Kratom

I was recently approached by one my patients about using Kratom. There is a documentary from 2018 that has given Kratom more attention recently. If you live in the St. Louis area you may have also noticed some new CBD Kratom stores opening up. In addition to CBD, I didn’t learn about this plant in medical school, so I decided to do some research. The following is what the formal medical community says about Kratom.

Kratom (Mitragyna speciosa), is an South-east Asian traditional herb with opioid and stimulant-like properties, contains indole alkaloids, principally mitragynine and 7-hydroxymitragynine, with mu-opioid receptor agonism. Mu-opioid receptors are the receptors in your brain and body where the endogenous (your body’s naturally occurring opiates like, endorphins) and exogenous opioids (these are medications such as morphine, codeine, hydrocodone and the like) exert their activity.

Kratom has been used for self-treatment of opioid withdrawal, with little evidence based research of efficacy. Additionally, there have been increasing numbers of reports of lethal overdose and other adverse effects. Kratom should not be used in patients actively withdrawing from opioids, however, some people report relief with Kratom when they are not in active opioid withdrawal.

Investigation of Kratom’s efficacy and toxicity is limited to case reports. In higher doses of 5 to 15 g, frequent and prolonged ingestion of Kratom for pain or recreational use has been associated with respiratory depression (decreased drive of breathing), anorexia, weight loss, seizures, depression, psychosis, physiologic tolerance, and withdrawal (similar to that seen with opioid withdrawal). Opioid withdrawal symptoms can emerge 12 to 24 hours after last use of Kratom and persist for up to seven days. There are no controlled trials supportive of specific pharmacologic treatment of Kratom withdrawal, but a 2019 review suggested treatment similar to withdrawal from other opioids, specifically using alpha-2-adrenergic agonists and symptomatic treatment.

Kratom use is prohibited in some countries and US states. The Food and Drug Administration in the United States has issued multiple advisories on Kratom. For example the advisories include, the health risks with its use for opioid withdrawal, its association with a multi-state Salmonella outbreak in 2018, and on a mandatory recall of Kratom-containing products associated with Triangle Pharmanaturals, LLC in 2018.

Here is my take on all of the above about Kratom for use:

• Traditionally, it is used in Thailand and Southeast Asia. The whole leaves were chewed to relieve musculoskeletal pain and increase energy. The whole leaves are very bitter and thus would be chewed with a sweetener. Because of the bitterness, lower amounts of Kratom is traditionally ingested and therefore limits the toxicity potential. This bitterness is typically not present with the capsule formulation of Kratom and therefore over-ingestion and toxicity can be a concern.
• Kratom may cause liver toxicity, especially with people who drink alcohol, have liver disease, or are taking other hepatotoxic medications. Be careful with the amount of alcohol that you drink in combination with Kratom. Ideally, you should not drink alcohol when taking Kratom. Because of the potential for liver toxicity, liver enzymes should be monitored and checked more frequently.
• Kratom works on the same receptors as opiates, hence there is risk of opiate-like side effects including, but not limited to: constipation (make sure to increase fiber intake), respiratory depression (decreased drive of breathing), addiction and dependence and withdrawal.
• There is also an increased risk of blood pressure with Kratom since it behaves like caffeine and has stimulant-like effects.
• If you are interested in taking Kratom I would advise that you first check with your Primary Care Physician to make sure you are a good candidate for Kratom.
• If you and your Physician decide to start Kratom I would recommend using the lowest effective dose. I would not recommend taking large amounts because of the increase risks of side effects and adverse events. When starting this herb a good rule of thumb for dosing is to “start low and go slow” when titrating the dose up.
• Kratom should not be taken as a long-term medication for pain mangement.