Kratom: A So-Called Legal Opioid
Henkin DR, Sullivan B, and Smith JS. Kratom: A So-Called Legal Opioid. J Gen Intern Med 2019; 34(2):S570-S571.
J Gen Intern Med
Learning Objective #1: Familiarize the reader of the substance called kratom Learning Objective #2: Assessment and management of intoxication, withdrawal and detoxification of kratom Recognize the legality and regulation of kratom in the U.S. CASE: We present a case of a 25 year old male who presented to an inpatient rehabilitation and detoxification center requesting help for an addiction to kratom. He disclosed a history of IV heroin use 2 years earlier, which he stated he was able to wean himself from using kratom. He endorsed ingesting kratom powder up to 40 grams twice daily for the last 2 years. The patient recognized his tolerance and ultimately his addiction, but attempting to quit "cold turkey" caused him to develop symptoms of myalgias, chills, diarrhea, rhinorrhea, arthralgias and fatigue. Given his apparent tolerance and withdrawal symptoms similar to that of a true opioid withdrawal, he was managed with a buprenorphine taper, which adequately allowed him to successfully complete detoxification. IMPACT/DISCUSSION: The substance called kratom has recently gained more recognition on the streets and in admissions to detoxification centers. Kratom (Mitragyna speciosa) is a plant indigenous to Southeast Asia and Thailand. At different concentrations of its leaves, ingestion will produce both stimulant and opioid-like effects, with studies showing its mode of action by binding mu opioid receptors. One online "Kratom User Guide" suggests that 1-5 grams elicit a stimulant effect and higher doses of 5-15 grams cause opioid-like effects. Intoxication at higher doses in long-term users or in acute toxicity has been reported to cause seizures and hepatotoxicity. The CDC has even traced kratom to a multi-state outbreak of salmonella. There is a noticeable increase in the number of articles referencing kratom, as well as an increasing amount of vendors and general information websites for kratom in the past few years which may suggest a greater overall demand. Conclusion: Kratom is an addictive substance whose use has actually been outlawed in many Southeast Asian countries. In the US, kratom is legally regulated as an herbal product under US law, FDA and DEA policies, and is therefore considered a legal substance in the United States. That being said, the Drugs and Chemicals of Concern list states, "There is no legitimate medical use for kratom in the U.S." In 2016, the DEA planned to classify kratom as a schedule I drug; however the DEA received significant challenges from the public and ended up releasing a withdrawal of notice of intent. In the time of writing this, kratom is still not a scheduled drug. As it remains easily accessible in local tobacco shops and online, we must be aware of its existence and use pattern as well as its effects, abuse potential and addictive properties.