28 October 2013

Krokodil Feeding Frenzy

Bad journalism and dodgy bulletins increase confusion and fear over desomorphine

 About twenty years ago, the Observer ran an article entitled "Ice Storm Cometh," detailing the experience of Crystal Meth in Hawaii, with police chiefs warning how it would devastate here next. Cue numerous senior Police Officers undertaking 'fact-finding missions' overseas, and American DEA bods coming here and briefing on the peril.

Since then it's been fairly quiet on the meth front; use has crept up slowly and is becoming a more significant issue in London in some parts of the club scene. But like the crack epidemic of which we were also warned, we've been spared the worst excesses so far.

But the media do love a good drug scare story. And the new villain in town is desomorphine. Except that's not very exciting so the Russian slang term Krokodil gets used instead.

Despite the fact that there's not been a single, toxicology-confirmed case of desomorphine use in the UK, it hasn't stopped the media running hyperbolic stories, shot through with factual errors and topped off with salacious graphic images of infected wounds. The mainstream media have been bad enough but the on-line and 'citizen media' have been just as irresponsible in their reporting.

So what's been said and what do we really know?

About the drug: 

 Desomorphine is the shortened chemical name of the drug dihydrodesoxymorphine. This drug was first synthesised and patented in the 1930s. It was marketed in Europe under the brand name Permonid as a short acting potent opiate analgesic.

As a drug in its own right it shares the same risks as other powerful opiates - risk of dependency, overdose, and risks relating to non-sterile injecting practices. As a drug, correctly synthesised in sterile conditions, it is not going to destroy body tissues or cause infections. So it is utterly erroneous to describe it as the "drug that eats addicts." The drug itself does no such thing. But contaminants in the drug and injecting practice can and will cause infections. The drug is widely referred to by its slang name Krokodil. The exact reason for this are unclear. Numerous articles claim it's because the necrotised, wounded skin of injectors looks reptilian. Others argue that during the conversion process an intermediate product called Clorocodide is produced, and Krokodil is a play on this term.

Desomorphine is synthesised from codeine ( 3-methylmorphine). There are a number of ways this can be done. One uses some of the same processes involved in the conversion of pseudoephedrine to methamphetamine, chemicals including phosphorous and iodine.

Often the chemicals involved in a synthesis will sound far more dangerous than they really are, especialy in the hands of a journalist. So for example ammonia may be involved in a synth or an extraction. it was widely used to make freebase cocaine in the sixties and seventies. So when reports say "ingredients include household cleaners" it is probably a reference to ammonia. Likewise, solvents are often required. So the presence of solvents like petroleum or kerosene are not going to be uncommon. Hydrochloric acid is routinely used to acidify base drugs, including pharmaceutical compounds. It just sounds much more spectacular in the media.

A key source of codeine will be pain-killer tablets. Tablets also contain lots of other material besides the active drug: fillers and binders, coating, flavourings and so on. A commonly available source of codeine, co-codamol tablets will contain a low dose of codeine alongside a high dose of paracetamol. If the paracetamol isn't successfully removed, it will end up causing significant liver damage with repeat use.

It is possible, with time and effort, to remove all these adulterants, and using a clean synthesis process end up with desomorphine.

In practice the end product will invariably be highly impure, and will include tablet residue, leftovers of the chemicals used in the synth, and other additives which may or may not intensify the hit - antihistamines, anti-nausea tablets, caffeine, benzos etc.

Desomorphine, if of high quality, would (according to wikipedia) be 8 - 10 times the strength of morphine (or effectively 3 times the strength of heroin/diamorphine) but with a shorter period of effect 1-3 hours.

Problems related to desomorphine use:

As a strong, short acting opiate, desomorphine use is likely to cause significant problems, especially when injected. The short duration of effect means that dependent users will need to use more frequently - starting to enter withdrawal after three or four hours will get in the way of sleep or other activities.
The short duration of effect also means more injections and this inevitably speeds up vein damage and wounding.

All these problems are going to be worsened by poorly-made street 'krokodil,' the slang name for the home-made desomorphine used in Russia and the Ukraine. The various chemicals used may be toxic, especially in high doses, and the presence of other contaminants increases the risk of infection. 

These problems are made much worse in Russia by the limited availability of treatment services for drug injectors. There is a desperate shortage of effective needle exchange, woundcare and opiate substitution therapy. This means that injectors will routinely reuse equipment, that wounds will go untreated until they are life-threatening, and alternatives such as methadone hard to come by.

So the pictures of "krokodil" with the clains that the drug is "eating victims" should be properly captioned stressing that a combination of poor chemistry, lack of sterile injecting equipment and poor treatment interventions caused these problems.

Desomorphine in the UK? 

So far there have been no confirmed cases of desomorphine use in the UK. However that hasn't stopped various commentators and the media talking up the drug. And if there's one way to increase interest in a substance amongs potential users, it's to write incessantly about how strong and dangerous it is. 

Concern about desomorphine in the UK have been fuelled by some ill-advised bulletins, some commentary from medical sources and some abysmal journalism. 

In July 2013 a warning started to circulate in Gwent, Wales,saying "
"there is in circulation mephedrone (MCAT)cut with petrol.  This is being both sniffed and injected.  It does smell of petrol.  Injecting is resulting in burns / serious wounds / necrosis around injecting sites.  It is reported to be being cut in Wales, following attempts to replicate what is being sold in and around Bristol.  It is being called various things including Fert and Crocodile."

This warning and follow up discussions were highly confusing. They were largely based on second-hand reports from users and there was no analysis (as far as I know) of this "mephedrone cut with petrol." What the bulletin and the subsequent media coverage did was create the idea that a product being called "Crocodile" was being sold, that it involved petrol in the mix, and that it was causing serious injecting complications.

So for example Wales Online cited Controlled Drugs liaison officer Roger Booth, saying  "there is a circulation of mephedrone cut with petrol.This is being sniffed and injected.Injecting results in burns and wounds leading to necrosis, it’s called crocodile – not to be confused with Krokodil.

Interviewed in the same article  Booth goes on to say "The only reason I can think they are using petrol [to cut with mephedrone] is because it allows them to take it in another way as it’s normally in powder form.”

This all sounds very serious but makes very little sense. Mephedrone is a water soluble drug which means it needs no further chemical treatment to make it injectable. The idea that adding petrol would be added either as a 'cut' or to 'take it another way'  is nonsense of the first order. 

Further, petrol is highly volatile (vaporises easily at room temperature) and so even if mephedrone were contaminated with a solvent like petrol, it would rapidly vaporise from the powder if left open at room temperature. 

Possible explanations include that someone was trying to remove another contaminant from mephedrone using a hydrocarbon as a solvent or it was another drug imported dissolved in a solvent. Possibly some mephedrone being sold was cut with something insoluble in water and users were using a solvent like petrol to make it injectable. But importantly this whole story so far lacks any of the drug being analysed.

One would hope the local drugs agency would help stop the myths spreading but instead Kaleidescope seemed to have added even more speculation, with Martin Blakeborough quoted in the same article saying: "It’s a very nasty concoction. It reacts to your skin , creating abscesses and it effectively burns your skin. It’s a very nasty drug because in many ways petrol is worse than mephedrone.Normally when people snort glue or petrol they do so because it acts as a hallucinogenic but in this instance I’m not totally sure what they get from it, perhaps it gives them a bit more of a rush.”

A couple of months later the issue of desomorphine was given a major lift in the media thanks to an article in the Gloucester Citizen in which local Doctor, Allan Harris rattles through a list of drugs that he's heard a bit about and makes some loosely factual statement about each. On Krokodil he says "Another drug coming into fashion is Krokodil. It is caused nasty necrosis, or cell death. It has come from Russia and is very unpleasant. There are plenty of warning signs that it could be in Gloucester. It is cheap and nasty and causes damage to the point where you can see someone’s bones through their skin."

This article didn't elaborate on these "plenty of warnings," but the Independent picked up on the Story giving Doctor Harris a whole article to expand on this. And the evidence in the Independent? . in an article shot through with errors Harris says "To date I have only seen one patient where I suspected he’d used Krokodil." The reason for this suspicion? Client saying they'd used this substance? Toxicology? No. "He had been a long-term heroin user, but suddenly lost a great deal of muscle tissue from gangrene at the site of an injection."

Dr Harris didn't get to expand on the evidence for this being Krokodil in this article. But Vice picked up on the Independent story and piled error on top of error with the willing help of Dr Harris, who had by this time clearly developed a taste for media attention.. So in an article entitled Has Krokodil, the Flesh-Eating Street Drug, Made Its Way to the UK?a 'journalist' conducts an interview with Dr Harris. 

Near the start there's an interesting point - where the writer says "We tried to negotiate whether to call the drug “krokodil” (from the Russian) or to Anglicise it now that it had made its way over from the mainland and start referring to it as “crocodile”. (I've used the former here, but Dr Harris was pretty adamant about using the latter.)" Two important points here, both underlined:

  • the article now asssumes it is "over here" and
  • the term Krokodil and term Crocodile are being mixed up, when Crocodile was already causing confusion as as term in Wales for some mephedrone that may have a petrol smell.
So the interviewer asks about the case mentioned in the Independent which Dr Harris thinks may have been Krokodil. He says:

"It’s a bit retrospective really because it was a few years ago now. At the time, I just thought it was the citric acid burns of a heroin user, but looking back the tissue destruction was far, far in excess [of what you'd expect from that]. When you get citric acid issues you usually get second-degree burns, but this actually took out a huge crater of all the forearm muscle. When you took out the dead tissue you could actually see the tendons moving at the base of this crater and the bones as well – so pretty much like these horrific pictures you see on the warning leaflets for krokodil... Looking back, it didn’t fit at all with citric acid because that’s an irritant but no worse, really, than a slight infection. This was actually very, very disproportionate."

The person in question had subsequently died, and the interviewer asks if it has been confirmed that Krokodil was involved. Dr Harris says "Investigations are ongoing. I couldn’t say for sure, I’m afraid. We’re still waiting on the toxicology results from the coroner."

Based on this Dr Harris appears to have had a client who had a very severe bacterial infection following injection. Many bacterial infections can cause the severe tissue damage and necrosis described by Dr Harris. In point of fact many of the injuries attributed to desomorphine and it's "flesh eating" properties are the result of bacterial infection through contaminants in the mix or non-sterile injecting practice. 

By the sounds of it no tissue samples were taken, and no identification of the pathogen causing the wound or the drug injected is now possible. but based on it looking like pictures of krokodil wounds, Dr Harris has been willing to be quuoted repeatedly saying he thinks it may have been Krokodil.

Astonishingly, before the end of the article, it does get worse, and goes in a loop back to the Welsh Mephedrone/Petrol/Crocodile story when Dr Harris abandons chemistry and grammar in one fell swoop saying "They’re krokodilising Mkat – you know, “meow meow” – to make it injectable and more potent so we’ve seen more intravenous mephedrone use recently to compensate for the reduction in heroin."

So the claim being made now is that the rationale for adding petrol to mephedrone was to make it more potent and injectable.Mephedrone should be water soluble without addition of any other chemicals, provided it hasn't been adulterated with an insoluble cut. And petrol only features in the production of desomorphine as a solvent. 

So thanks to a confusing, unsubstantiated briefing from Wales and a Doctor in Gloucester who has piled further unwarranted assertions on top of each other, and some journalists unable to fact check and take unconfirmed single-sources we end up in a position where the following has become "fact"
  • krokodil is in the UK
  • MCAT is being treated with petrol as a way of "krokodilising it.
Not wanting to miss out on the Krokodil feeding frenzy, the Huffington Post arrives late at the table  with an attention-grabbing headline: 'Krokodil' Trend Of Flesh-Rotting Drugs Hits UK.

Having little new to add the article is salaciously padded with pictures of injecting wounds. The article starts with the claim "Branded "cannibal heroin" for literally rotting users from the inside out, it costs £5 a hit on the street and contains a toxic mix of codeine, gasoline, paint thinner, industrial cleaning oil, and alcohol."

There's not a single source mentioned for this availability or price point. And it hadn't been branded "Cannibal heroin" until the Huff needed a snappy name for it. Once again Dr Harris appears for a quote, saying ""I've already treated one case and I'm sure that in the coming years I will see more." Other drugs workers who tried to balance the piece, stressing that there was no confirmed evidence that Krokodil was on sale in the UK were selectively quoted and their caveats disregarded.

The article also builds on the mephedrone/petrol idea saying Mephedrone "after a spate of alleged deaths...disappeared into obscurity. Now, it has been reincarnated as an injected drug to rival crack and heroin, with experts warning its use is parallel to the deadly krokodil...Police have warned mephedrone is being mixed with petrol and the toxic combination, unsurprisingly, reacts to skin, creating abscesses as it effectively burns flesh. Dr Harris, along with police officials, have branded the trend "krodilising" for having the same fixing process and level of addictiveness."

Despite the unwarranted reporting in the Huff article, it was recirculated by agencies including, unbelievably, Drugscope, who should have been writing corrective pieces not redistributing the offending article.

In Conclusion

 The use of Krokodil in Russia is clearly a significant health issue The loss of life and wounds are horrific but importantly are not caused by the drug desomorphine per se. The risks stemming from a poorly-made short acting drug are worsened by poor access to needle exchange, healthcare and treatment.

There may be desomorphine being prepared and used in the UK. It's certainly possible. But there's no evidence of it at this time.  Relatively low access to OTC Codeine should reduce the risk of it becoming a mass-market drug as is claimed in Russia.
There are certainly people injecting mephedrone and, since prohibition the quality of mephedrone has become more variable. Irrespective of the addition of petrol or not, there is plenty of evidence that mephedrone injecting can cause serious soft tissue infections. 

And we have plenty of things to be aware and concerned about - some potentially stronger-than-average heroin in Wales and Milton Keynes; deaths related to PMA in pills sold as Ecstasy.

What we desperately don't need is wildly inaccurate articles which start off as supposition and hearsay, and over a couple of months morph into fact thanks to poor journalism and professionals who should really be more careful with what they say. There is clearly a public health lesson here. But it's not about desomorpine. It's the reporting of desomorphine.


Unknown said...

I've watched Krokodil being manufactured in the Republic of Georgia. It is difficult for me to believe reports that petrol or any of the other substances used in its manufacture were present in the syringe at the end of the process. Moral panic is, however, present in most of the reporting on this drug.

Unknown said...

Splendid article! A meticulous analysis of moral panic construction.

That 'journalists' write such crap signifies that the journaille will write everything to up sales, but also the power of "conventional wisdom," which they uncritically accept and regurgitate, lifting in this case krokodil to a mythical status without any of the alleged cases in the UK and US confirmed.

HuffPo’s branding the drug as “cannibal heroin” further adds to its mythical status. I did not expect such a prominent news outlet to deliberately use such a clever marketing clause for their reporting. Once more, a prime example of sowing moral panic.

When writing the paper below, I pondered calling krokodil the “crack of opioids” or “poppy crack,” just as a little social experiment, to see how the media would react to such a term. But, we would not want to be responsible for the harm that might arise if they would really do so, so we abstained from acting on that thought.

In science we have ethical standards that, in the end, help us decide about such interesting but potentionally harmful working methods. How about these journalists?

Beyond profit or fame, why do journalists reproduce such abject nonsense? Why are medical doctors eager to add to the confusion??

Perhaps the answer lies in the meaning of the term
conventional wisdom. “Conventional Wisdom” is an idea widely accepted as true by both the public and (media) ‘experts,’ but unexamined and preserving the status quo”. (John Kenneth Galbraith, 1958).

Thus, by mythologizing krokodil, mephedrone or any other new intoxicant on the market, these so called reporters add to the general irrationality and ignorance of the genuine health and social justice problems that stupid or malignant drug policies are engendering. This indeed supports the perpetuation the status quo and of great social injustice.

For those interested in reading a scientific review of krokodil in Russia, Ukraine and Georgia, check the paper I wrote with colleagues in the International journal of drug policy: Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia http://www.ijdp.org/article/S0955-3959(13)00051-0/abstract
Free PDF: http://download.journals.elsevierhealth.com/pdfs/journals/0955-3959/PIIS0955395913000510.pdf

Not enough time for reading science? Check the video that summarizes the paper: http://drogriporter.hu/en/krokodil

Jean-Paul Grund, PhD
CVO – Addiction Research Center, Utrecht – NL
Department of Addictology, 1st Faculty of Medicine, Prague – CR
Author of Coffee Shops and Compromise: Separated Illicit Drug Markets in the Netherlands – http://www.opensocietyfoundations.org/reports/coffee-shops-and-compromise-separated-illicit-drug-markets-netherlands

Unknown said...

I would also really like the first commentator to contact me. I would really like to talk to you about the production of krokodil in Georgia. Or to anyone else who has first hand / eyewitness knowledge of the production process in the CEE region.

You can contact me at: jpgrund [at] drugresearch.nl

KFx said...

journalists rehash the same story, embellishing it so a story expands. Unfortunately, the bodies who were once "authorities" in the UK are less prominent than they once were so the go-too sources of accurate information have been supplanted by a rent-a-quote mob who offer unevidenced opinion as fact. so the cycle continues.
thanks again

Rhys Ponton said...

Great write up of this stupidity seen over the last month or so.
The commentary on the Dr Harris quotes were right in line with what i have been saying too- no evidence for use of 'krokodil'. I can't help wonder if it was naivety or craving for media attention that got him to push his story...

chani said...

Congratulations for the rigor of this post.
Excelent and meticulous analysis of the krokodil situation.
We trust in the journalist responsability to be not alarmist with news about this drug.
Thank´s for information