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Kratom, Anxiety and Opioids - What You Need to Know

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What is Kratom (Mitragyna speciosa)

  • Kratom is a tropical evergreen tree related to the coffee plant and native to Southeastern Asia
  • Also known as krathom, kakuam, ithang, thom, ketum, biak-biak, mambog
  • Used by indigenous populations as a stimulant to enhance stamina and reduce fatigue and for the management of pain and opioid withdrawal
  • Used for centuries in traditional medicine as an antidiarrheal, a cough suppressant, an antidiabetic, and as an intestinal deworming agent
  • For over the past decade, Kratom has gained popularity in the West and is used to boost energy, relieve pain, to self-manage opioid withdrawal, to stop or reduce use of prescription or illicit opioids, also for mood or anxiety disorders, or for its euphoric effect

Modes of Use

  • fresh leaves are chewed (1-3 at a time) and swallowed; salt is added to “prevent” constipation
  • leaves are dried and made into a powder that can be used to make a tea
  • lemon juice is often added to facilitate the extraction of the active alkaloids
  • traditionally sugar or honey is added to mask the bitter taste of the tea
  • less commonly the leaves can be dried and smoked
  • also prepared as a cold cocktail in Thailand for alcohol-mimicking effect, called “4x100”
  • contains leaves, a caffeinated soft drink, and codeine-containing cough syrup; ice cubes, an anxiolytic, an antidepressant, or an analgesic can also be added
Kratom comes in many formsKratom Products

  • Low-cost, over-the-counter kratom products are available as “dietary supplements” in retail stores and online
  • Leaves, dried or crushed into powders
  • Liquids or “shots”, extracts, gum/resin
  • Tablets and Capsules are most popular forms
  • Online prices are less expensive than in retail stores, especially if bought in bulk
  • Powder- 100 grams for $20; Capsules- 500 (250 grams of powder) for $60

Lack of Quality Control

  • There is a lack of quality control and standardization in the production and sale of commercially available kratom preparations
  • FDA found Kratom products that exceeded the level of safe exposure to nickel and lead
  • There have been reports of Salmonella outbreaks associated with kratom products
  • Although the product packaging sometimes recommends a specific dose,  the amount of active ingredient (as well as other agents) is unknown

How Many Types of Kratom Are There?

  • Generally there are 3 different types of kratom leaves
  • Red Vein, White Vein, and Green Vein Kratom are further divided into several varieties or stains which have distinct properties that are achieved by mixing the three types
  • The color of the vein keeps changing throughout the lifecycle of a kratom leaf with varying alkaloid concentrations

The Legal Status of Kratom

  • The use and sale of kratom is illegal in Australia, Poland, Denmark, Sweden, Malaysia, and Vietnam
  • In the US, kratom was legal to grow and purchase in all 50 states until 2015 when DEA identified kratom as a substance of concern
  • In 2016, DEA wanted to place kratom into Schedule I of Controlled Substances Act, but did not proceed due to large public outcry from kratom user community
  • As of February 2020, kratom is illegal to buy, sell, and use in Wisconsin, Indiana, Rhode Island, Vermont, Arkansas and Alabama
  • Illegal in San Diego CA, Washington DC, Denver CO, and Sarasota FL

Widely Used But Not FDA Approved

  • Kratom is not regulated or approved by the FDA
  • 3 to 5 million Americans use kratom regularly
  • According to an internet survey of 10,000 kratom users, most are college-educated, employed white men, age 31 to 50 who take kratom to:
    • treat chronic pain (68%)
    • treat anxiety/depression (65%)
    • reduce symptoms of opioid withdrawal from use of illicit drugs (7.7%), or use of prescription opioids (26%)
    • 41% had disclosed their use of kratom to a healthcare provide

What Kratom Does From a Pharmacology View

  • Kratom exhibits dose-dependent effects:
    • a mild stimulant at low doses (< 5 grams of raw leaves)
    • opioid-like effects, (analgesia, constipation, euphoria), at 5-15 grams
    • sedation at doses >15 grams
  • After taking a few grams of dried leaves:                                     
    • invigorating effects and euphoria are felt within 10 minutes, which can last for 1-1.5 hours
  • After taking large doses, 10-25 grams, of dried leaves:                  -
    • initially sweating, dizziness, nausea, dysphoria which quickly subside followed by calmness, euphoria, dream-like state which can last up to 6 hours. Contracted pupils (miosis) noted
  • Initial effects of kratom typically begin within 10 to 20 minutes of consumption
  • Full effects are experienced in 30-60 minutes and can last  for several hours

Adverse Effects

  • Stimulant effects- anxiety, irritability, increased aggression
  • Opioid-like effects- sedation, nausea, constipation, itching
  • These effects are dose dependent and vary from one individual to another
  • Chronic (>1 year), high-dose usage associated with skin hyperpigmentation, tremor, weight loss, insomnia, extreme fatigue, constipation
  • There have also been reports of seizures, delusions, hallucinations, respiratory depression, hepatotoxicity, coma, and death
  • An emerging concern is the potential development of fatty liver infiltrates leading to cholestatic liver damage
  • There have been increased number of calls to poison control centers related to kratom
  • OVERDOSE – some reports of mixed results with Naloxone
  • 55% of regular users of kratom become dependent

  • High risk of relapse due to cravings (78%-89% at 3 months)

Kratom-related Deaths

  • As of February 2018, the FDA had received reports of 44 deaths associated with kratom
  • There have been reports of fatal overdoses involving kratom, particularly when co-ingested with other agents, including one case involving Seroquel
  • There have also been reports of deaths attributed to kratom alone;  in one such case a 35-year-old man had a fatal cardiac arrest due to kratom use with no other co-ingestants
  • Among the reports of deaths in which kratom was the only substance consumed, the mitragynine blood levels were higher than the levels after consuming traditional kratom teas

Withdrawal Syndrome

  • Abrupt discontinuation of high-dose, long-term kratom use can produce withdrawal symptoms which resemble those of opioid withdrawal
  • Nausea, diarrhea, sweating, chills, muscle and joint pain, tremors and twitches, jerky limb movements, rhinorrhea, lacrimation, mydriasis
  • Insomnia, restlessness, irritability, fatigue, anxiety, mood disturbances
  • Symptoms start 12-24 hours after last use of kratom and can last up to 7 days
  • Withdrawal intensity is correlated to daily amount consumed, and   duration and frequency of use
  • In 2 case reports, the newborns of women who used kratom during pregnancy experienced Neonatal Abstinence Syndrome

Treatment

  • To date, no guidelines exist for long-term management of kratom use disorder (KUD)
  • There are a few case reports in literature that have used buprenorphine naloxone (BUP/NLX or Suboxone) to treat kratom use disorder (KUD), and successfully transitioned to BUP/NLX maintenance

So What Does this Mean?

"Kratom use is on the rise with increasing probability of developing opioid-type dependence due to chronic use," states Joanna Missygar,  PA-C for Symetria Recovery. "Therefore, greater awareness among health professionals and users about its risks is necessary. There is evidence that patients with kratom use disorder can be successfully transitioned to maintenance with Suboxone, which should be considered especially if the use of kratom is high risk, involves high doses, and meets DSM-5 diagnostic criteria for a moderate or severe use disorder. Consideration should also be given to referral of patients for counseling or enrollment in treatment programs. Further research on the possible therapeutic uses, toxic effects, and abuse potential of Kratom is needed." 

 

Symetria Recovery  is the pioneer and leader in complete, personalized, evidence-based recovery care through outpatient opioid, heroin and alcohol (all substance use) treatment committed to providing state-of-the-art, whole-person care, not just the addictive or dependency behavior. Its unique approach to dependency is known as The Symetria Method. This method combines medication-assisted treatment (MAT), psychiatry, and support from a single treatment team of behavioral health, medical and psychiatric professionals to reduce the risk of relapse and give patients sustainable results. Symetria Recovery’s highly-successful outcomes have been validated by an independent, retrospective analysis of more than 1.5 billion commercial claims from 3+ million OUD patients for five years. The analysis demonstrates superior results on all metrics when compared with treatment as usual. 

Symetria Recovery currently operates six locations in Illinois (Des Plaines, Highland Park, Joliet, Lakeview/Chicago, Naperville and Palos Heights) and six in Texas (College Station, Fort Worth, Hurst, Jersey Village, Lewisville and Spring). To help patients suffering from a substance use disorder find facilities that deliver quality treatment and care, Blue Cross and Blue Shield of Illinois (BCBSIL) recognizes all six of Symetria Recovery’s Illinois locations with its Blue Distinction® Center for Substance Use Treatment and Recovery (BDC Substance Use Treatment and Recovery) designation – a new designation under the Blue Distinction Specialty Care program. To learn more, please visit www.symetriarecovery.com.

References:

Buresh M. MD, Treatment of Kratom Dependence With Buprenorphine-Naloxone Maintenance. J Addict Med. November/December 2018;12(6):481-483.

Khazaeli A, Jerry JM, Vazirian M. Treatment of Kratom Withdrawal and Addiction With Buprenorphine. J Addict Med. 2018;12(6):493–495.

Kruegel A.C. Uprety R. 7-Hydroxymitragynine Is an Active Metabolite of Mitragynine and a Key Mediator of Its Analgesic Effects, ACS Cent Sci. 2019 June 26; 5(6):992-1001

Prozialeck W.C. PhD; Jivan J.K. BS; Andurkar S.V. PhD Pharmacology of Kratom: An Emerging Botanical Agent With Stimulant, Analgesic, and Opioid-Like Effects, Journal of the American Osteopathic Association: December 2012- Volume 112, 792-799.

Stacie C.N MD, MRO, FASAM. FAPA, Penders T.M. MS, MD Best Practices in Managing Patients with Kratom Addiction, PCSS Webinar. October 6, 2020.

Stacie C.N. MD, MRO, FASAM. FAPA, Hybicki B.G. MD; Penders T.M. MS, MD Kratom: What We Know, What To Tell Your Patients, Current Psychiatry:   March 2020; 19(3):37-42

Stevens A. MD, MPH; Mascorro A. RN, CARN, PHN; Bell G.K. RN, MSN, RN-BC, CARN, PHN. Kratom Use- Review of Induction and Maintenance with Buprenorphine, ASAM Annual Conference, San Diego, CA; April 12-15, 2018.

Weiss, Stephanie T. MD, PhD; Douglas, Heather E. MD Treatment of Kratom Withdrawal and Dependence With Buprenorphine/Naloxone, Journal of Addiction Medicine: August 26, 2020 - Volume Publish Ahead of Print - Issue

 

 

 

AnnMarie Fauske
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