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Toxicology

Kratom: A New Wonder Drug or Physician Nemesis?

Jaclyn Caffrey, MD
Brown University, Emergency Medicine Residency

Have you had a patient using Kratom yet? This drug is being recognized more and more as a source of intoxication among our patient population. The reason for its popularity? It has both stimulant and opioid like effects and is being marketed as a safe alternative to opioids with the potential to help wean off narcotics.

Background. Although a new drug in the United States, Kratom is actually an old drug. Its use goes back many years in South East Asia where it was traditionally used for its stimulant effect among farmers and day laborers. It became increasingly more popular in Asia around the mid 19th century after opium prices skyrocketed and Kratom served as a cheap alternative. Its popularity has slowly spread worldwide with first instances of use noted in the US in 2008.

The source of Kratom is the Mitragynea speciosa plant, more specifically, the leaves of the plant. It can be ingested by chewing the leaves but it is more commonly dried and powdered. The powder can be mixed with tea, pressed into tablets or capsules, or less commonly, smoked. Kratom’s strong bitter taste means it is often mixed with other liquids to make it tolerable.

Active ingredients
. The leaves of the plant contain greater than 25 alkaloids but there are 2 which are primarily responsible for the drug’s effect on humans. Mitragynine and 7-Hydroxmitragynine act on mu and delta opioid receptors, block the serotonin 5-HT2 receptor, and stimulate post synaptic alpha 2 adrenergic receptors giving them their stimulant and opioid like effects. The combination of these alkaloids in different quantities gives different strains of the plant varying effects. Limited research has been done on Kratom at this point in time and as research continues new information regarding the mechanism of this drug will likely emerge.

Symptoms. Small quantities of Kratom show a stimulant like effect. With increasing doses, patient will experience a greater opioid like effect. Because of its plant origin, large quantities of the leaves are required to induce effects with mild doses ranging in the 1-5 g range and large doses typically greater than 15 g. Side effects are typically mild and wide ranging. Examples include; nausea, dry mouth, constipation, weight loss, frequent urination, fatigue, sweating. The side effect profile increases as the dosage increases and typically only with high doses or chronic use are withdrawal symptoms seen.

Withdrawal. Withdrawal symptoms can range from muscle aches and irritability to jerking movements and aggression. To date, the most serious consequences of use of Kratom is seen in combining Kratom with other illicit or prescription drugs or alcohol which has led to a number of Kratom related deaths.

Legal status. Currently in the United States, Kratom is legal to buy. However, there are specific states and counties which have individually banned the substance. The FDA has stated that Kratom has no legitimate medical use in the US which means Kratom cannot be sold as a medicine in this country. However, the product can be marked as “not for human consumption” and continue to be sold legally. The DEA has placed Kratom on its drugs of concern list. Since 2016, there has been an increase in media surrounding Kratom. Particularly when the DEA announced plans to classify Kratom as a schedule I substance and supporters of Kratom successfully protested the classification.

Persistence. At this time, we are seeing increasing use of Kratom in the United States. The attraction for its users lies in its stimulant and opioid like properties and reportedly ability to help wean off narcotics. It can be used in many forms, mainly orally. It has a wide but mild side effect profile. However, it can be dangerous in large quantities or for chronic daily users, and potentially lethal especially when combined with other substances. It is not part of routine drug screening in this country. It remains a hotly debated topic in the media, especially in regards to its legal status and research potential.

References

  1. Warner ML, Kaufman NC, Grundmann O. The pharmacology and toxicology of Kratom: from traditional herb to drug of abuse. Internal Journal of Legal Medicine. (2016) 130:127-138
  2. Lydecker AG, Zuckerman MD, Hack JB, Becker B, Cherkes JK, Boyer EW, Babu KM. Intravenous Kratom Use in Patient with opioid addiction. J Toxic Pharm. 2017. 1:003. 
  3. What its like to be high on kratom, according to the people who use it. The Washington Post. By Christopher Ingraham. Sep 16, 2016. 
  4. Should Kratom Use be Legal? Scientific American, 2017. By Larry Greenemeier. 
  5. Kratom. DEA. Jan 2013. 
  6. Kratom. National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. Feb 2016. 
  7. Anwar M, Law R, Schier J. Notes from the field. Kratom (mitragyna speciosa) Exposures Reported to Poison Centers – United states, 2010-2015. MMWR Morb Mortal Wkly Rep 2016; 65; 748-749
  8. Singh, D., et al., Kratom (Mitragyna speciosa) dependence, withdrawal symptoms and craving in regular users. Drug Alcohol Depend. (2014)
  9. Chang Chein, George, Is Kratom the New ‘Legal High’ on the Block?: The case of an Emerging Opioid Receptor Agonist with Substance Abuse Potential. Pain Physician 2017; 20: E195-E198
  10. Prozialeck, Walter. Update on the Pharmacology and Legal status of Kratom. J AM Osteopath Assoc. 2016; 116(12): 802-809
  11. www.sagewisdom.org/kratomguide.html. The Kratom User’s Guide. Oct 12th, 2016. By Daniel Siebert. 

 

 

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