Kratom: Fear-worthy foliage or beneficial botanical?

Depending on what you read, the botanical herb kratom is a dangerous, addictive drug with no medical utility and severe side effects — including overdose and potentially death — or it is an accessible pathway out of chronic pain and opiate withdrawal. How can the US Drug Enforcement Agency (DEA), medical professionals, and millions of regular kratom users have such divergent views of the same plant? How can we get on the same page?

What is kratom?

Kratom (Mitragyna speciosa) is a tropical tree from the coffee family native to Southeast Asia, with properties that range from stimulant-like, energizing and uplifting, to opioid-like, causing drowsiness and euphoria. Kratom has dozens of active components, which makes it difficult to characterize as one particular type of drug, such as stimulant or opioid. The two main chemicals, mitragynine and 7-hydroxymitragynine, have activity at the main opioid receptor, the "mu" receptor, which is the same one stimulated by heroin and oxycodone.

Kratom is thought to be used by as many as two million to 15 million Americans, many of them using it successfully to help alleviate undertreated chronic pain, or to help as a harm reduction method with symptoms of opioid withdrawal. Kratom is commonly consumed orally (with added sweetener to overcome its harsh bitterness), made into tea, or swallowed as a pill.

There are much more concentrated and potent kratom products on the market than there used to be, which increases the potential harms. Side effects can include agitation, tachycardia, drowsiness, vomiting, and confusion. There can also be grave side effects such as seizures, as well as respiratory suppression and cardiac arrhythmia.

Kratom can be found in gas stations and paraphernalia shops in most parts of the US, except in the handful of states and cities that have banned it. Many people purchase kratom over the Internet, where it is sold "for soap-making and aromatherapy" to avoid the fact that in 2014 the FDA made it illegal to import or manufacture kratom as a dietary supplement. None of these avenues of procurement — or these products — are regulated at all.

What are some of the problems with kratom?

There is little to no control or reliable information on the growth, processing, packaging, or labeling of the kratom sold in the US, which adds to the already considerable uncertainty of its health risks. In 2018 the FDA instituted a mandatory recall over concerns about Salmonella contamination of kratom-containing products. The DEA has recently placed kratom on its Drugs and Chemicals of Concern list, but has not yet labeled it as a controlled substance, and currently does not seem as if they are planning to restrict it on a federal level.

Kratom can be addictive due to its opioid-like qualities. According to one study, 12.3% of kratom users qualified as addicted. A small minority of people addicted to kratom require treatments for opioid use disorder, such as with suboxone (buprenorphine). Others have characterized kratom addiction as comparable to caffeine addiction (and, yes, there are bad outcomes to caffeine addiction as well, such as insomnia, gastritis, and arrhythmia.)

The CDC claims that between 2016 and 2017, there were 91 deaths due to kratom, but this claim should be greeted with skepticism, as all but seven of these casualties had other drugs in their system at the time of death, making it impossible to uniquely implicate kratom.

Why do people use kratom?

The DEA maintains that kratom has no medical uses or benefits, but in Asia kratom has been used for hundreds of years to treat cough, diarrhea, opioid withdrawal, and chronic pain, and to boost energy and sexual desire. More recently, in the US there has been an uptick in the use of kratom by people who are self-treating chronic pain and acute withdrawal from opiates. They are seeking a safer and more accessible alternative to prescription medications.

One could argue that this is quite important given how inadequate our current medical system is for treating both of these conditions. Despite a vocal community of supporters, and numerous anecdotal testimonials of effectiveness, these treatment practices using kratom have not been rigorously studied as either safe or effective.

A patient wishing to use kratom for pain or to mitigate withdrawal symptoms would encounter several problems, not all of which have to do with the intrinsic properties of kratom itself.

• While kratom is not currently scheduled under the Controlled Substance Act, the DEA periodically threatens to make it a Schedule 1 controlled substance, in the same category as heroin or methamphetamine. This would make it difficult to access, and would likely make the supply as a whole even more dangerous. Given how many kratom users there are, and given the potential benefit it offers, it seems unlikely that the federal government will aggressively move against kratom, but several jurisdictions have banned it.
• The complete lack of oversight or quality control — the wholesale lack of regulation — in the production and sale of kratom makes its use more dangerous, especially as increasingly concentrated products appear on the market.
• Kratom has not been well studied for any of the uses its proponents claim, though as the saying goes, "absence of evidence of benefit isn't evidence of absence of benefit."
• A final problem is that kratom doesn't show up on drug screens, and one can argue that the wider adaptation of another potentially addictive opioid-like substance, in the midst of an opioid epidemic with tens of thousands dying each year, is the last thing we need.

Is there a sensible path forward with kratom?

I'm not sure that anyone has the answer to this question, as there are so many different perspectives, concerns, and interests surrounding kratom. At bare minimum, safety could be improved with:

• Regulation: It would be safer if people knew the exact dosages they were consuming and that it was free of contamination. Ideally, the super-concentrated products could be reined in.
• Education: Educated consumers, who know the dangers and potential benefits, are far less vulnerable to misleading claims.
• Research: If kratom does have benefits for either addiction or chronic pain, we should be able to demonstrate this. It is critical that we better define the risks of using kratom, so that people can make informed choices.

If all of the above could somehow be accomplished by scientists and public health specialists, without overdue distortion from corporate interests, antidrug ideology, and romanticism by kratom enthusiasts, we could then have enough clarity to answer the questions: is kratom helpful, and how can we best use it to improve health?