Kratom (Mitragyna speciosa) is a psychoactive plant in the coffee family that has been used medicinally for generations in Southeastern Asia across diverse contexts. Manual laborers use it to enhance stamina and energy; and it is widely used to relieve pain, diarrhea, and cough. In addition, kratom has long been used to relieve symptoms of opioid withdrawal.[1,2] Within the past decade, the use of kratom has increased considerably in the West, and it is now estimated that millions of people in the United States take kratom regularly. The expansion of kratom use to the West has resulted in widespread curiosity, concern, and controversy.

Controversy

In August 2016, the US Drug Enforcement Administration (DEA) announced its intention to place kratom on Schedule I, along with heroin and cannabis, as a substance with high potential for abuse and no currently accepted medical use. They cited anecdotal reports of "kratom-related deaths," seizures, and liver failure, along with concerns that kratom is highly addictive and linked to psychosis. Further, the DEA warned that withdrawal from kratom is associated with hostility and aggression in addition to other mental and physiologic symptoms.[3]

A public backlash to the DEA's announcement was swift and furious; citizens wrote to politicians, petitioned the White House, and talked to the media about what they saw as an infringement on their right to use a helpful plant. Researchers expressed concern that the study of kratom's potential medical uses could be crippled by the expensive and time-consuming regulatory hurdles that scientists must clear before studying Schedule I substances. In an unprecedented response, the DEA responded by withdrawing their intent to schedule, citing an effort to gather additional scientific information and to accept public comment. Over the next 6 weeks, more than 23,000 people submitted comments; over 99% expressed support for keeping kratom legal.

On November 14, 2017, the US Food and Drug Administration (FDA), citing their science-based obligation to the public, issued an advisory warning of "deadly risks" associated with kratom use, listing 36 deaths (later increased to 44) "associated with the use of kratom-containing products." The FDA also warned of the risk for harm from adulterated kratom products and serious side effects including seizures, liver damage, and addiction.[4]

Meanwhile, kratom advocates continue to argue that the FDA's kratom "death count" is largely meaningless because it is anecdotal and consists primarily of individuals who took other potentially deadly substances. Advocates have organized in an effort to keep kratom legal federally and in the 44 states that have not yet banned its use. Many claim that the influence of lobbying groups (for example, the pharmaceutical industry) is behind government warnings.

The Science

Kratom is not a classical opioid; however, studies in rodents indicate that alkaloids in kratom bind to opioid receptors and have antinociceptive properties. These studies also suggest low toxicity and levels of respiratory depression that are markedly lower than those induced by classical opioids.[5] At low doses, the plant has stimulating effects; while at higher doses, people report relaxation.

The limited scientific data on the short-term effects of kratom in humans contrasts with the dire warnings of the DEA and FDA and indicates that no causal relationship has been established between kratom consumption and fatalities or psychosis.[6,7] Existing studies converge to provide evidence that people are using kratom to successfully manage pain, improve mood and anxiety, and as an opioid replacement.[7,8,9] There is no high-quality (nonanecdotal) evidence to link kratom to seizures, liver damage, or premature death.

Kratom may have public health benefits; on February 4, 2018, nine North American scientists wrote to the Trump Administration to express concerns that restricting access to kratom might reasonably be expected to increase deaths because "people who have found kratom to be their lifeline away from strong opioids will be vulnerable to resumption of that opioid use," whether the use was for pain relief or to combat opioid addiction using kratom as a replacement.

Potential benefits of kratom use notwithstanding, scientific findings provide evidence for dose-dependent side effects, especially for people taking doses of greater than 5 g of plant material per dose or using kratom more than 21 times per week. These side effects include nausea and vomiting, dizziness, sedation, chills and sweats, and visual disturbances.[8,9] Moreover, heavy users who stop may experience an uncomfortable flu-like withdrawal syndrome that includes irritability and anxiety.[7] The existing literature does not indicate a link between kratom and violence, suicide attempts, or criminal behavior. Indeed, preliminary indications are that even heavy kratom use results in little impairment in social functioning.[10]

At this time, the study of kratom is in its infancy, and people on both sides of the kratom debate agree that more research is necessary. Rigorous longitudinal studies, including randomized clinical trials, have yet to be conducted, leaving much to be learned about this plant.

My Opinion

In light of the science on kratom, the FDA's dire warnings make little sense and risk conjuring drug hysteria—a phenomenon characterized by the spreading of biased, sensational stories that can lead to the pursuit of harmful regulatory approaches that are out of proportion to any demonstrated public health risk. Severely restricting access to kratom may, in fact, worsen a legitimate public health crisis by removing access to a harm reduction tool—an alternative to the dangerous and too often deadly opioids heroin and fentanyl. Moreover, people with chronic pain are not always able to access effective medical care, and banning kratom would remove a pain relief option without science-based justification. Instead, the FDA should take regulatory action, immediately passing restrictions on non-adult use and ensuring the purity of kratom products.