Krokodil: Withdrawal Timeline

Krokodil is a synthetic drug that typically combines codeine with other products to produce an alternative to heroin that is far less expensive and far more potent with a much quicker onset of action. This drug became very popular in Russia where heroin is very hard to get and codeine is relatively easy to get. It subsequently became popular in Eastern European countries in the early 2000s.

Speculation that abuse of the drug is rampant in the United States has been largely refuted by the United States Drug Enforcement Administration (DEA) and articles in professional journals. Nonetheless, the DEA does report cases of krokodil abuse in the United States, although its abuse is not widespread.

Manufacture and Abuse

Krokodil is produced similarly to how street methamphetamine (crystal meth) is made from ephedrine or pseudoephedrine. Additives are used to extract codeine from the medicines and create desomorphine, a synthetic opiate drug that is extremely potent. Some of the products that may be used in the process of manufacturing krokodil include sulfuric or hydrochloric acid, gasoline, paint thinner, iodine, and phosphorus. The chemicals are mixed and combined at various stages and heated or boiled. Many of the potential toxic substances in the concoction, such as phosphorus, remain in the final product.

Desomorphine is most often injected in the same manner as heroin. The toxic chemicals in krokodil can lead to skin ulcers, skin abscesses, and the development of gangrene. Hence, the name of the drug reflects the effects it has on skin, producing a green scaly appearance like a crocodile, particularly at the injection sites. Green, scaly, damaged and abscessed skin is not unusual in abusers of the drug, and some individuals may develop gangrene, require amputations, develop other serious infections, and have a significantly shortened lifespan as a result of using this concoction. The DEA reports the average lifespan of users in Russia was two years once they began using the drug.

The psychoactive substance in krokodil, desomorphine, is a controlled substance and classified by the DEA as a Schedule I controlled substance. All the drugs in this classification are believed to have no medicinal uses, are extremely prone to be abused, and cannot be safely used even under the supervision of a physician. Desomorphine cannot be legally obtained or possessed except with special permissions by the federal government.

Desomorphine is believed to be highly potent (between eight and 15 times more potent than morphine). In addition, it has a significantly faster onset of action than morphine does and a very short half-life. The National Library of Medicine’s Toxicology Network and the DEA report that the drug has a half-life of about an hour.

The extremely short onset of action and short half-life result in individuals often bingeing on the drug in order to maintain the psychoactive effects. Obviously, repeatedly injecting a seriously dangerous substance with toxic chemicals leads to further potential for tissue damage and infections as well as increased tolerance and an early onset of withdrawal symptoms in chronic abusers.

Withdrawal from Krokodil

Numerous sources suggest that the withdrawal syndrome associated with krokodil abuse is significantly longer than the withdrawal syndrome associated with other opiate drugs like heroin. However, the National Institutes of Health’s National Library of Medicine does not indicate that there is a significant difference between the withdrawal timeline for desomorphine and other opiate drugs like morphine and heroin. However, due to the potency of the drug and its short half-life, individuals may take higher doses of the drug and take it at more frequent intervals then they might take heroin and/or morphine. This can increase the complexity of the withdrawal syndrome and result in more severe and lengthier withdrawal periods in chronic abusers.

The National Library of Medicine reports that the common symptoms of withdrawal include:

• Pain, including aching muscles and joints, particularly in the back and legs
• Nausea, vomiting, diarrhea, and appetite loss
• Alternating bouts of chills, fever, and sweating
• Insomnia with extreme lethargy
• Restlessness, irritability, mood swings, including swings between anxious and depressed feelings
• Dilated pupils, runny nose, excessive watering of the eyes and/or goosebumps
• Confusion and extreme emotional duress
• Cravings for krokodil that are often related to the intensity of the withdrawal symptoms, with more frequent and stronger urges for the drug associated with more intense withdrawal symptoms

Symptoms associated with withdrawal from desomorphine are not considered to be potentially fatal in the same way that withdrawal from alcohol or benzodiazepines can produce potentially fatal seizures; however, individuals who are extremely emotionally distraught are at risk of making irrational or impulsive decisions, prone to accidents, and prone to harming themselves either intentionally or accidentally. Because individuals undergoing the withdrawal syndrome may become very emotionally distraught and desperate, the potential for overdose is increased while bingeing on the drug or when a relapse occurs during the withdrawal period.

The length and intensity of the withdrawal symptoms can be affected by numerous factors, as mentioned above, including the length of time the individual has been abusing the drug, the amount of the drug they typically abuse, individual differences in metabolism, emotional factors, how the person stops using the drug (stopping all at once or slowly tapering down the dosage), and other factors. Typically, the timeline for withdrawal from desomorphine follow a general course.

• Due to the short half-life of the drug, the onset of withdrawal symptoms often occurs relatively quickly after the person has stopped using the drug. In some individuals, this may begin to occur within six hours of discontinuation. The range can be 6-24 hours after stopping the drug.
• Once the person experiences the onset of withdrawal, symptoms will typically worsen for 1-3 days and then slowly begin to decrease in intensity.
• Withdrawal from desomorphine is typically completed within 5-7 days after discontinuing the drug, but other factors may increase the overall timeline.
• Many chronic abusers of opiate drugs continue to experience cravings, depression, sensitivity to perceived stress, and problems with motivation for weeks, months, or even years after discontinuing their drug of choice. Many of these symptoms continue after the drug has been eliminated from the system. These prolonged symptoms are not believed to be directly associated with the physical withdrawal process but indicative of other emotional or psychological factors that should be addressed in recovery.

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Again, even though the withdrawal syndrome associated with krokodil abuse is not considered to be potentially fatal, serious complications can occur that can lead to serious or fatal outcomes. One of the issues associated with Krokodil abuse is that individuals who develop gangrene, abscesses, or other skin infections are often hesitant to enter treatment because they are embarrassed. These individuals often need professional consultations to get them into treatment.

Treatment for abuse of krokodil should begin by addressing any acute medical needs and getting the person involved in a physician-assisted withdrawal management program (medical detox). This process involves administering opioid replacement drugs, such as methadone or Suboxone, in place of krokodil. These medications are designed to alleviate withdrawal symptoms from opioid drugs like desomorphine, but they do not have the same intensive psychoactive effects. They also have a ceiling effect, such that other opiate drugs do not produce significant psychoactive effects; people on these medications cannot get as high from them as they do from other drugs, and taking other opiate drugs while on them does not produce any additional euphoria. Other drugs can be administered to control any residual symptoms that may occur. As the withdrawal management program progresses, the physician slowly tapers down the dosage of the opioid replacement medication to wean the individual off opiates while at the same time avoiding any withdrawal effects.

A physician-assisted withdrawal management process significantly reduces the risk for relapse, provides medical management in the early stages of recovery, and allows individuals to slowly begin to prepare for long-term recovery. Most often, individuals suffering from krokodil abuse fare best in inpatient withdrawal management programs, as physicians and other medical personnel can monitor their condition around the clock and address any emergencies.

Those who attempt to withdrawal without professional assistance very often relapse and place themselves in significant danger of overdose.

In addition, going the “cold-turkey route” often results in individuals going through cycles of heavy drug abuse followed by short periods of abstinence, followed by heavy periods of bingeing and continued drug abuse. The withdrawal management process helps individuals commit to recovery and begin to develop a long-term program of recovery while protecting them against potentially dangerous complications.

Simply going through the withdrawal management process without subsequent treatment is not a sufficient strategy for long-term recovery. Individuals who complete a physician-assisted withdrawal management program and do not engage in a long-term program of recovery will inevitably relapse.

Remaining involved in treatment and maintaining abstinence for a minimum period of 5-7 years is required before an individual is considered to be at a decreased risk for relapse; however, individuals in recovery are always at a high risk for relapse even if they been abstinent for decades. This is why many people remain involved in treatment-related activities at some level for the rest of their lives.