Crocodile Drug: A Clinician’s Guide to Krokodil (Desomorphine), How It Is Made, the Devastating Skin and Tissue Damage, Why It Emerged in Russia, and the Treatment of Krokodil Addiction

What the crocodile drug is, how desomorphine is produced from codeine in clandestine kitchens, why it produces the catastrophic skin damage that gave the drug its name, the history of the Russian krokodil epidemic and its spread to other countries, the medical complications of injection use, and what treatment and recovery look like for the survivors.

Clinically reviewed by Dr. Ponlawat Pitsuwan, Physician and Addiction Medicine Specialist, Phuket Island Rehab.

The crocodile drug, known as krokodil in Russian and Ukrainian, is an illicit form of desomorphine, a synthetic opioid first patented in 1932 that is approximately 10 times more potent than morphine. The street drug is produced in clandestine kitchens by combining codeine-containing tablets with red phosphorus from match strikers, iodine, hydrochloric acid, and gasoline or paint thinner; the synthesis produces desomorphine plus a toxic mix of unreacted starting materials and reaction byproducts that are injected without purification. The injection produces the characteristic dark green or black, scaly, reptilian skin damage at and around the injection sites that gave the drug its name, with deep necrotic wounds that often expose underlying muscle, tendon, and bone. The crocodile drug emerged in Russia and Ukraine in the early 2000s when codeine was available over the counter and heroin was expensive; the epidemic peaked around 2010-2012 with millions of users in the affected countries. Use spread to other countries including Germany, the United States, Belgium, and the United Kingdom in smaller numbers. Mortality is extremely high: most users die within 2 to 3 years of starting injection, from sepsis, multi-organ failure, gangrene, or overdose. Recovery is medically and surgically complex, requiring inpatient detoxification, treatment of the wound complications, addiction medicine care, and often reconstruction of the destroyed tissue.

What the crocodile drug actually is and where the name comes from

The crocodile drug is the street name for an illicit form of desomorphine, a semi-synthetic opioid first patented by the German pharmaceutical company Roche in 1932 as an analgesic. Desomorphine is approximately 10 times more potent than morphine on a milligram basis and has a faster onset and shorter duration of action. The pharmaceutical product was used briefly in Europe and Russia in the 1930s and 1940s under names including Permonid before being largely abandoned because of its high abuse potential and the availability of safer alternatives. Desomorphine remained known in the pharmacological literature but was not a commercially significant medication for the second half of the twentieth century.

The drug re-emerged in clandestine production in Russia and Ukraine in the early 2000s under the street name krokodil, which translates as crocodile and which refers to the characteristic dark green or black, scaly, reptilian skin damage that appears at and around the injection sites. The damage gives the appearance of crocodile skin or scales, and the metaphor stuck in Russian street drug-using communities and then in international press coverage of the epidemic. The Russian word krokodil is now used in the medical literature as the standard term for this specific clinical syndrome regardless of the local language.

The street drug is not pure desomorphine. The synthesis used in clandestine kitchens produces desomorphine plus a toxic mixture of reaction intermediates, unreacted starting materials, and contamination from the crude production methods. The principal toxic components include red phosphorus from match strikers, iodine, hydrochloric acid, gasoline or paint thinner used as solvents, and various organic byproducts of the chemistry. The crude product is typically a brownish liquid that is filtered minimally if at all before injection. The skin damage and the systemic toxicity that characterise krokodil use are produced as much by the toxic contaminants as by the desomorphine itself.

Pure pharmaceutical desomorphine, if it were available, would produce typical opioid effects: analgesia, euphoria, sedation, respiratory depression at high doses, and addiction potential similar to other strong opioids. The pure compound would not produce the characteristic crocodile skin damage and would not produce the rapid tissue destruction that has made krokodil one of the most lethal drugs of abuse documented in modern history. The catastrophic harms of krokodil are a consequence of the production method as much as of the underlying drug. This distinguishes krokodil from other illicit drugs, where the synthesised compound itself is the primary cause of harm.

How krokodil is produced and why it is so toxic

The synthesis of krokodil in clandestine kitchens involves taking codeine-containing tablets, typically over-the-counter codeine analgesics or codeine-containing cold medications, dissolving them in hydrochloric acid, and reducing the codeine to desomorphine using red phosphorus (extracted from the striker strips on matchboxes) and iodine. The reaction is conducted with crude equipment in the user’s own kitchen, with no temperature control, no purity assessment, and no purification of the final product. The reaction takes 30 to 60 minutes and produces a brown liquid that is typically drawn into a syringe and injected within minutes of completion.

The chemistry of the synthesis is reasonable in pharmaceutical terms: codeine differs from desomorphine by an oxygen at position 14 and a methyl group at the 3-OH position, and red phosphorus with iodine can in principle perform the dehydroxylation and demethylation that converts codeine to desomorphine. The yield in clandestine production is typically 20 to 40 percent, with the remaining starting material and partial reaction products contributing to the toxicity. The phosphorus and iodine are present in the final product in concentrations that produce severe local tissue damage when injected, particularly at and near the injection site where the concentrated material first contacts living tissue.

The toxic contaminants in krokodil include trace amounts of red phosphorus that produce direct tissue corrosion and chemical burns at the injection site, residual hydrochloric acid that produces additional chemical burns, iodine that produces both local and systemic toxicity, gasoline or paint thinner that produces solvent toxicity to local tissue and to the liver and kidneys when systemically absorbed, and various organic byproducts of the chemistry whose specific identities have not been fully characterised. The total contamination load in injected krokodil is substantial and is responsible for the catastrophic skin and tissue effects that define the syndrome.

Different production batches vary substantially in their contamination profile, which is part of why the clinical presentation of krokodil users varies somewhat between countries and even between users of different suppliers within the same city. Production methods became more refined in some regions as the epidemic developed, with some producers attempting to filter or purify the product to extend the user’s life and the user’s relationship with the supplier. The Russian and Ukrainian street market saw both more crudely produced and slightly cleaner versions of the drug, with the cleaner versions still producing severe damage but with somewhat slower progression.

The skin and tissue damage that gives the drug its name

The characteristic skin damage of krokodil use begins at the injection site and spreads outward over days to weeks. The initial injection produces a localised area of acute inflammation, with redness, swelling, pain, and induration. Within 24 to 72 hours, the skin in the affected area begins to develop a dark green, black, or grey discolouration with a scaly or rough texture. The discolouration is initially superficial but extends progressively deeper into the underlying tissue. The skin pattern resembles crocodile or reptile scales, which is the origin of the street name.

Over the subsequent weeks, the affected tissue undergoes necrosis (cell death) and ulceration. The dead tissue separates from healthy tissue and forms deep ulcers that often extend through the subcutaneous fat to expose underlying muscle, tendon, and in severe cases bone. The wounds do not heal because the user typically continues to inject at or near the same sites, the contaminated injectate continues to add tissue damage with each use, and the underlying tissue is no longer viable. Many active krokodil users have multiple ongoing ulcerations over their arms, legs, abdomen, and face, in various stages of progression.

The mechanisms of the tissue damage are several. Direct chemical injury from the phosphorus, iodine, hydrochloric acid, and solvents in the injectate produces immediate cell death at the injection site. Vascular injury, including thrombosis of the small vessels in the area, produces ischaemic necrosis of the tissue downstream from the injection. Infection with skin and soft tissue pathogens including staphylococcus aureus, streptococcus, and gram-negative bacteria adds to the tissue destruction. Repeated injection at the same site prevents healing and propagates the damage outward.

Severe cases progress to gangrene of the affected limb. The dead tissue extends to involve the underlying muscle, tendon, and bone, and the limb becomes nonviable. Surgical amputation is sometimes the only intervention that can stop the progression, and many surviving krokodil users have lost arms, legs, fingers, or toes to the disease. Compartment syndrome, deep vein thrombosis, septic arthritis, and osteomyelitis (bone infection) are common complications. The wounds are often colonised with multiple bacterial species and are difficult to treat even with aggressive surgical debridement and antibiotic therapy.

The Russian and Ukrainian krokodil epidemic

The krokodil epidemic emerged in Russia and Ukraine in the early 2000s and reached its peak around 2010-2012, when an estimated 100,000 to 1 million users were affected across the two countries. The Russian Federal Drug Control Service estimated 250,000 to 1 million users at peak, with the higher estimate widely cited in international press coverage. The Ukrainian situation was similar in proportional terms. The epidemic was driven by several converging factors: the availability of codeine in over-the-counter analgesics and cold medications, the high price and limited supply of heroin, the existing population of injection drug users who substituted krokodil when heroin became unavailable or unaffordable, and the relatively simple synthesis that could be performed in any kitchen.

The Russian government responded to the epidemic with several measures. In 2012 the federal authorities required prescriptions for all codeine-containing medications, which had previously been available over the counter. The schedule change substantially reduced the availability of starting material for krokodil synthesis and is credited with reducing the epidemic over the following years. Law enforcement also targeted clandestine production sites, and treatment programs received some additional funding. The Russian harm reduction and addiction treatment infrastructure remained limited compared to Western European countries, however, and many active users had no access to medical or addiction services.

The Ukrainian situation followed a similar trajectory. The 2014 conflict in eastern Ukraine and the broader political and economic disruption complicated public health responses. International humanitarian organisations including Doctors Without Borders documented krokodil use in conflict-affected areas and provided some treatment services. The Ukrainian addiction treatment system, like the Russian one, was overwhelmed by the scale of the epidemic and could not provide adequate care to most users.

Mortality during the peak epidemic period was extraordinary. Most active krokodil users died within 2 to 3 years of starting injection, with causes of death including sepsis from infected wounds, multi-organ failure, gangrene with subsequent overwhelming infection, accidental overdose, and the medical consequences of multiple amputations in patients without adequate medical care. The mortality rate among diagnosed krokodil users was approximately 30 to 50 percent per year during the peak period, compared to roughly 2 percent per year for heroin users in similar settings.

International spread and current status

Krokodil use spread from Russia and Ukraine to other countries during and after the peak epidemic period. Case reports of krokodil use appeared in Germany, the Czech Republic, Belgium, France, the United Kingdom, and the United States. The case reports from Western countries were often associated with Russian or Ukrainian immigrant communities or with travellers returning from the affected countries. The numbers in Western countries remained small compared to the Russian epidemic, but the case reports documented the same clinical syndrome and the same catastrophic outcomes.

U.S. case reports include several documented cases in Arizona, Illinois, Oklahoma, Pennsylvania, and other states, mostly in the period 2013 to 2015. Some of the reported U.S. cases were later questioned by addiction medicine specialists who noted that the wound patterns could be produced by other necrotising soft tissue infections in injection drug users, particularly those using xylazine-contaminated heroin or fentanyl. The distinction between true krokodil (desomorphine produced from codeine) and similar-appearing wounds from other injection drug contamination requires laboratory confirmation of the specific compound, which was not always available in the U.S. case reports.

Current krokodil prevalence is substantially lower than during the peak epidemic. The Russian schedule change reduced production substantially, the surviving users either died or entered treatment, and the population of new users did not grow at the rates seen in 2008-2012. International monitoring including the European Monitoring Centre for Drugs and Drug Addiction has tracked declining case reports across Europe since 2014. The xylazine-fentanyl combination now circulating in North America produces similar-appearing wounds in some cases, though the underlying pharmacology and the production process are different from krokodil.

The legacy of the krokodil epidemic includes thousands of surviving users with permanent disabilities including limb amputations, chronic wounds requiring ongoing surgical and medical management, complex post-traumatic stress responses to the experience of the addiction, and the social marginalisation that comes from visible scarring and disability. The treatment infrastructure in the affected countries has gradually built capacity to support these patients, though resources remain limited and many surviving users continue to struggle with both the medical consequences of their use and with substance use disorder generally.

Medical complications beyond the skin

Krokodil use produces medical complications throughout the body, not just at the injection sites. Sepsis from infected wounds is the most common immediate cause of death and presents with fever, hypotension, altered mental status, and multi-organ failure. The wound bacteria spread to the bloodstream and produce systemic infection that overwhelms the immune system, particularly in users who are malnourished and have compromised immunity from their drug-using lifestyle. Sepsis treatment requires intravenous antibiotics, source control of the infected wounds, and intensive care support; mortality rates from krokodil-associated sepsis are very high.

Hepatic toxicity from the phosphorus, iodine, and solvent contaminants in krokodil is universal among regular users and progresses to clinical liver failure in many cases. The liver dysfunction is independent of the hepatitis C infection that most injection drug users acquire and adds to the overall mortality risk. Renal failure from the same contaminants and from rhabdomyolysis associated with the muscle damage is also common. Many active users have detectable elevations in liver and kidney function tests on routine blood work, and a meaningful proportion progress to clinical hepatic or renal failure.

Cardiovascular complications include the bacterial endocarditis that affects all injection drug users at elevated rates and the specific cardiac toxicity associated with phosphorus and iodine exposure. Pulmonary complications include pulmonary embolism from the cellulose fillers in the injected tablets, septic emboli from infected wounds spreading to the lungs, and the chemical pneumonitis associated with inhaled solvent fumes during the synthesis process. Many regular users have detectable pulmonary infiltrates on chest imaging even in the absence of acute respiratory symptoms.

Neurological complications include the cognitive impairment associated with chronic opioid use plus the additional neurotoxicity from the contaminants. Phosphorus exposure can produce specific neurological effects including peripheral neuropathy and central nervous system effects, and the cumulative exposure in regular users contributes to the severe cognitive and functional impairment that characterises advanced krokodil addiction. Many survivors have permanent neurological deficits that limit their capacity for recovery and reintegration even after their substance use has stopped.

Why people use the crocodile drug despite the obvious harm

Understanding why people continue using krokodil despite the visible catastrophic harm requires understanding the social and economic context of the epidemic. The Russian and Ukrainian krokodil users were not generally choosing krokodil over a safer alternative; they were choosing between using krokodil or using nothing in a context where heroin was unavailable or unaffordable and where established opioid dependence required continued use to prevent withdrawal. The drug was substantially cheaper than heroin and could be produced from readily available starting materials, which made it the rational choice in the local market despite its devastating effects.

The opioid dependence that drove krokodil use was real and physiologically demanding. People who were dependent on heroin and lost access to the supply faced opioid withdrawal that includes severe physical pain, gastrointestinal distress, anxiety, insomnia, and a felt sense of impending doom that drives the user back to opioids. Without medication-assisted treatment options (methadone and buprenorphine were and remain limited in availability in Russia and Ukraine), the user faced a binary choice between continuing to use opioids by any available means or experiencing severe withdrawal. The krokodil supply provided the available means, and the catastrophic effects emerged over weeks to months while the immediate withdrawal pressure was immediate.

The recovery options for opioid dependence in Russia and Ukraine were limited during the peak epidemic period. Methadone maintenance therapy is essentially unavailable in Russia (the federation has opposed the practice politically and methadone is not a registered medical treatment). Buprenorphine is available in limited quantities in some regions. Naltrexone is more widely available but is unsuitable for active users because it precipitates immediate withdrawal. The detox-only approach to opioid use disorder that Russia and many neighbouring countries used has very high relapse rates and contributed to the cycle of dependence and substitution that drove krokodil use.

The dangerous nature of the drug was apparent to most users from early in their use, but the addiction processes that maintain opioid use disorder are not responsive to logical arguments about long-term harm. Users described knowing that the drug would kill them within months to years but being unable to stop because the alternative was opioid withdrawal in the immediate term. The opioid dependence pattern is one of the strongest forms of substance use disorder, and the absence of effective treatment options in the affected countries meant that most users continued until they died or until the epidemic was reduced by other means.

Treatment of krokodil addiction and survival recovery

Treatment of active krokodil use is medically and logistically complex. The user typically presents with acute opioid intoxication, multiple infected wounds in various stages of progression, malnutrition and dehydration, often co-occurring sepsis or systemic infection, hepatic and renal dysfunction, and the wide range of medical complications described above. Initial treatment requires hospital admission, typically to a medical-surgical ward or intensive care unit depending on the severity. Opioid withdrawal is managed with buprenorphine or methadone where available, or with symptomatic treatment using clonidine, antiemetics, and adjunct medications where opioid agonist therapy is not available.

Surgical management of the wounds is essential and often extensive. The dead tissue must be debrided down to healthy tissue, which often means deep excision involving subcutaneous fat, muscle, and sometimes bone. Many patients require multiple debridement procedures, complex wound closure including skin grafts and flaps, and sometimes amputation of limbs that cannot be salvaged. The surgical care is provided by plastic surgeons, general surgeons, vascular surgeons, and orthopaedic surgeons working together, and the patient may spend weeks to months in the hospital for wound management alone.

Addiction medicine treatment runs in parallel with the medical and surgical care. Medication-assisted treatment with methadone or buprenorphine is the standard approach where available, and substantially improves outcomes compared to detox-only management. Behavioural therapies including cognitive behavioural therapy, motivational interviewing, and contingency management support the recovery work. Peer support and integration with community recovery resources are important for long-term success. The treatment of co-occurring mental health conditions (depression, anxiety, post-traumatic stress disorder) is part of integrated care.

Long-term recovery from krokodil involves ongoing medical care for the wound complications, prosthetic rehabilitation for amputees, treatment of chronic pain from the residual tissue damage, ongoing addiction medicine support, and gradual social reintegration. Many survivors have permanent disabilities and require disability support, vocational rehabilitation, and ongoing social services. The recovery journey is typically measured in years rather than weeks or months, and many survivors require lifetime support.

When opioid use and drinking have become more than occasional

For readers who have a family member or friend using injection opioids, or who are themselves using opioids in patterns that have become problematic, the krokodil story illustrates the extreme end of the harm that injection opioid use can produce. Most people with opioid use disorder do not use krokodil, but the trajectory toward severe medical consequences is similar across all forms of injection drug use: tolerance builds, doses escalate, the user’s life becomes organised around the drug, the available supply becomes increasingly dangerous, and medical complications accumulate. The moment to engage with treatment is now, regardless of where on the trajectory the person is.

Medication-assisted treatment with methadone or buprenorphine is the most important single intervention for opioid use disorder and is widely available in the United States, Canada, the United Kingdom, Australia, and most Western countries. The medications reduce overdose mortality by 50 percent or more compared to no treatment, dramatically reduce illicit opioid use, and support engagement with the broader work of recovery. Patients who are using injection opioids should be on medication-assisted treatment unless there is a specific clinical reason not to be.

Heavy drinking commonly coexists with opioid use disorder and amplifies the overdose risk because alcohol adds to the respiratory depression of opioids. The combination is one of the leading patterns in fatal overdose. Honest disclosure of all substance use to the treatment team is essential to safe planning. Phuket Island Rehab provides residential addiction medicine treatment for opioid use disorder, alcohol use disorder, and polysubstance use cases, with integrated medical and mental health care.

Alcohol use disorder, the clinical term for problematic alcohol use, is defined by the DSM-5 criteria including drinking more than intended, unsuccessful efforts to cut down, craving, tolerance, withdrawal, and continued use despite consequences. Many people with opioid use disorder also meet AUD criteria. The integrated treatment of both substance use disorders together produces better outcomes than treating either in isolation, and is the standard of care in modern addiction medicine practice.

Summary

The crocodile drug is an illicit form of desomorphine produced in clandestine kitchens from codeine-containing tablets combined with red phosphorus, iodine, hydrochloric acid, and gasoline or paint thinner. The synthesis produces desomorphine plus a toxic mixture of contaminants that are injected without purification. The injection produces the characteristic dark green or black, scaly, reptilian skin damage that gave the drug its name, with deep necrotic wounds that often expose underlying muscle and bone. The drug emerged in Russia and Ukraine in the early 2000s and produced an epidemic that peaked around 2010-2012, with hundreds of thousands of users and very high mortality. The Russian government’s 2012 schedule change for codeine-containing medications substantially reduced production. Use spread to other countries including Germany, the United States, and the United Kingdom in smaller numbers. Treatment is medically and surgically complex, requiring management of opioid withdrawal, treatment of the wounds and systemic complications, and long-term addiction medicine care. As Dr. Ponlawat Pitsuwan summarises, “Krokodil is one of the worst drug-related health emergencies of the past century, and it emerged not because of an inherent property of desomorphine but because of the absence of effective opioid use disorder treatment in the affected countries. Where medication-assisted treatment is available, users have a real alternative and the population of people pushed toward dangerous substitutes is much smaller.”

Frequently asked questions

What is the crocodile drug?

The crocodile drug, known as krokodil in Russian, is an illicit injection drug containing desomorphine produced from codeine in clandestine kitchens. The drug is approximately 10 times more potent than morphine and produces characteristic dark green or black, scaly skin damage at and around the injection sites, which is the origin of the crocodile name.

Why is it called the crocodile drug?

The name comes from the characteristic skin damage that appears at injection sites and spreads outward, producing a dark green or black, scaly, reptilian appearance that resembles crocodile or alligator skin. The damage is produced by the toxic contaminants in the crude street product including red phosphorus, iodine, hydrochloric acid, and solvents, combined with infection and vascular injury at the injection site.

Where did the krokodil epidemic happen?

The krokodil epidemic peaked in Russia and Ukraine in 2010-2012, with an estimated 100,000 to 1 million users across the two countries. The Russian Federal Drug Control Service estimated 250,000 to 1 million users at peak. Use also spread to other countries including Germany, the United States, the United Kingdom, and Belgium in smaller numbers, often associated with immigrant communities.

Is krokodil still used?

Krokodil use has substantially declined since the 2012 Russian schedule change that required prescriptions for codeine-containing medications. The change reduced production by limiting access to starting material. Surviving users either died from the medical complications or entered treatment, and the population of new users did not grow at the rates seen during the peak epidemic. Some krokodil use continues at much lower levels in the affected countries.

Can krokodil wounds heal?

Krokodil wounds can heal if the user stops using the drug, but the process is medically complex and often requires extensive surgical debridement, antibiotic treatment, wound care, and sometimes amputation of nonviable tissue. Many surviving users have permanent disabilities including limb amputations, chronic wounds requiring ongoing management, and scarring. Healing is essentially impossible while injection continues at or near the affected sites.

How long do people live who use krokodil?

Most active krokodil users die within 2 to 3 years of starting injection use, with mortality rates of 30 to 50 percent per year during the peak epidemic period. Causes of death include sepsis from infected wounds, multi-organ failure, gangrene with overwhelming infection, accidental overdose, and the medical consequences of multiple amputations without adequate care. Users who enter treatment early and remain engaged can survive long-term, but the prognosis is poor for active users.

Sources

• Grund JP, Latypov A, Harris M. Breaking worse: the emergence of krokodil and excessive injuries among people who inject drugs in Eurasia. International Journal of Drug Policy. 2013;24(4):265-274. https://www.sciencedirect.com/science/article/abs/pii/S0955395913000352
• Gahr M, Freudenmann RW, Hiemke C, et al. Desomorphine goes ‘crocodile’. Journal of Addictive Diseases. 2012;31(4):407-412. https://www.tandfonline.com/doi/abs/10.1080/10550887.2012.735570
• European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Krokodil (desomorphine) profile. https://www.emcdda.europa.eu/publications/drug-profiles/krokodil-desomorphine
• National Institute on Drug Abuse (NIDA). Heroin DrugFacts. https://nida.nih.gov/research-topics/heroin
• Substance Abuse and Mental Health Services Administration (SAMHSA). Medications for Opioid Use Disorder. https://www.samhsa.gov/medications-substance-use-disorders
• U.S. Drug Enforcement Administration (DEA). Desomorphine (Krokodil) drug intelligence brief. https://www.dea.gov/
• World Health Organization (WHO). Information on opioid receptor agonists. https://www.who.int/teams/mental-health-and-substance-use/treatment-care/treatment-of-drug-use-disorders

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