Kratom: Dangerous Legal Opioid, or Harmless Herbal Supplement?
Recently, the Kingdom of Thailand legalized kratom and marijuana for medicinal use and research, partially reversing a ban that has been in place since 1943. Those who produce, distribute, or do research on these drugs will need a special license. Users (patients) will need a prescription. Recreational use is still banned; and Thailand has very harsh drug laws. So it is a small step, but one that could alleviate a lot of unnecessary suffering.
I assume that anyone reading this knows what marijuana is. But what is kratom? What does it do? And is it safe? Should its use be restricted or banned?
Kratom (Mitragyna speciosa) is a tropical evergreen shrub that grows wild throughout southeast Asia, especially Thailand and Malaysia. It is a relative of the coffee plant. People in the region have used kratom for centuries as a stimulant and pain reliever. It is also used to alleviate withdrawal symptoms from opium or heroin by addicts who are trying to quit. Users typically chew on the fresh leaves or make a tea out of dried leaves. It has recently caught on in the west, where it is available online or in head shops, typically as a loose powder or in gel tablets. It is the most commonly used illicit drug in Thailand — more common than opium, heroin, and marijuana, which are all produced in the region.
The main active ingredient in kratom is mitragynine, though there are other alkaloids that might also be psychoactive. The subjective effects are stimulation, especially at low doses, and opiate-like effects at higher doses, including sedation, pain relief, and euphoria. Mitragynine works by binding to and activating mu-opioid receptors (MORs), just like morphine, heroin, and other opioid drugs do. There is some evidence, however, that it works differently from those other drugs. Activation of a MOR has two distinct downstream effects: 1) initiation of G-protein signaling pathways, which reduce pain and cause euphoria, and 2) initiation of beta-arrestin signaling pathways, which are responsible for respiratory depression. Kratom seems to increase the G-protein signaling but not so much the beta-arrestin signaling. Thus, mitragynine (or synthetic analogs) could be a safer alternative to other opioid pain relievers.
It is not clear what causes the stimulating effects. Some evidence suggests that mitragynine also affects dopamine receptors (like cocaine) and adenosine receptors (like coffee). Or there could be other alkaloids in kratom that cause stimulation. Personally, I have never received any noticeable stimulating effects from kratom. But that could be because I have taken it only after dinner. Or it could be due to some weird quirk in my neurochemistry.
Studies have found that mitragynine is an effective analgesic, with effects that are comparable to oxycodone. That might make kratom sound like a powerful drug, but mitragynine makes up only about 0.5–1.5% of the dry weight of kratom, so the concentration is very low. You would have to choke down several cups of dried kratom to achieve anything approaching a high dose of oxycodone. And isolated mitragynine is not available outside of laboratories.
Back in 2016 the DEA announce its intent to place kratom in the Schedule-I category of the Controlled Substances Act but backed off after receiving letters of protest from concerned citizens, scientists and medical researchers, and fifty members of congress.
According to the CDC, Kratom was involved in 91 known overdose deaths from July 2016 to December 2017 (about 60 per year). But kratom was determined to be the sole cause of death in only seven of those cases. In the other 84 cases kratom was mixed with other drugs, such as alcohol, sedatives, or other opioids. About half of all overdose victims who had ingested kratom also had fentanyl in their system! Given that fentanyl is about 50 times more powerful than heroin, I think it is safe to say that anyone who overdoses with fentanyl and kratom in his system almost certainly was killed by the fentanyl.
Also, we need to compare the half-dozen or so kratom overdoses to the nearly 50,000 annual U.S. overdose deaths from other opioids (i.e. opium, heroin, prescription painkillers, etc.). Some people might object that the number of opioids users far outweigh the number of kratom users. That’s true. 11.4 million Americans have used other opiates for non-prescription use in 2017 compared to an estimated 2 to 4 million who used kratom. Even if we assume the low number of kratom users (2 mill), that would add up to 2.3 annual overdose deaths per million users of Kratom compared to 4,298 overdose deaths per million users of other opioids. That means that traditional opioids are more than 1,800 times more deadly. Kratom is even safer than alcohol. About 173.8 million adults in the US consumed alcohol at least one time in 2018; and there were about 2,200 overdose deaths. That amounts to 12.7 annual overdose deaths per million users. (And that is ignoring the almost 20,000 annual alcohol-related driving fatalities and the 60,000 deaths from alcohol-related medical conditions, such as liver disease.)
The FDA claims that kratom contains the same addictive, potentially dangerous chemicals found in opioids. But that is extremely misleading, if not outright false. First, it does not contain the same — or even similar — chemicals. Mitragynine is a distinct, unique chemical compound unrelated to those found in opium (which contains morphine and codeine) and is different chemically from synthetic opioids such as fentanyl. It is also misleading to suggest that kratom has the same addictive and overdose potential. It may contain the same type of addictive and overdose potential (i.e. similar withdrawal symptoms, suppression of breathing), but certainly not the same degree. You have to wonder how much of this push to ban kratom is driven by the pharmaceutical industry trying to eliminate a cheap, non-prescription alternative to their patented meds.
Although kratom is currently legal at the federal level, it is banned in six states: Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin. It is also banned in a few cities, including San Diego and, surprisingly, my hometown of Denver (one of three U.S. cities to decriminalize magic mushrooms). Some states have imposed age restrictions. It is also illegal in many countries. In Asia it is banned in Israel, Japan, Burma (Myanmar), Malaysia, Singapore, South Korea, and Vietnam. In Europe, it is outlawed in Denmark, Finland, Latvia, Lithuania, Poland, Romania, Russia, and Sweden. It is also banned in Canada, but only if intended for human consumption, which means it can still be sold as incense or plant food (wink-wink).
I use kratom occasionally, and I can testify that it is too weak to be dangerous… or much fun. A medium-sized dose sometimes provides a little mood elevation; but most of the time I don’t feel anything at all. Higher doses just make me feel drowsy. For people who are seeking a legal high, there are better, more powerful alternatives. It is, however, an extremely effective pain reliever. I cannot comment on its effectiveness in combating opioid withdrawal since I have never used opioids regularly.
Some puritanical teetotalers want to forbid all chemical sources of pleasure. But outlawing kratom is likely to do more harm than good. For one, if it were banned then the only way to get it would be from a drug dealer or on the dark net. In that case, procuring kratom would be just as difficult as procuring heroin or oxycodone. Why bother with kratom if it is just as easy to get smack? Thus, if it were outlawed, many current users would switch to more potent substances. Also, many opiate addicts quit with the help of kratom. Banning the substance would take away a useful tool for fighting addiction. This is especially important given the current opioid crisis and lack of treatment options for addicts.
Some experts claim that kratom might be more dangerous than we think. But the argument is based on postulating huge numbers of unreported kratom overdoses. This is the worst kind of argumentum ad ignorantiam fallacy (appeal to ignorance). Essentially the argument is this. There could be hidden evidence that kratom is deadly. Therefore, it is deadly, in spite of no evidence that it is and plenty of reason to think that it isn’t. This same sort of “soft data” argument could be used to support all sorts of absurd claims, such as the claim that the sounds from windmills cause cancer. There is no evidence that they do, and plenty of reason to think that they don’t. But maybe that is only because no one has looked into data linking wind turbines to malignant tumors.
