Kratom use and toxicities in the United States

Kratom use and toxicities in the United States

Tyler Stevens, PharmD, CentraCare Health- St. Cloud

Background: Kratom is an herbal supplement made from the leaves of Mitragyna speciosa. Native to Southeast Asia, the leaves of this plant have been a part of traditional medicine for centuries in areas of Southeast Asia for its stimulatory and analgesic effects. Use of kratom in the United States has gained popularity since 2010, with claims that it is a safe option for the treatment of pain, mood disorders, opioid use disorder (OUD) and opioid withdrawal. While marketed as a safe-alternative for OUD, the active component of kratom, mitragynine, has agonist activity at the mu opioid receptor which has potential for dependence and addiction. Other components of kratom include hydroxymitragynine and synthetic 7-hydroxymitragynine, believed to produce more potent opioid effects than mitragynine. Multiple other alkaloids with unknown potency or clinical effects can also be found in kratom. Due to increasing reports of kratom associated toxicities and deaths, the FDA has released statements warning the public on the risks associated with its use. Starting in 2012, kratom has been identified on import alerts for unapproved drugs by the FDA. Since then, they have recalled or seized large quantities of kratom on numerous occasions. The Department of Health and Human Services has recommended the DEA classify kratom as a Schedule I substance.

Purpose: To examine the prevalence of adverse effects and deaths due to kratom use. 

Study design: This review article examined data from the U.S. National Poison Data System (NPDS) on voluntarily reported exposures to kratom from January 1, 2011 to July 31, 2018 and kratom-associated fatalities identified by a county medical examiner’s office in the state of New York.  

Results: Of 2,312 kratom exposures reported, 935 were single kratom exposures. There was also a sharp increase in reported exposures in 2016. Route of exposure was predominantly oral (86.2%) and reason for exposure was most often intentional abuse or misuse (61.6%). The most common adverse effects reported were agitation (18.6%), tachycardia (16.9%), and drowsiness (13.6%). Serious adverse effects reported were seizure (6.1%), withdrawal (6.1%), hallucinations (4.8%), respiratory depression (2.8%), coma (2.3%), and cardiac or respiratory arrest (0.6%). Four cases of neonatal abstinence syndrome and two deaths were also reported to the NPDS. According to the New York medical examiner’s office, kratom was listed as a cause or contributing factor of death in four cases, two of which, kratom was identified as the sole contributor.  

Conclusion: The results presented demonstrate potential adverse effects associated with kratom, raising concerns about the risk for serious toxicity and death from kratom use. Reports of neonatal abstinence syndrome suggests kratom can produce dependence similar to opioids. The data collected by NPDS was given voluntarily, therefore the prevalence of kratom toxicity is likely greater than depicted in this report.  Based on the data presented and because there have been 44 kratom-related deaths reported by the FDA, the authors pose kratom’s availability as an herbal supplement should be reconsidered.

Key Point: Kratom is an herbal supplement, typically used to treat pain, OUD, and mood disorders, and is associated with serious adverse effects and death. This supplement’s availability will likely be reconsidered in the near future. 

References:

  1. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom use and toxicities in the United States. Pharmacotherapy. 2019; 39(7): 775-777.

  2. Anwar M, Law R, Schier J. Notes from the field: kratom (Mitragnya speciosa) exposure reported to poison centers - United States, 2010-2015. MMWR Morb Wkly Rep. 2016; 65(29):748-9.

  3. Statement from FDA Commissioner Scott Gottlieb, M.D. on FDA advisory about deadly risks associated with kratom [FDA Statement]. U.S. Food & Drug Administration. Nov 2017.

  4. Statement from FDA Commissioner Scottt Gottlieb, M.D., on the agency’s scientific evidence on the presence of opioid compounds in kratom, underscoring its potential for abuse [FDA Statement]. U.S. Food & Drug Administration. Feb 2018.

  5. FDA and Kratom [Public Health Focus]. U.S. Food & Drug Administration. April 2019.

  6. FDA oversees destruction and recall of kratom products; and reiterates its concerns on risks associated with this opioid [FDA News Release]. U.S. Food & Drug Administration. Feb 2018.