This is an interesting study with three important things for medical professionals to be aware of.

First, according to the FDA, kratom is not a drug or dietary supplement, but is legal for sale in many states and cities in the U.S. with little regulatory oversight. So, patients can take kratom and increase their dosages over time without your advice, knowledge or monitoring. That should be concerning since kratom is a novel opioid that has shown addiction and drug interaction potential. It provides stimulant instead of depressant effects, which trades the risk for seizures and arrhythmias for the lower risk for respiratory depression.

Second, interest in kratom among the U.S. population is huge. According to Prevete and colleagues, kratom-related videos on YouTube from 2019 have over 19 million views and hundreds of thousands of comments. This interest extends across all social media platforms, online chat forums and internet websites. My reviews of kratom in the American Journal of Health System Pharmacy in 2018 and 2019 and a commentary in The Conversation had over 377,000 views and 167 comments.

Kratom has army of devotees who spend hours finding people expressing concern about it online and attacking them. It is unclear to what extent this army of devotees is motivated by altruistic reasons, fear that a Drug Enforcement Administration Schedule I product designation will deny them the therapy that feeds their addiction or profit through direct or circuitous means from kratom sales. My many discussions have led me to believe that people falling into all three categories are involved.

Third, kratom is not being used primarily for recreational purposes because it does not give users their desirable opioid effects. It is instead being actively touted as an effective treatment for acute pain, chronic pain and for opioid use disorder. While there are innumerable cases of people expressing what a godsend kratom is for their opioid addiction or pain, the clinical trial data is in its infancy with insufficient evidence that it works better than placebo or other over-the-counter or prescription alternatives. Is kratom truly an effective pain reliever, or is it just a legal substitute for an opioid in an addicted patient with resulting opioid induced hyperalgesia? Does kratom help maintain abstinence from other opioids better than methadone or facilitate less loss of work due to its stimulant effects?

Kratom is an interesting natural product that should generate wide discussion in the U.S., but this discussion must include the voices of health professionals. We must push for quality research so the true effects of kratom can be understood and people are not manipulated by testimonials to try a drug with addiction potential. We do not want to go for decades before realizing it does have valuable benefits in certain conditions like we did with cannabinoids.

We have many patients that the U.S. health care system cut off from accessing prescription opioids who are unable or unwilling to overcome their opioid addiction with treatment in the medical environment. Just eliminating kratom will not make them all seek out proven treatments but rather drive some to use heroin and other illegal opioid sources or to consume mega-dose loperamide, which is in and of itself very risky. By the same token, leaving kratom in limbo does not prevent children from accessing it and prevents pregnant women and patients at risk of seizures, arrhythmias, drug interactions and liver damage from hearing warnings about kratom from health professionals. In the current environment, health professionals need to reach out to their patients and ask if they had used or considered using kratom, especially if they have previously had longer term therapy with opioids.

References:

White, CM. The Conversation. The dangers and potential of kratom. https://theconversation.com/the-dangers-and-potential-of-natural-opioid-kratom-87581. Accessed April 8, 2021.

White, CM. Am J Health Syst Pharm. 2019;doi:10.1093/ajhp/zxz221

White, CM. Am J Health Syst Pharm. 2018;doi:10.2146/ajhp161035.

The findings of Prevete and colleagues are highly consistent with what we've heard from several thousand respondents to online surveys regarding kratom use conducted here at Johns Hopkins and elsewhere.

Therefore, physicians who have patients approach them about using kratom for medicinal purposes need to consider what other medications the patient is taking, since we do know that taking kratom in combination with other medications like opioids or with benzodiazepines can increase the chances of potential problems.

There is also the potential for people who take kratom to experience adverse effects such as sedation or gastrointestinal distress. People who take kratom may also become dependent on it, and experience withdrawal when they try to discontinue or reduce kratom use. In addition, physicians should warn patients that products touted as containing kratom are not well-regulated, and thus could possibly contain contaminants or adulterants.