Kratom

Oftentimes there is no guarantee of the quality, potency, and claims of kratom products on the market. For the most part, kratom products are not monitored by regulatory bodies, partly because kratom is not considered a supplement, a food, or a drug in the regulatory definitions of many countries. Thailand initially banned the use of kratom because of its addictive properties. Recently, kratom was removed from Thailand’s illegal substances list but still remains highly regulated.^[9] Although it is still illegal to use kratom in Malaysia, its use remains high because the plant is geographically native.^[10] The Drug Enforcement Administration (DEA) in the U.S. intended to classify kratom and its ingredients mitragynine and 7-hydroxymitragynine as schedule 1 controlled substances but withdrew this motion after opposition. The U.S. Food and Drug Administration (FDA) has issued numerous public warnings about kratom’s effects and also about the risk of contamination and adulteration of kratom products. These factors make for unfavorable conditions under which to conduct clinical research and to consistently regulate the quality of kratom products.^[11][12] Potential quality concerns related to kratom products include contamination with toxins such as lead, adulteration with drugs, and inaccurate statements about product potency and effects.^[13][14][15] It is important to be aware of these quality concerns when trying a kratom product.

Generally, an equal weight of kratom extract contains more active ingredients and is more potent than kratom powder. Kratom powder usually refers to dried powdered leaves, whereas kratom extract is an end product of processing kratom leaves with a solvent to make a higher yield of active ingredients (such as mitragynine). The extract potency can vary greatly depending on the extraction solvent and process. For example, in a laboratory study, 600 mg of powdered kratom leaves extracted with water, ethanol, and methanol yielded approximately 60 mg of extract containing mitragynine at concentrations of 3.9 mg/g, 58.8 mg/g, and 35.9 mg/g, respectively.^[21]

In short, we don’t know. There is no human clinical research assessing the use of kratom for managing symptoms of opioid dependence and withdrawal. However, in a cross-sectional survey study in 136 chronic kratom users living in Malaysia, users reported taking an average of 3 glasses of kratom tea daily to reduce opioid intake and to manage withdrawal symptoms.^[16] There are also some promising preclinical studies of kratom use in mice with opioid dependence.^[19]

In Southeast Asian countries such as Thailand and Malaysia, kratom has been traditionally used for centuries for conditions such as fever, cough, diarrhea, diabetes, hypertension, pain and also for opioid and alcohol withdrawal. It has also been used to increase energy and to increase sexual desire. Although regulatory authorities have been restraining kratom use in Thailand and Malaysia, it remains widely used, especially in rural areas.^[3][20]

Informal surveys suggest that kratom is commonly used in the Western countries for pain relief, but research in humans is very limited.^[22] To date, one randomized clinical trial in 26 male chronic Kratom users living in Malaysia showed that drinking a kratom tea decoction increases pain tolerance one hour after ingestion compared to drinking a placebo. Increased pain tolerance was measured because participants who ingested a kratom drink were able to keep their hand in an ice-cold bath for about 10 seconds longer compared to those who consumed a placebo.^[23] However, there is animal research showing that kratom and its main ingredient mitragynine can reduce acute and chronic pain. At least 23 studies in animals (mice, rats, or dogs) suggest that kratom extract and its ingredient mitragynine have therapeutic effects in alleviating experimentally induced acute pain (via thermal or mechanical stimulus), and at least two animal studies suggest that it is beneficial for chronic neuropathic pain.^[22]

There is emerging evidence of kratom (tea, powder, tablets) ingestion leading to liver toxicity and injury in rare cases. Kratom-induced liver injury is usually cholestatic (notable reduced/stopped bile flow) or mixed – a combination of cholestatic and hepatocellular (notable death and inflammation of liver cells). People often recover from this liver injury after stopping kratom use and receiving emergency supportive treatment. Corticosteroids, sometimes in combination with N-acetylcysteine (which is also used to treat other drug-induced liver toxicities), have been given for kratom-induced hepatotoxicity, but there is no evidence that these agents actually improve recovery. In previous cases, it took anywhere from 1 to 8 weeks for symptoms of liver injury to start showing (e.g. fatigue, nausea, itching, dark urine, jaundice).^[7] In a more recent case series of 11 people (mostly male, ages 25–70), severe liver injury symptoms that required hospitalization started showing after 5 to 28 days of kratom use. In 3 of those 11 cases, the kratom product was available for analysis and was found to contain 0.8–2.0 mg of mitragynine per gram.^[8] LiverTox a website that provides information related to liver injury rates Kratom as a likely cause of clinically apparent liver injury, although cases are rare.^[7] More research is needed to determine whether certain doses, usage patterns, concomitant substance use, or preexisting conditions predispose a person to developing liver toxicity with kratom.

In short, it is possible. Limited research has found that chronic kratom use has been associated with dependence and opioid-like withdrawal. However, withdrawal after kratom seems to be more mild than opioid withdrawal. Withdrawal symptom severity seems to be dependent on the quantity and duration of kratom use. Symptoms can include mood disturbances (anxiety and depression), muscle spasms, pain, fever, and diarrhea. Chronic kratom users reported cravings for kratom and dependence on kratom to be able to function well throughout the day.^[16][17][18]