codeine. It was initially reported in Russia in 2003, and its current prevalence is estimated to be around 5 percent to 7 percent among people who inject drugs in Russia and Ukraine. Since Russia banned over-the-counter sale of codeine-containing tablets starting on June 1, 2012, Krokodil use has reportedly been declining.

Krokodil is a mixture of several substances with the primary opioid component being desomorphine and is highly impure due to contamination with multiple toxic ingredients used during its production. Desomorphine (dihydrodesoxymorphine) was first developed in the United States in 1932 and is as much as 10 times more potent than morphine. It was marketed in Switzerland until 1952, under the trade name Permonid, as a postoperative analgesic. Interestingly, its production continued until 1981 for analgesic needs of a single patient with a rare disorder. Desomorphine has a rapid onset of action and shorter elimination half-life, accounting for its increased addictive potential and leading krokodil users to perform more applications as compared with heroin users. krokodil can be conveniently produced from codeine-containing tablets, iodine, and red phosphorous (phosphate source is usually obtained from striking pads of matchboxes), with paint thinner or gasoline (organic solvent) and hydrochloric acid. The inferior chemistry involved in its production results in serious injuries such as thrombophlebitis, skin and soft tissue infections, tissue necrosis, and gangrene. Krokodil-addicted patients die within an estimated two years of addiction.

In September 2013, reports from Phoenix claimed that local hospitals treated two people for “symptoms consistent with Krokodil use,” following which USA Today reported that “Flesh-rotting ‘Krokodil’ Drug Emerges in USA” (http://www.usatoday.com/story/news/nation/2013/09/26/heroin-krokodil-flesh-rotting-arrives-us-arizona/2879817/). Since then, Time magazine has published more than 10 articles on both suspected and reportedly confirmed reports of Krokodil use in the United States. The most recent one, by Simon Shuster published on December 9, 2013, and titled “Krokodil Tears” (http://content.time.com/time/magazine/article/0,9171,2158683,00.html), discusses its origin in Russia and spread across Europe and the United States. CNN, not far behind, also has published several stories about suspected cases of Krokodil use in Illinois, calling it the “flesh-eating zombie drug” (http://www.cnn.com/2013/10/16/health/krokodil-zombie-drug/).

So, how much of all this is true? In January, Joseph Moses, a spokesperson for the Drug Enforcement Administration, emphatically declared that there has not been a single toxicology report confirming desomorphine in reported cases, and it has not shown up in drug samples reported to be Krokodil. Jacob Sullum, a Forbes contributor, added to the discussion in an article published in Forbes on January 10 (http://www.forbes.com/sites/jacobsullum/2014/01/10/krokodil-crock-how-rumors-of-a-flesh-eating-zombie-drug-swept-the-nation/) titled “Krokodil Crock: How Rumors of a ‘Flesh-Eating Zombie Drug’ Swept the Nation.” Sullum argued that the reason for the popularity of Krokodil in Russia and Eastern Europe has been the high price of heroin and low price of codeine. On the contrary, in the United States heroin can be much more easily obtained. Also, with much stricter prescription laws in this country, codeine-containing tablets are harder to obtain.

Krokodil use may not have reached our soil (yet), but the Krokodil hype has certainly taken this country by storm. In today’s information frenzy, a drug like Krokodil that captures the public’s imagination—and fear—can be perceived as far more prevalent than it really is. In contrast, drugs of abuse that fail to feed the media’s and the Internet’s sweet tooth for sensational images, such as prescription pills, continue to go largely unnoticed. In 2014, we are lucky to be able to readily access news from any part of the world within moments of its being reported. At the same time, we are quite vulnerable to the false positives of what has become the social equivalent of a polymerase chain reaction. If our primary source of information comes from Google.com (and we bet you are just about to Google Krokodil, if you haven’t already done so), then we shouldn’t be all that surprised when the resulting data turn out to be considerably more sensitive than specific. ■

Vishesh Agarwal, M.D., is a third-year resident at Einstein Medical Center in Philadelphia. Petros Levounis, M.D., M.A., is chair of the Department of Psychiatry at Rutgers New Jersey Medical School in Newark, N.J. He is the coeditor of The Addiction Casebook from American Psychiatric Publishing. APA members can buy the book at a discount at http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=62458.

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