Kratom

The popular Southeast Asian botanical Kratom may be part of the solution to America’s opioid and mental health epidemics, or it may be part of the problem.

Joe (not his real name) was a veteran and heroin addict in his mid-30s. He presented to the emergency room with a deadly blood infection. So weak that he could barely walk, Joe ended up in the intensive care unit in a major hospital. Heroin followed him there, with drug dealers delivering to him in his room. Slowly he improved. He is off heroin. Today, Joe is in rehabilitation, gaining strength and trying to put his life back together.

There are hundreds of thousands of “Joes” nationwide. Suffering from mental health problems such as depression, anxiety, and post-traumatic stress, they use opioids (such as morphine and oxycodone), heroin, or fentanyl to ease their physical and psychic pain. West Virginia, lacking jobs with the decline of the coal industry, is particularly hard hit. In the city of Huntington, which has twice the national average of overdoses, overwhelmed police called the national guard for assistance in this war on drugs.

America’s opioid crisis killed 42,000 people in 2016. In response, authorities are cracking down on opioid use. Doctors and hospitals sharply curtail prescriptions, and offer other modalities such a neuromuscular medicine, acupuncture, yoga, tai chi, meditation, counseling, exercise, diet, and safer drugs to help patients. According to the advocacy group American Kratom Association, “millions” of people also turn to Kratom, which surfaced in the US before 2010.

Kratom (Mitragyna speciosa) is an evergreen tree in the coffee family common in Indochina and Malaysia. For centuries, locals have chewed its leaves or brewed Kratom tea to ease pain. Currently, Kratom also comes in pills and liquids. Low doses have a stimulant effect, similar to caffeine, and high doses act as a sedative, like opioids. Some patients on Kratom have had hallucinations and have become psychologically addicted. Kratom works by binding to opioid receptors in the brain. Unfortunately, there have been no human trials, so science’s knowledge of Kratom’s effects in man is limited. The US Food and Drug Administration considers Kratom a dangerous drug without a valid medical use, but advocates say that it is relatively safe and effective in controlling pain and mental health symptoms. At least, many contend, taking Kratom is better than having people go back to opioids.

The US Drug Enforcement Agency (DEA) has associated Kratom with 44 deaths since 2011. This number may be too high because some of those who died also had other deadly drugs such as opioids or alcohol in their systems at time of death, and it is not clear what drug actually killed them. However, it may also be too low, since doctors do not screen for Kratom in toxicology tests and medical examiners often do not look for it during autopsies. Early research suggests that Kratom does not depress the respiratory system as much as opioids do, which is the most common cause of death in opioid overdose. Due to the fatalities, the DEA considered banning Kratom in October 2016 but stopped the effort after a public outcry to allow for further study.

Kratom is banned in Thailand, Australia, Burma, and Malaysia. It is regulated as a schedule 1 drug (high addictive potential, no medical use) in Denmark, Germany, Finland, Romania, and New Zealand. Kratom is more loosely regulated in Russia, South Korea, and the United Kingdom. Among US states, Wisconsin. Tennessee, Vermont, and Indiana have banned it entirely, while Illinois, and some parts of Florida have heavily regulated it.

Kratom is cheap, only $9-20 per ounce on the open market. Walmart, eBay, and other mainline retailers sell it in stores and online. Unfortunately, product purity and consistency are other concerns. Some Kratom formulations available online are laced with opioids, while others contain inconsistent concentrations of the active ingredient. A user can underdose with a certain amount of one formulation and overdose with the same amount of another.

The debate on regulating Kratom is acrimonious and growing. Banning it entirely will freeze research, a problem since no one knows much about Kratom’s actual effectiveness and safety. A ban would also drive many users back to opioids, alcohol, and more dangerous drugs. This seems unwise, or at least premature.

However, regulating products containing Kratom to ensure consistency of dosing and purity is important. Customers buying Kratom should get Kratom, and nothing else. Consumers buying Kratom should not face the physical and legal dangers of opioids unknowingly. Adding Kratom to recommended drug screens would vastly increase the amount of real world knowledge on this drug. A combination of human clinical trials and usage data would answer the questions and help policy makers decide what to do about Kratom.

There are too many “Joes” in the United States, especially in the veteran population. As a nation we are duty bound to help restore those who helped defend us. Advances in mental health, the wise adoption of effective practices from other traditions such as acupuncture, hypnosis, and herbal medicine, and a “whole person and community” approach to healing are parts of the solution. Kratom may be an ally, or it may be an enemy. Only strenuous research, careful policy, and time will tell.

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