What is Kratom (Mitragyna speciosa)
Kratom Products
- 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
- 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 “4×100”
- 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 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
- 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
- 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 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
- 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
- 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
- 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 an 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)
- 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 drugs or alcohol use
- 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
- Abrupt discontinuation of high-dose, long-term kratom use can produce withdrawal symptoms that 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 the last use of kratom and can last up to 7 days
- Withdrawal intensity is correlated to the 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
- To date, no guidelines exist for long-term management of kratom use disorder (KUD)
- There are a few case reports that have used buprenorphine-naloxone (BUP/NLX or Suboxone) to treat kratom use disorder (KUD), and successfully transitioned to BUP/NLX maintenance
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