Kratom Use in the US: What Clinicians Should Know

The herbal substance kratom (Mitragyna speciosa) has been the focus of much debate and regulatory wavering in the United States over the past decade. Studies suggest that kratom, derived from a tree in the coffee (Rubiaceae) family that is native to Southeast Asia, is typically used to ease pain and symptoms related to mental health disorders and opioid withdrawal.1

Of more than 40 alkaloids found in kratom, mitragynine and 7-hydroxymitragynine target the opioid receptors and have been identified as the plant’s primary psychoactive compounds.2 The effects of kratom appear to be dose-dependent, with stimulatory effects occurring at low doses and analgesic effects occurring at higher doses.3

The prevalence of kratom use has reportedly been on the rise in the US since 2007.4 In 2 studies published in 2021, results showed that 0.7-0.8 of the US population had used kratom in the preceding year.5,6

Amid growing accounts of toxicity associated with kratom, the US Food and Drug Administration (FDA) has issued multiple consumer warnings against consuming the herb.7 In 2016, the US Drug Enforcement Administration (DEA) proposed that kratom should be classified as a Schedule I drug. However, these efforts were tabled due to public resistance.3

People report using kratom for pain relief, mood improvement, energy, and substitution for potentially more harmful opioids.

Among other points, critics of placing kratom on Schedule I have noted that nearly all cases of kratom-associated overdose deaths have involved other congested substances such as alcohol, fentanyl, or benzodiazepines.8

These findings align with research demonstrating high rates of polysubstance use and various substance use disorders among people who use kratom. In a study published in 2021, for example, prevalence rates of stimulant use disorders and opioid use disorder were 16.5-fold and 18-fold higher, respectively, among kratom users compared to nonusers.9 Authors cautioned that these results should not be interpreted as support for a causative link between kratom and SUDs, and they note the need for further research to elucidate the herb’s therapeutic benefits and safety profile.

We interviewed the following experts for additional insights regarding kratom use and key implications for clinicians: Albert Garcia-Romeu, PhD, assistant professor in the department of psychiatry and behavioral sciences and researcher at the Center for Psychedelic and Consciousness Research at Johns Hopkins University School of Medicine in Baltimore, Maryland, and Marc T. Swogger, PhD, clinical psychologist, researcher, and associate professor in the department of psychiatry at the University of Rochester Medical Center in New York. Along with other colleagues, Dr. Garcia-Romeu and Dr. Swogger co-authored a 2022 guide to educate health care providers about kratom use.1

While some may use it for the “high,” what are other reasons why people may use kratom — and are there any “legitimate” uses for it?

Dr. Garcia-Romeu: There doesn’t seem to be much of a “high” from kratom use as far as we can tell, though certainly some people may take it recreationally.9 Most people who use kratom in the US report using it as a supplement to help with pain, mood, and anxiety-related issues.1 Kratom is a plant related to coffee, and many people often report using kratom for energy like coffee, including people in Southeast Asia who have used kratom traditionally for generations. Also, some people who have developed opioid or other drug or alcohol issues have reported using kratom as a means of cutting back or stopping their opioid, alcohol, and sometimes other substance use successfully.1

Dr. Swogger: People report using kratom for pain relief, mood improvement, energy, and substitution for potentially more harmful opioids.1 In observational studies and surveys, users consistently report that kratom is helpful for each of these purposes. Whether taking kratom is a good idea for any individual is a complicated choice since so much remains to be learned about the plant. However, studies to date indicate that, for some, kratom can be a lifeline away from dependence on classical opioids like oxycodone because kratom may be more easily tapered and has little respiratory depression, the primary mechanism of death in opioid overdose.10

What are some of the main concerns regarding kratom use? For example, what is known about its potential for abuse and dependence, and what are the potential side effects?

Dr. Garcia-Romeu: It’s hard to say because there is very little controlled research, so what data we do have comes from things like surveys or reports on ER visits, which largely amounts to anecdotal evidence. It does seem that kratom can be habit-forming or even addictive, and that people can develop tolerance for kratom and show withdrawal symptoms when stopping use. However, this generally seems to be far milder than dependence and withdrawal from traditional opioids.

In a survey study I published in 2020, for instance, we found about 10%-12% of respondents who were kratom-using adults in the US reported definite withdrawal symptoms upon stopping kratom use, including symptoms like craving and insomnia, and about 12%-15% met criteria for a kratom use disorder, indicating some level of kratom dependence.11 However, less than 3% met criteria for a moderate or severe use disorder, meaning in most cases this seemed to be fairly mild.

Some of the potential side effects of kratom seem to be sedation, agitation, nausea, constipation, and — in cases of heavy, chronic use — potential for liver damage. There are also risks related to drug interactions with medications like opioids or benzodiazepines, for example, which could cause synergistic effects with kratom and lead to bad reactions.1

Dr. Swogger:  Side effects include nausea and, occasionally, vomiting, along with constipation, chills, and sweats, temporary visual changes, dizziness, itching, and sedation.1

Of more concern is the potential for dependence on kratom. While dependence on kratom is relatively rare and usually much less severe than that of classical opioids, it can be a problem for some people, especially those who use it daily or near-daily in high doses — eg, more than 5g/day — and for a long period of time, [as in] weeks to months. Those who run into problems with dependence will experience withdrawal symptoms when they cut down or cease using kratom, and these are uncomfortable and disruptive.1 

Concerns about psychosis are most likely unfounded, based on the peer-reviewed, observational literature and, while there are some case studies that discuss liver damage and death, these outcomes have rarely been linked to kratom alone. Concerns about adulteration of kratom products remain, so anyone seeking to legally purchase and use the plant should investigate vendor Good Manufacturing Program (GMP) status, which indicates whether a kratom vendor is selling a product that is tested for purity.

What are the recommendations for clinicians in terms of screening and treatment for problematic kratom use? For those who wish to stop using kratom, is there a need to taper off, and are there any data on how to approach this?

Dr. Garcia-Romeu: To clarify, I’m not a medical doctor, so I’m not providing any medical advice here. However, for clinicians, it’s probably a good idea to ask about kratom use and particularly to warn patients who are using kratom in combination with other medications about risks of possible interactions. It seems that people with a history of opioid or other drug use problems may be more likely to use kratom or to develop problems with their kratom use, so those would be good people to ask about kratom use as well.9

For people who are using heavily and would like to stop, tapering the dose over time would likely be the best method, though we don’t have any definitive information about this and there are no approved treatments to help people seeking to stop kratom use. Some clinicians have reported using medicines like buprenorphine to help patients presenting with kratom dependence, though it’s unclear if that is optimal at this point.12

Dr. Swogger: There is no 1 program that is right for all people who deem their kratom use problematic. Tapering slowly with support is preferred. Similar to any harmful substance use, recovering people benefit from psychotherapy, exercise, connection with others, and treatment of underlying conditions like depression and anxiety. Some providers use opioid medications like buprenorphine to treat kratom use. It is not clear how often this is a beneficial practice, but it has proved helpful for some individuals. Screening for harmful kratom use is similar to screening for other harmful substance use and focuses on the consequences of use.  

What are your thoughts about the FDA’s consumer warnings7 against kratom use, such as the one from 2022?

Dr. Garcia-Romeu: I think that based on the available data, this messaging from FDA is heavily overstating the negatives and not taking into account any of the substantial body of reports of benefits from users and the relatively benign risk profile compared to other substances like traditional opioids or alcohol.

What are the main points of controversy regarding the possibility of the DEA classifying kratom as a Schedule I controlled substance, and what is your opinion on this proposal?

Dr. Garcia-Romeu: I have gone to DC to speak to Congressional representatives to recommend against placing kratom on Schedule I and have also provided similar comments to the WHO when they were considering making kratom a controlled substance at the international level. At both junctures, after weighing the available evidence, regulatory bodies in the US and at the WHO both determined that kratom does not pose the necessary public health risks to place it under such severe restrictions, and that, conversely, doing so could possibly lead to negative outcomes.10

Many people seem to use kratom safely and have good benefits in managing pain, mood, anxiety, and other symptoms that they cannot get relief from using traditional treatments. Kratom is also accessible to people who may not have health insurance or cannot afford or readily access medical treatment. The risks of kratom seem relatively low, though of course this is not completely risk-free and there are possible dependence and abuse to consider.

Nevertheless, if kratom were made illegal, many people who now use it may revert back to using more dangerous substances including prescription and illicit opioids that have a higher potential for dependence and, of course, fatal overdose risk. Importantly, kratom does not seem to carry the same risk profile of fatal overdose as traditional opioids, as evidenced by the very small number of kratom-related fatalities in the literature worldwide — numbering in the dozens, not hundreds nor thousands. There are very few documented cases where kratom was considered the sole cause of death; typically, kratom-related deaths involve use of kratom in combination with other drugs and/or alcohol.8

Additionally, as a researcher who studies Schedule I drugs, I can attest to the fact that placing a substance on Schedule I makes it far harder, more complicated, and more expensive to study, and that seems like a bad idea considering the available data suggesting that kratom or its alkaloids could likely be useful as a therapeutic for conditions like pain and opioid dependence. I would say that regulating kratom like a supplement would be a welcome turn, since that could assure that kratom products are not adulterated, contaminated, and do not contain dangerous levels of certain alkaloids or other potentially harmful chemicals. 

Dr. Swogger: When the DEA announced intent to schedule kratom years back, they learned that many people in the US were already using kratom to good effect. The DEA put their intent to schedule on hold due to consumer backlash and the work of some scientists who realized that a Schedule I designation would cripple attempts to study the plant. Frankly, criminalizing most drugs has negative public health effects through creating a black market, contributing to the mass incarceration problem, and reducing scientific study and dissemination of facts to the public. Criminalization also does little to solve the demand for drugs.13 

​The failed drug war must end, so it is a positive public health development that the DEA withdrew from criminalizing kratom and that the FDA seems to be toning down unsubstantiated rhetoric about waves of “kratom deaths,” most of which were not properly analyzed and reported in the first place. What we need is evidence from controlled, scientific studies — not drug hysteria.

This article originally appeared on Psychiatry Advisor

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