Current reports indicate that a drug called kratom is used by more than 5 million people in the United States to treat a broad variety of conditions, including chronic pain, opioid use disorder (OUD), mood disorders, and insomnia.
Kratom, also referred to as Thom, Biak, Kakuam, or Thang, is a plant leaf extract traditionally used as a stimulant at low doses and an analgesic at higher doses in Southeast Asia. In recent years, through online transactions and at local headquarters, it has reached the US (often illegally).
However, its use has gained considerable attention, and the US Drug Enforcement Agency now lists kratom as a “drug of concern” (DEA). While the use of kratom is legal at the federal level, many states, including Alabama, Arkansas, Indiana, Wisconsin, Rhode Island, and Vermont, have outlawed kratom. In addition, many restrictions on kratom have been imposed by the US Food and Drug Administration (FDA), including bans on its import.
Miracle Medicine or Herb of Abuse?
With patients increasingly leaning towards alternative and complementary pain-relieving agents, such as marijuana, CBD products, coca tea, ephedra and kratom, health care providers face more questions – and more responsibilities – about understanding these “natural” products. Many of these substances are inconsistently regulated and lack data, leaving clinicians unable to disseminate quality information on risks and benefits to their patients.
Kratom, in particular, is a herbal substance used for snowballing in the United States. It was first imported to the US in the 1980s and currently has an estimated 3 to 5 million users in America.1 People use kratom to help manage a variety of conditions and symptoms, such as opioid dependence, constipation, mood disorders, chronic pain, and muscle spasms.
Herein, we address what is known about the history, pharmacology, risks, and benefits of kratoms, with the aim of empowering pain management providers to partner with their patients to openly discuss their use.
Dose Dependent Effects and Withdrawal Symptoms
The key feature of kratom is its dose-dependent effects. Low doses, ranging from 1 gram to 5 grams, are most likely to result in stimulating effects, such as increased alertness, energy, and restlessness. At doses greater than 5 grams, the opioid-like effects of kratom, including analgesia, sedation and possible euphoria, are predominant. This unique feature is observed even when the historical use of indigenous populations is reviewed.
Kratom’s use to relieve symptoms of opioid withdrawal has also been reported. Alpha-2 noradrenergic activity of kratom may explain the reported use of kratom to minimize opiate withdrawal symptoms. Clonidine is an alpha-2 agonist commonly used in opioid withdrawal protocols.12 Stimulation of alpha-2 receptors is also thought to contribute to stimulating effects such as those seen at low doses.
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