Mitragyna speciosa Korth refers to a tropical tree in the same family as the coffee tree, indigenous to Southeast Asia. Kratom, derived from the leaves of the Mitragyna tree, has been used as an herbal drug for decades by laborers and farmers.
As Associate Addiction Medicine Program Director George Singletary, MD, MPH, of Tulane University, notes, “Here in the United States, kratom is sold at gas stations with significant lack of product controls and some FDA regulation and is overly commercialized. In contrast, in Southeast Asia, it is treated more like we treat coffee.” The unregulated U.S. kratom market is worth roughly $1.5 billion. The Tampa Bay Times reported more than 580 deaths in Florida from a kratom-involved overdose in the last decade. Most deaths involved other substances, too, but 46 were due to kratom alone.
In 2021, the FDA received 78 reports (75 adverse event reports and three product complaints) involving kratom products. Of 75 reports, there were 20 deaths (27 percent) and 20 hospitalizations (27 percent). Results of medical examination and toxicology testing were obtained for 10 death reports. Kratom toxicity was the sole cause of death in four cases (40 percent), and a contributory factor in the other six cases (60 percent).
At low doses, kratom produces psychostimulant effects. At higher doses, sedating, opioid-like effects are produced. Effects occur within 5 to 10 minutes after ingestion and last 2 to 5 hours. Food can delay absorption.
Regular kratom consumption leads to an opioid-like syndrome called kratom use disorder, where withdrawal symptoms occur when decreasing or discontinuing use for a day or more.
Usual servings of kratom leaf products range from 1 to 10 g containing 20 to 200 mg of 25-plus alkaloids isolated from kratom, but concentrated kratom extracts contain many times that amount. Mitragynine and 7-hydroxymitragynine are the primary psychoactive alkaloids in the plant.
People report taking the drug for pain, anxiety, energy, or SUD. They assume it must be safe if it has been used for centuries in Southeast Asia. Others believe the drug is safe because it comes from a plant. But dosages are difficult to calculate, packaging labels are useless, and some kratom sellers add many more psychoactive ingredients than kratom naturally possesses. In addition, some kratom products have included heavy metals like lead and harmful bacteria like Salmonella.
Kratom is promoted as a legal psychoactive product on numerous websites, but its use carries its own risk of addiction. Patients with polydrug, opioid, and alcohol use histories have used kratom to self-manage substance use disorder (SUD) symptoms. However, this attempt generally fails.
There is no evidence kratom contributes to the current opioid epidemic of fentanyl. However, Tulane’s Singletary cautions, “There’s a whole community posting ‘home detox’ regimens.” He added, “I have had multiple patients having a prior history of opioid use, often opioid pain pills, subsequently retriggering their addiction when they used kratom.” Singletary says opioid use disorder-like treatment of kratom use disorder patients with buprenorphine is considered.
Not everyone agrees on whether kratom should be restricted or banned. Singletary says prominent warnings should be required with age restrictions on sales of kratom. Placing the substance under the Controlled Substances Act (CSA) could criminalize consumers and possession and increase overdose deaths.
THE BASICS
Ohio State University and Harvard professor Edward Boyer, MD, PhD, who is also a kratom expert, reminds us kratom can be an important part of harm reduction efforts. “Patients with OUDs and no beds or no treatment slots available, or those outside of major cities, need help and help now. If you can't get into formal treatment right off the bat, using kratom tea as a bridge to treatment makes sense and is highly preferable to injecting heroin or taking opioid pills or fentanyl. I don't want people using kratom, but there is a role for kratom in helping people transition from use to MATs.” Dr. Boyer adds that the full range of toxicity from kratom, including the extent and severity of respiratory depression, has not been defined. Says Boyer, “We don't know how route of administration matters, but if you take leaves and just make a tea and drink it, overdose seems unlikely.”
An editorial by University of Florida professors Chris McCurdy, Ph.D., and Oliver Grundmann, Ph.D., summarized the need for regulations. Kratom leaf material contains mitragynine in about 2 percent, but some products containing more than 40 percent are also sold.
The professors warn, “As researchers…we strongly recommend that kratom in its native form (unadulterated fresh or dried leaf material) remain available to consumers. In addition, there must be thorough and proper oversight and regulation, including clear labeling that describes the amount of mitragynine per kratom dose, recommended maximum daily doses, potential for drug interactions, and implementation of proper Good Manufacturing Practices.” They believe Florida's passage of the Kratom Consumer Protection Act on July 1, 2024, was a major step forward in the regulation of kratom products.
