Editor, Alcoholism & Drug Abuse WeeklyMs. Knopf has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Many mental health providers are starting to hear about kratom from their patients. Consumed in Southeast Asia (except for Malaysia, where it is banned) for centuries, it’s a plant that has opioid-like qualities but is not regulated. Kratom is a tropical tree with the scientific name Mitragyna speciosa, native to Southeast Asia.
Kratom is widely available for purchase in the US on the internet and in smoke/vape shops. It is sold in botanical form as dried leaves, or in pill, capsule, extract, or gum form. Some people chew kratom leaves or brew the dried or powdered leaves as a tea, and sometimes the leaves are smoked or eaten in food.
How kratom works Kratom appears to bind to the mu-opioid receptor and has all the characteristics of opioids—pain relief, euphoria, and the potential for addiction. Two compounds in kratom leaves, mitragynine and 7-α-hydroxymitragynine, interact with opioid receptors in the brain, producing sedation, pleasure, and decreased pain. Notably, mitragynine activates opioid receptors less strongly and in a different way than opioids such as morphine, indicating that this chemical might have therapeutic potential for the treatment of pain and addiction.
Mitragynine also interacts with other receptor systems in the brain to produce stimulant effects. Paradoxically, kratom seems to be energizing in low doses and sedating in high doses. When kratom is taken in small amounts, users report increased energy, sociability, and alertness instead of sedation. Its psychoactive effects usually last 4 to 6 hours.
While there is currently no scientific evidence that kratom is effective or safe for any therapeutic purpose, people report use of kratom as an herbal alternative to medical treatment for conditions including pain, anxiety, depression, drug withdrawal, and other symptoms associated with addiction to opioids, alcohol, and methamphetamine. More research is necessary to determine if any of the active alkaloids in kratom could be developed into medications to treat these conditions. Others use kratom in small doses to improve their energy level—much like caffeine.
Like other drugs with opioid-like effects, kratom may cause physical dependence, which means users will feel physical withdrawal symptoms when they stop taking the drug. Case reports have documented successful treatment of kratom withdrawal with buprenorphine/naloxone (Weiss ST and Douglas H, J Addiction Med, Epub ahead of print. PMID: 32858563).
Quality control issues Not only is there no research on kratom for pain, the products patients find in vape stores are not subject to quality control or even checked for contaminants. In addition, kratom’s interactions with other medications are not well understood.
According to the National Institute on Drug Abuse, commercial forms of kratom have been laced with other compounds that have caused death. Finally, deaths have been reported that involve kratom and other potent substances, including illicit drugs, opioids, benzodiazepines, alcohol, gabapentin, and over-the-counter medications such as cough syrup.
The industry The American Kratom Association wants to use the Dietary Supplement Health and Education Act of 1994 to classify kratom as an herbal supplement, not a controlled substance. The association compares kratom to chocolate, cheese, and other substances in its ability to bind to the mu-opioid receptor. Currently, the FDA identifies no approved uses of kratom and recommends against its use (www.fda.gov/news-events/public-health-focus/fda-and-kratom).
Connection to K2 or spice? Kratom does not have any chemical relationship to bath salts or K2/spice/kush. Bath salts are cathinones, a kind of stimulant, and they interact with one of the same signaling systems (the adrenergic system) as the active compounds in kratom leaves, mitragynine and 7-α-hydroxymitragynine. The stimulant effects of kratom, however, are far more mild than those of synthetic cathinones. While K2/spice/kush are sold as dried leaves much like kratom is, they are synthetic cannabinoids and have entirely different biological targets.
Few patients are likely to ask you to recommend K2/spice to help them with pain or withdrawal, but you may get requests for information about kratom, so it’s important to note the distinction. On the other hand, this doesn’t mean you should recommend kratom, said Paul H. Earley, MD, president of the American Society of Addiction Medicine. “If you tell your patient to take any substance or plant that has not been studied, there are huge liability risks,” said Earley. “This is the Wild West.”
CATR Verdict: Kratom should not be prescribed for chronic pain. There’s no research supporting this and no quality control over the product. However, many patients do use it—it remains readily accessible without a prescription—and there is research underway on possibilities as a medication. Case studies suggest kratom withdrawal can be treated with buprenorphine/naloxone.