Desomorphine (4,5-alpha-epoxy-methylmorphine) is a product derived from codeine, an active ingredient found in some analgesic and cough-suppressant preparations. In some countries, including Russia, codeine-based preparations can be purchased without a prescription.
The synthesis of desomorphine is therefore carried out in an improvised, homemade manner starting from codeine tablets, which are certainly less expensive than heroin and legally available. Low cost is not the only, or even the main, reason for the spread of desomorphine: it is reportedly capable of producing an effect 8–10 times more intense than heroin. It is therefore an attractive substance both in general, with a potentially greater capacity to induce addiction, and as a product useful to people with opioid dependence who are tolerant to high and expensive doses of heroin and no longer experience its effects.
People with drug dependence tend to seek new substances according to a principle of increasing the intensity of the effect: changing the route of administration (from intranasal to intravenous), combining substances that make the effect more intense, combining substances that control side effects so that larger doses of the primary drug can be used, and switching to drugs with a more intense effect but lower cost.
The preparation is nicknamed “krokodil” because of its toxic effects on the skin, which are associated with the mixture of substances used in the process of synthesizing desomorphine. These substances cause inflammation of the tissues beginning around the veins that supply them, followed by tissue destruction and superimposed infections (gangrene). This characteristic is not simply the result of an error, but rather of the “urgency” associated with addiction, whereby the goal of obtaining a powerful substance takes precedence over foreseeable toxic risks.
A person with drug dependence prepares or seeks out krokodil because of a compulsive drive that prevents them from adequately considering the risks, or at least from assigning appropriate weight to foreseeable risks. This mechanism makes the substance initially attractive primarily to people who are already drug-dependent: driven by this pathological desire, they are not deterred by the risk of infections, amputations, disfiguring effects, or inflammatory reactions that may leave them seriously ill.
Others, who are not drug-dependent, presumably do not take this risk and choose to spend more money on heroin. Obviously, if a less toxic formulation were to become available in the future, there could be a new and less controllable wave of cases of desomorphine dependence, again originating from freely available codeine.
Substances with intense effects are usually kept illegal or otherwise strictly controlled, and their market price does not tend to be low, precisely because of their attractiveness to people who misuse drugs. Substances widely used for therapeutic purposes, by contrast, are generally controlled and selected from among those that do not have strong appeal for people with drug dependence (for example, methadone), or are formulated in ways that make them less suitable for non-medical use (for example, buprenorphine).
The paradox in the case of these drugs is that they are instead available on the market and not controlled through prescription requirements, as a consequence of healthcare policies that are not based on their actual dangerousness but on historical patterns of commercialization. The same fate that certain anxiolytics have experienced in our country has, in other regions, affected substances that are considerably more dangerous.
In addition to the risk of inducing drug dependence, opioids used illicitly also carry a certain risk of overdose, either on their own or through accidental or intentional combination with other substances, including commonly used substances such as alcohol.
As an extreme paradox, Russia is also one of the countries with some of the least favorable healthcare policies for containing the phenomenon of drug dependence: on the one hand, liberalization of the market for certain opioids with a recognized potential for misuse (codeine); on the other, delays and obstacles to the widespread use of opioid medications that, while not presenting the same risks, are currently indispensable for containing and treating dependence on heroin and codeine.