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Kratom Use Among Health Professionals

Learn about kratom being prohibited by the DEA and then reversing its decision and why. Should we include kratom in health professional testing?

February 23, 2020

Actual Case
A 37-year-old anesthesiologist participating in residential treatment for opioid use disorder went on a therapeutic leave home to another during the third month of his treatment. Upon returning, a urine drug screen documented the presence of 7-hydroxymitragynine (kratom). Upon confrontation, he stated he has purchased it at a local store prior to admission to try and help get off of fentanyl. He stated that kratom is legal and non-addictive; however, he admitted the effect of the drug felt very similar to fentanyl.

History of Incompetent and Irresponsible Opioid Policies in the U.S.
The history of opioids in the United States is replete with the introduction of new substances initially thought to be benign but later found to be harmful. These “safe” drugs included heroin (1898), oxycodone (1916), meperidine (1938), propoxyphene (1957), tramadol (1963), and numerous others. All of these drugs were introduced as non-addictive. Drug companies, doctors, and patients are constantly seeking  an opioid that is non-addictive.

When Are We Going to Learn That Anything That Stimulates μ-opioid Receptors is Going to Be Addictive?
For all of the drugs listed above, decades went by resulting in many individuals who became addicted or died before the drug was controlled or prohibited. For example, in the case of tramadol, it took about 20 years following its introduction in the US for enough cases of addiction1, morbidity, and mortality to convince the DEA to schedule it.

Kratom Appears on the Scene
The latest substance in this notorious lineup of “safe opioids” is Mitragyna speciosa, commonly known as kratom. Kratom comes from a tropical tree indigenous to Southeast Asia and parts of Africa. It is now available in the United States in many forms, including: dried/crushed leaves, powder. capsules, tablets, liquids, and gum/resin. The most common route of administration is ingestion as a brewed tea, although smoking, chewing the raw leaves, and the ingestion of extracts have also been reported. 

The main active constituents of the plant are believed to be mitragynine and 7-hydroxymitragynine (7-HMG). These active constituents exert their effects as partial agonists for the euphorigenic μ-opioid receptor and possibly κ-opioid receptors. Both substances are reported to be more potent than morphine, and many of their effects are reversible with naloxone.2

The DEA Prohibits Kratom and Then Backs Down
Kratom first started appearing in the U.S. in about 2012. Soon after, in August 2016 the DEA announced that it would temporarily reclassify kratom as a Schedule I drug.3 This meant that it  would be prohibited and considered unsafe without clinical benefit. The public response was immediate and intense, including public demonstrations, petitions, and calls by Congress to overrule the decision. There were organized efforts by advocacy groups, such as the American Kratom Associationand the Botanical Educational Alliance, resulting in demonstrations near the White House, phone calls to Congress, and a petition sent to the White House with over 100,000 signatures. In general, the reaction stressed the view that kratom does not possess the harm that the DEA claimed and that it is useful in managing pain and other conditions, as well as opiate addiction; therefore, it should remain available  to the public without restrictions.4 Advocates maintained that kratom is safer than prescription opioids and that the relatively low number of deaths attributed to kratom when compared with opiates is due to other drugs being used simultaneously. Many testimonials from users touting kratom’s beneficial effects quickly appeared on numerous websites. A bipartisan letter drafted by U.S. Representative Mark Pocan (D-WI) and Matt Salmon (R-AZ) to the heads of the DEA and the Office of Management and Budget was signed by more than 50 members of Congress5 calling the decision to ban the “internationally recognized her supplement” as “hasty” and nothing that this would have a serious effect on consumer access and innovation in treating individuals suffering from addictions. Finally, in an unprecedented move, the DEA withdrew its notice of emergency scheduling.6 

Kratom Abuse and Misuse
Because kratom remains uncontrolled, it is sold widely in the U.S. over the internet, from marijuana dispensaries, etc. The use of kratom has spread widely and is marketed as a non-addictive wonder drug. In June 2019, the FDA issued warming letter to two of the largest marketers and distributors of kratom products, Cali Botanicals of Folsom, CA and Kratom NC of Wilmington, NC, for illegally selling kratom-containing drug products with unproved claims about their ability to treat or cure opioid addiction and withdrawal symptoms, and unsubstantiated claims about kratom treating pain, depressions, anxiety, and cancer.

The FDA cited these false claims:

  • “Kratom is used as a natural alternative to treat depression, anxiety, addiction, diabetes, chronic pain and fatigue…Kratom has been reported to have taken the place of brand-name drugs like Hydrocodone and Oxycodone for individuals, all the way to weaning people off of heroin.”
  • “Some researchers have claimed that kratom can protect you against cancer!”
  • Kratom is used for energy, to increase attention/focus, to relax, and also to treat pain and addiction. Many customers have used kratom to treat…chronic pain, migraines, opiate addiciton, ADHD/ADD, anxiety, depression, arthritis, insomnia, and much more!”

Remarkably, one statement by a company that sells kratom states, “Many people use kratom to overcome opiate addiction; however, people using kratom to overcome a preexisting opiate addiction many need to use kratom daily to avoid opiate withdrawal“. To me, this is reminiscent of when the package insert was changed for tramadol to state “Tramadol can be addictive in people prone to addiction“. Let’s face it, kratom is an addictive drug and I predict it will eventually be scheduled again once enough people are harmed.

Recently labs have started to include mitragynine and 7-hydroxymitragynine in health professional panels. We will likely be seeing many more patients using kratom before it is finally prohibited.
Health care professionals and consumers are encouraged to report any adverse events related to kratom to the FDA’s MedWatch Adverse Event Reporting program. To file a report, use the MedWatch Online Voluntary Reporting Form. The completed form can be submitted online or via fax to 800-FDA-0178.

1 Skipper G, et al. Tramadol Abuse and Dependence Among Physicians. JAMA Oct 20, 2004-Vol 292, No. 15:1818-1819.

2 Prozialeck WC, Jivan JK, Andurkar SV. Pharmacology of kratom: an emerging botanical agent with stimulant, analgesic and opioid-like effects. J Am Osteopath Assoc. 2012;112(12):792-799.

3 Drug Enforcement Administration (DEA). Schedules of controlled substances: temporary placement of mitragynine and 7-hydroxymitragynine into Schedule I. Fed Regist. 2016;81(169):59929-59934.

4 Harven M. Herbal drug kratom faces uncertain legal future, despite public outpouring. PBS NewsHour. December 12, 2016. Accessed January 23, 2017

5 Nelson S. Dozens of Congressmen ask DEA not to ban kratom next week. U.S. News. September 23, 2016. Accessed January 23, 2017.

6 DEA. Withdrawal of notice of intent to temporarily place mitragynine and 7-hydroxymitragynine into Schedule I. Fed Regist. 2016;81(198):70652-70654. Accessed January 23, 2017.

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