What are the risks and recommendations for Kratom use?

Kratom: Risks and Recommendations for Use

Kratom should be avoided due to its significant risks including liver toxicity, seizures, physical and psychological dependence, and potential for death, particularly when used with other substances. 1

What is Kratom?

Kratom (Mitragyna speciosa) is a plant-based substance containing over 40 alkaloids, with mitragynine and 7-hydroxymitragynine (7-OH-MG) being the primary psychoactive compounds. These alkaloids act on mu, delta, and kappa opioid receptors, as well as adrenergic, serotonergic, and dopaminergic pathways 1.

Risks Associated with Kratom Use

Physical Health Risks

• Liver toxicity: Kratom has been linked to hepatotoxicity 1
• Seizures: Case reports have documented seizures associated with kratom use 1
• Death: Fatalities have been reported, particularly in cases of polysubstance use 1
• Respiratory effects: While lower risk than traditional opioids, respiratory depression is still possible 1
• Cardiovascular effects: May cause tachycardia or bradycardia 2

Dependence and Withdrawal

• Physical dependence: Users can develop tolerance requiring increased doses 1
• Withdrawal symptoms: Similar to classic opioid withdrawal upon cessation 1
• Psychological dependence: Can develop with regular use 1

Drug Interactions

• Kratom can potentiate toxicity of other medications through:
  • Modulation of cytochrome P450 enzymes
  • P-glycoprotein interactions
  • Uridine diphosphate glucuronosyltransferase enzyme interactions 1
• Particularly dangerous when combined with:
  • Benzodiazepines
  • Other opioids
  • Alcohol
  • CNS depressants 1, 3

Purported Uses and Claims

Despite its risks, kratom is used for:

• Pain management as an alternative to prescription opioids 3
• Self-management of opioid withdrawal symptoms 3
• Treatment of anxiety, depression, and PTSD (though evidence is lacking) 1
• Recreational purposes for mild euphoria 1

Recommendations for Healthcare Providers

Patient Assessment

• Screen patients for kratom use, particularly those:
  • With chronic pain conditions
  • Currently prescribed opioids
  • With history of substance use disorders
  • Reporting unexplained liver abnormalities or seizures 3

Patient Education

• Inform patients about:
  • Lack of FDA approval for any medical use
  • Potential for dependence and withdrawal
  • Risk of contamination (no quality control standards)
  • Dangerous drug interactions
  • Signs of toxicity requiring immediate medical attention 1, 3

For Patients Using Kratom for Opioid Withdrawal

• Recommend evidence-based alternatives:
  • Medication-assisted treatment with buprenorphine or methadone 4
  • Supervised medical detoxification
  • Referral to addiction specialists 2

For Patients Using Kratom for Pain

• Recommend evidence-based alternatives:
  • Nonopioid pharmacologic therapies (NSAIDs, acetaminophen) 2
  • Nonpharmacologic approaches (physical therapy, exercise) 2
  • Referral to pain specialists when appropriate 2

Tapering Recommendations for Kratom Users

For patients wanting to discontinue kratom:

• Gradual tapering: Reduce dose by 10% of the original dose per week 4
• Slower tapers (5-10% per month) may be needed for long-term users 4
• Monitor for withdrawal symptoms: Similar to opioid withdrawal 1
• Consider supportive medications for specific symptoms:
  • Clonidine for sympathetic hyperactivity
  • Loperamide for gastrointestinal symptoms
  • Hydroxyzine for anxiety 4

Regulatory Status

• Not FDA-approved for any medical use
• Not currently scheduled under the Controlled Substances Act
• Banned in several states and countries
• Easily accessible online and in specialty shops 1

Conclusion

While kratom has gained popularity as an alternative to prescription opioids and for self-management of opioid withdrawal, the significant risks of liver toxicity, seizures, dependence, and potential fatal outcomes outweigh any purported benefits. Healthcare providers should discourage kratom use and direct patients toward evidence-based treatments for pain and substance use disorders.