What's All the Hype About Kratom?

Kratom, also known as ketum, kakuam, biak or thom, is a mind-altering substance extracted from the leaves of Mitragyna speciosa, a tropical evergreen tree. Found mainly in the humid jungles of Southeast Asia (particularly Thailand, Indonesia and Malaysia), the plant has been used by farm populations and manual laborers in these regions to "combat fatigue and improve work productivity," and to treat opium addiction and morphine dependence in Malaysia and Thailand, according to the U.S. National Library of Medicine, operated by the National Institutes of Health.

Within the last decade, kratom found its way to the United States where it is now readily available. Based on 2016 information collected by the Botanical Education Alliance, the kratom industry in the United States is worth more than $1.13 billion.

Supporters swear by kratom's medical and therapeutic benefits, touting the plant-based substance as an all-natural remedy to boost energy, enhance mood, reduce anxiety, minimize depression and alleviate chronic pain.

But U.S. health and safety agencies have raised concerns about products derived from the plant.

While kratom is not listed as a controlled substance by the Drug Enforcement Administration (DEA), it is a "drug of concern" due to potentially opioid-like effects. The agency is weighing evidence to review available data before making a final decision. In 2016, the DEA moved to ban the sale of kratom but put the decision on hold after public outcry.

The Food and Drug Administration (FDA) warns that the substance is inherently addictive and can cause adverse effects. "There are currently no FDA-approved therapeutic uses of kratom and importantly, the FDA has evidence to show that there are significant safety issues associated with its use," states a public health advisory issued by the agency.

To drive the point home further, former FDA commissioner Scott Gottlieb tweeted, "There are no proven medical uses for kratom and #FDA strongly discourages the public from consuming it. Kratom is an opioid and it's an inherently addictive product that can cause harm, which is reason enough not to consume it, but also may make users sick."

How is kratom used?

Leaves from the plant can be smoked or chewed, but because of the bitter taste, it's most commonly purchased as a powder and stirred into yogurt, peanut butter, apple sauce, soda or juice. It can also be taken in gel capsule form or brewed into tea.

Where can you buy kratom?

In the U.S., the herb and powder can be ordered on the Internet or found in vitamin stores, gas stations or paraphernalia/smoke shops. Popular strains and varieties include Indo, Bali, Green Malaysian, Maeng Da, Thai and Borneo. Because it's unregulated, there's no guarantee it's going to be safe. Which sellers are reputable? Which ones aren't? Is it pure? If not, what else is in it? There are no drug warning labels; no way to gauge the potency.

Is kratom legal?

While currently legal at the federal level, seven states—Alabama, Arkansas, Indiana, Rhode Island, Tennessee, Vermont, Wisconsin—and the District of Columbia have banned sale of the product. The FDA banned importing and manufacturing kratom as a dietary supplement in 2014, and the substance was banned in all forms as an import in 2015. In addition, municipal bans have been enacted in San Diego, California; Jerseyville, Illinois; and Sarasota County, Florida. The substance is illegal for human consumption in Denver, Colorado, and throughout Canada.

Since 1943, it's been illegal in Thailand to possess kratom leaves for recreational purposes. In Malaysia, it's a banned substance because of its high propensity for abuse.  

In 2016, the DEA weighed in on kratom's safety and considered classifying it a Schedule 1 drug, which is defined on the DEA website as a "drug with no currently accepted medical use and a high potential for abuse." If added to the list of Schedule 1 drugs, it will join heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone and peyote. Possession of these substances or unlawful distribution or possession with intent to distribute, manufacture, import or export carry serious prison penalties and fines.

According to the U.S. National Library of Medicine, operated by the National Institutes of Health, "preclinical data and case reports published in scientific literature, as well as anecdotal experiences posted online, kratom is not a safe drug. Its consumption is associated per se with drug dependency, development of withdrawal symptoms, craving, serious adverse effects, and life-threatening effects, especially in a multidrug-intoxicating scenario. Furthermore, the idea that legality can equate with the safety of a product might still remain a common insidious misbelief amongst drug users."

In documented cases in the U.S., the substance has been linked to liver toxicity, and—according to the Centers for Disease Control—was the "likely source" of at least 132 cases of salmonella across 38 states. 

Is kratom addictive?

More study is needed, but some experts are sharing anecdotal evidence of kratom addiction. According to George Dawson, MD, "As an addiction psychiatrist, I can attest to the fact that [kratom] is addictive, and with any addiction, there is a tendency to escalate the dose."

Can you overdose on kratom?

When mixed with other drugs, absolutely. Symptoms of an overdose include:

• Shallow or labored breathing
• Slurred speech
• Impaired motor skills
• Lethargy
• Tremors
• Delusions
• Hallucinations

People have died as a result of using kratom, although many of those deaths included other factors, such as pre-existing conditions or multiple drug use. The interaction of kratom with other substances hasn't been well-studied.

What are the side effects?

According to The Kratom Bible, one of the most common side effects of kratom use is "the wobbles," particularly common after drinking strained kratom tea. The wobbles is "defined by the difficulty to refocus the eyes at a specific point without strain and annoyance; this effect can lead to headaches and nausea."

Other side effects of high-dose kratom use include:

• Tachycardia
• Dizziness
• Hypotension
• Dehydration
• Constipation
• Tremors
• Weight gain
• Seizures
• Psychotic symptoms of mental confusion, delusions and hallucinations 

At this point, human clinical trials are lacking regarding long-term risks of kratom use. Unlike heroin or other drugs, no one really knows how the body is affected after years of repeated drug abuse. One substance abuse study done in Southeast Asia, however, reported that all 293 habitual kratom users were dependent on the drug, some severely. Many claimed they were unable to quit due to withdrawal symptoms.

What are the withdrawal symptoms?

Physical withdrawal symptoms include:

• Weight loss
• Decreased libido
• Insomnia
• Muscle spasms
• Aching muscles/bones
• Jerky movements of the limbs
• Watery eyes/nose
• Flushed skin
• Decreased appetite
• Diarrhea

Psychological withdrawal symptoms can include hostility, restlessness, anxiety, aggression and sadness. Long-term users may develop skin pigmentation issues, due to the mitragynine increasing the production of melanocytes.

Does it work in the same way as opioid drugs?

In some ways, yes. In some ways, no. It's likely that the primary active ingredients in kratom, mitragynine and 7-hydroxymitragynine, act on the brain's opioid receptors. As clinical toxicologist Oliver Grundmann explains in The Scientist "On the molecular level, what we know in terms of interaction with the different opioid receptors is that yes, they bind to the opioid receptor, but how they interact with the opioid receptor is distinctly different from classical opioids." That means comparing heroin, morphine, fentanyl or oxycodone to kratom isn't really an apples-to-apples assessment. The main difference? Mitragynine and 7-hydroxymitragynine compounds in kratom seem to mitigate pain without suppressing breathing. Further research needs to be done, however, to determine if some of the compounds in the plant can be harnessed for less-addictive medical benefits.

We asked clinicians at the Hazelden Betty Ford Foundation to discuss kratom and its relationship to opioid and heroin withdrawal.

What are the risks associated with kratom use?

It's an unregulated substance. Buyers don't know what they're getting. It's basically the Wild West. Anything goes.

Additionally, there's a lack of scientific evidence about how it interacts with other substances in a person's system. This could be extremely dangerous.

The bigger picture here is addiction. This drug is addictive. It causes withdrawal. When you rely on it to function in your day-to-day activities, you're living in an addictive state.

What are your thoughts about taking kratom to wean yourself from heroin or prescription opioids?

When people use it as an alternative to heroin or prescription opioids, they're trading one addiction for another. This adds fuel to the fire when it comes to the opioid epidemic. It's a temporary Band-Aid and can lead to relapse and other health concerns. If using kratom has not contributed to your substance use disorder recovery, we recommend considering addiction treatment.

Instead of following expert advice about treating addiction as a chronic disease and well-established principles of recovery, some people just want to hear whatever confirms their beliefs. Just because you don't have to buy a drug from a dealer doesn't mean it's ok. It's not a safe way to treat addiction.

How is kratom like an opioid drug?

Much like heroin and prescription opioid drugs, kratom has been shown to hijack the brain's natural neurotransmitters.

At low doses, it acts like a stimulant, making users feel more energetic. Increased doses can bring on a euphoric state. And at even greater doses, it can act as a sedative, making users feel sleepy. When used in low doses, the effects can last up to two hours. Higher doses have longer-lasting effects, for up to eight hours.

What happens when you go without it? Your body starts craving it, you make impulsive decisions. The brain isn't allowed to heal.

Why are people so terrified of opioid withdrawal?

People will try almost anything to avoid the physical and emotional discomfort of opioid withdrawal, but the reality is there's no "easy" way out of the loop. It requires hard work. The incredible thing, though, is what it's like on the other side of addiction. So many people have gone through similar struggles and now lead really good, really healthy, really meaningful lives in recovery. Their relationships are better, they're more present in their kids' lives, they're thriving and they're living the life they were meant to live.