Kratom is an herb that comes from a tropical evergreen tree in Southeast Asia. The leaves may be chewed, smoked, made into a tea, or taken as tablets or capsules. A member of the same family as gardenia and coffee, it acts as a stimulant in low doses and as an opioid in higher doses. Common uses include pain relief, mild stimulation, and opiate withdrawal.
The leaves have been used in Malaysia and Thailand for centuries to help with fatigue and improve energy, but some countries in Southeast Asia have now made its use illegal. In the United States, it has been used as an alternative medication for diarrhea and muscle pain as well as a treatment for opiate addiction and withdrawal. Research is not available to substantiate its safety or efficacy in Asia or the U.S.
Is Kratom Safe?
On February 6, 2018, the Food and Drug Administration (FDA) said it had no information to support using the herb for medical treatments. The FDA also issued a warning against using it as a substitute for prescription opioids or as a treatment for opioid withdrawal. Instead, the agency recommends using approved medications, such as methadone, buprenorphine, and naltrexone, from a licensed health care provider in addition to counseling. The FDA also says there are better substitutes for pain.
The New York State Office of Alcoholism and Substance Abuse Services says the herb is similar to morphine in high doses and may lead to addiction, and the FDA calls it a “drug of concern.” Some poison centers are reporting a rise in calls concerning its use.
In February 2018, the U.S. Centers for Disease Control and Prevention (CDC) reported an outbreak of kratom-related salmonella infections in 20 states. Although there were no deaths, there were 28 reported cases, 11 of which required hospital stays. Officials know the sick consumed tea, powder, or pills, but they have no other details.
There have been 44 reports of deaths related to the substance. Some included the use of other drugs and substances in conjunction with kratom. The dangers are still largely unknown. Reports of overdose are uncommon, but it can be harmful when used with drugs or alcohol. While it has not been banned in most American states, the herb poses major risks because it is addictive, unregulated, and dangerous when mixed with other substances.
Risk of Addiction
As is the case with opioids, long-time abuse of kratom may lead to dependence. Its use changes the wiring system in the brain by interacting with the opioid receptors in the central nervous system, flooding the brain with neurotransmitters that control its reward centers. If dependence has occurred and the supply is withdrawn, withdrawal can result. The Drug Enforcement Administration (DEA) lists these potential physical side effects:
- Bone and muscle pain
- Runny nose and watery eyes
- Mood swings
More serious withdrawal symptoms might include confusion, delusions, or hallucinations. Emotional symptoms may also result from withdrawal. They include:
- Cravings for the drug
Long-time use of the substance may result in the abuse of increasingly larger amounts for an extended time in spite of the problems it can cause economically, physically, emotionally, and socially. It can also cause serious side effects like a fast heartbeat and low blood pressure.
Lack of Regulation
Until 2014, suppliers in the United States sold kratom as a nutritional or dietary supplement. Although the FDA has attempted to limit its import, the New York Times states it is still sold as tablets or powders in tobacco shops where it is labeled as incense. Online vendors often label it as “ketum.”
Because it is not a controlled substance, nobody regulates its quality or composition, raising the danger that the product may not be what the label says. There are also no official drug labels to recommend proper doses and no warnings of possible dangers or side effects. It may be cut, mixed with other drugs, or contain dangerous pesticides and chemicals.
The legality of kratom is a gray area, and regulations that exist vary widely. Canada and a few other countries around the world have completely legalized the drug while others, including Malaysia, Thailand, and the United Kingdom, schedule it as a banned substance. Malaysia banned it entirely in 2003, and Thailand did so in 1979. It is against the law to buy, sell, or use the products in these countries.
In other countries, including several European nations as well as New Zealand and Australia, it is a controlled substance. They place specific limits on their use, marketing, importation, and selling. It is not completely illegal in these locations, however.
In Germany, the drug was openly imported and marketed until 2011 when the government added it to a list of unapproved pharmaceutical drugs, making it against the law to sell, buy, carry, or import products with kratom. Offenders may face incarceration, penalties, and fines.
In countries like Russia, Denmark, Burma, and Myanmar, the product is illegal, and laws are enforced. Other locations, including Poland, Israel, and Romania, consider it a controlled substance. In Norway, it is a prescription drug.
In the United States, regulations vary widely because there are a number of state and federal regulatory agencies as well as several different law enforcement agencies. This means a drug can be unregulated by the federal government but individually regulated by the states, making the situation difficult to understand.
In 2018, however, these restrictions were in effect in specific locations. In Florida, for instance, it is illegal to use only in Sarasota County while the substance is legal everywhere in California except San Diego. In Illinois, it is legal for buyers 18 or older except in Jerseyville, but it is legal for everyone over 18 in New Hampshire.
Alabama, on the other hand, lists it as a schedule 1 controlled substance while Tennessee and Arkansas basically list it as a banned controlled substance. Wisconsin bans only the primary alkaloids in the substance, and Indiana has banned it as a synthetic drug.
Other states have regulations that are less clearly defined. The movement to make it illegal in the U.S. because of its psychoactive and addictive properties is strong, but the opposition argues that it could be a less harmful replacement for other dangerous opioids. It is, nevertheless, entirely banned to members of the U.S. military.
Interactions With Other Drugs
Throughout the world, different cultures combine kratom with other substances, and that increases the potential danger of every drug in the combination. In Southern Thailand, young Muslims mix the herb with caffeinated beverages or codeine cough syrups to create a beverage that has an effect similar to alcohol. Users may also mix it with other psychoactive drugs like cocaine, cannabis, and LSD. It is also mixed with stimulants to produce feelings of euphoria, creating combinations with the potential to cause seizures or even death.
When combined with opioids like hydrocodone or morphine, the substance has been shown to make depression worse or cause fatal interactions. These mixtures not only increase the risks of side effects, but they make it more likely for addiction, dependence, or overdose to occur.
The CDC says deaths from drug overdoses continue to rise each year. In 2016, over 63,000 Americans died from drug overdoses. Of those, 66 percent involved an illegal or a prescription opioid. Deaths went up in every category of drugs examined for both genders and all races. They also rose among those 15 or older in both urban and rural locations.
Kratom and the FDA
The FDA, which warns against the use of kratom, has no approved uses for the drug, and it solicits reports about safety issues from users. The agency says it is actively reviewing scientific information and cautions against kratom-like products or those containing its psychoactive compounds: mitragynine and 7-hydroxymitragynine.
After issuing import alerts for unapproved drugs in 2012 and 2014, the FDA has taken several steps. In 2014, U.S. Marshals seized over 25,000 pounds of raw kratom material valued at more than $5 million. In 2016, U.S. Marshals confiscated nearly 90,000 bottles of dietary supplements that contained the drug. They valued the haul at $400,000. In the same year, Marshals seized over 100 cases of products valued at over $150,000.
More recently, in 2018, the FDA issued warning letters to companies about health claims on the product and the agency’s ongoing medical concerns. They also warned about products that claimed to treat pain, opioid addiction, or other conditions. Another announcement warned of recall for salmonella-laced products.
In 2017, Scott Gottlieb, M.D., the head of the FDA, spoke of his concerns over kratom-like products in a meeting of the FDA in Kansas City. He reported 36 deaths associated with the use of the substance and reiterated the dangers of consumers putting themselves in harm’s way in an attempt to relieve pain or deal with addictions. According to Gottlieb, poison control centers receive hundreds of calls about the products every year, and more than 340 million packages containing illegal opioids, kratom-like substances, and other dangerous products come into the U.S. annually.
In February 2019, USA Today reported that poisonings from kratom had soared as the herb became more popular as a treatment for recovery from opioid withdrawal and addiction. Calls to poison control centers increased by 50 times from 13 in 2011 to 682 in 2017, likely as a result of increased use.
Danger of Overdose
Kratom can be harmful on its own, but it is especially dangerous when combined with other substances. Someone who is drinking the herb as part of a mixed drink or taking a dietary supplement, for instance, may also be taking prescription painkillers, which is a potentially deadly combination. Overdose can cause the following symptoms:
- Aggressive behavior
- Nausea and vomiting
Even small doses can cause side effects, especially when used for an extended period of time. These include:
- Loss of appetite
- Dangerous interactions with other drugs
Large doses may lead to complications like kidney failure and liver damage. Signs of serious damage to the kidneys and liver include dark urine and yellow-colored eyes and skin. Use of the substance is particularly harmful to the liver because it is unable to remove toxins as easily as the kidneys. The kidneys, however, are not designed to filter harmful drugs, and people with liver damage are more susceptible to kidney problems.
Although kratom has its proponents and may actually be helpful in some circumstances, its safety has not been proven, and its use is entirely unregulated. Based on available information, its risks seem to outweigh its benefits. Even if it proves useful for addiction recovery, users need to know they’re getting a high-quality product and clear instructions before using.