Is Kratom (mitragynine) safe to use for pain management?

Kratom Safety for Pain Management

Kratom should NOT be used for pain management due to serious safety concerns, lack of regulatory oversight, potential for dependence and withdrawal, and explicit warnings from major medical societies. 1, 2

Guideline-Based Recommendations Against Kratom Use

The Society for Perioperative Assessment and Quality Improvement (SPAQI) explicitly recommends discontinuing kratom use and warns against its use due to potential serious adverse effects. 1, 2 This represents the clearest guideline-level evidence available on this topic.

Specific Safety Concerns

Serious adverse effects associated with kratom include:

• Neurologic toxicity: Seizures, hallucinations, delusions, and coma have been reported with chronic use 2, 3
• Withdrawal syndrome: Patients taking more than 5-15g per day may experience withdrawal if discontinued abruptly, similar to opioid withdrawal 2
• Hepatotoxicity: Liver damage has been documented 3
• Cardiovascular effects: Myalgias, chills, and other systemic symptoms 3
• Mortality risk: The FDA has attributed 36 deaths to kratom, though many involved polypharmaceutical ingestions 4

Regulatory Status and Quality Control Issues

The FDA has issued public health warnings against kratom use and banned its sale as a dietary supplement, yet it remains widely available online without federal regulation. 3, 4 This lack of oversight creates significant risks:

• No standardization of dosing or alkaloid content 5, 6
• Potential for contamination and adulteration 7
• No quality control mechanisms 5
• Products marketed inappropriately without safety data 7

Pharmacologic Profile and Abuse Potential

Kratom's active alkaloids (mitragynine and 7-hydroxymitragynine) act as opioid receptor agonists with potency potentially exceeding morphine in animal studies. 3 The substance also affects:

• Mu- and delta-opioid receptors 3
• Alpha-2 adrenergic receptors 3, 4
• 5-HT2A receptors 3

Kratom produces both analgesic and euphoric effects, leading to documented addiction and physical dependence. 3, 5, 6 Withdrawal symptoms occur in both adults and newborns exposed in utero. 5

Detection and Drug Interaction Concerns

Kratom does not appear on standard drug screens, making it difficult to identify as a cause of harm, especially when combined with other substances. 5, 4 Additionally, kratom acts as both a cytochrome P-450 substrate and inhibitor, creating potential for significant drug interactions. 5

Evidence-Based Alternatives for Pain Management

Instead of kratom, established multimodal pain management strategies should be employed: 1

For Acute/Moderate Pain:

• Acetaminophen as first-line therapy when not contraindicated 1
• NSAIDs with appropriate ulcer prophylaxis 8
• Combination therapy (NSAID plus acetaminophen) offers statistically significant superiority over either agent alone 8

For Neuropathic Pain:

• Gabapentin or pregabalin as first-line adjuvants 8, 1
• Duloxetine for neuropathic pain conditions 8
• These agents have established efficacy and safety profiles unlike kratom 8

For Severe/Refractory Pain:

• Opioid therapy in carefully selected patients with appropriate monitoring 8
• Morphine remains the standard starting opioid for opioid-naïve patients (5-15 mg oral or 2-5 mg IV) 8
• Fentanyl for patients with renal insufficiency or poor morphine tolerance 8

Critical Clinical Pitfalls

Common mistakes to avoid:

1. Assuming "natural" means safe: Kratom's opioid-like properties carry similar risks to prescription opioids without the benefit of standardization 2, 3

2. Failing to screen for kratom use: Since it doesn't appear on standard drug screens, direct questioning is essential in patients with unexplained symptoms or those on opioid therapy 5, 4

3. Abrupt discontinuation: Patients using >5-15g daily require gradual tapering to avoid withdrawal 2

4. Ignoring polypharmacy risks: Many kratom-related deaths involved multiple substances; assess all substances of abuse 4

Special Population Considerations

Chronic pain patients on prescription opioids represent a particularly vulnerable population, as some use kratom to self-treat opioid withdrawal symptoms. 3 This creates a dangerous cycle of:

• Unmonitored opioid receptor stimulation 3
• Unpredictable drug interactions 5
• Risk of precipitating withdrawal from either substance 3
• Undermining legitimate pain management strategies 1

The CDC recommends nonopioid therapies as preferred for chronic pain due to opioids' small short-term benefits and uncertain long-term benefits—guidance that applies equally to kratom given its opioid-like mechanism. 1

Bottom Line for Clinical Practice

No controlled human pharmacologic, pharmacokinetic, or clinical trials support kratom's safety or efficacy for pain management. 4 The available evidence consists primarily of animal studies, case reports, and surveys—insufficient to justify clinical use given documented serious adverse effects. 5, 6, 4

Opioid stewardship programs within healthcare institutions should include kratom surveillance to minimize opioid-related harm. 1 When patients disclose kratom use, transition them to evidence-based pain management strategies with appropriate monitoring and support. 1, 2