Kratom: the new opioid?

Kratom is an herb in the coffee family extracted from the leaves of a tropical evergreen tree that is native to Southeast Asia. It has been used in herbal medicine for the past several decades to treat chronic pain and diarrhea, increase stamina and energy, and substitute opioids. At low doses, kratom acts as a stimulant. At higher doses, it can reduce pain, act as a sedative, and have psychoactive effects which has led to more recreational use. (Mayo Clinic, 2020; image from Cracking Down on Kratom, 2018)

In many Southeast Asian countries, chewing these leaves is a common occurrence, and not considered addictive. Reportedly, chewing kratom leaves makes someone more alert, talkative, and sociable. You could compare this habitual use to that of people in the Andean region commonly chewing coca leaves, or many of us who drink coffee on a regular basis.

Kratom contains natural alkaloids (mitragynine, 7-hydroxymitragynine, and MGM-9) that act as agonists of both opioid and alpha-2 receptors. As we have discussed in class, alpha-2 receptors are adrenergic receptors mainly located in the membrane of adrenergic axon terminals and in the pancreas. The effect of binding inhibits norepinephrine release from axon terminals – for example, inhibiting insulin secretion in the pancreas. Alpha-2 agonists are used in the treatment of hypertension; ADHD; symptoms of alcohol or opioid withdrawal; and adjuncts for sedation (Ismail et al, 2019; Boron & Boulpaep, 2017; Giovannitti, Thoms, & Crawford, 2015).

There is inadequate research regarding the effectiveness of Kratom for these medicinal uses. It seems that its’ pharmacologic properties may have some promise as an opioid alternative, although some studies have shown that kratom can lead to similar withdrawal symptoms. Side effects of kratom include hypotension, respiratory depression, hallucinations, aggression, and vomiting. There have been several reported cases of acute liver injury from chronic kratom use, as well as instances of seizures, coma, and death from overdose. The US FDA has illuded to concern about its’ adverse effects, potential drug interactions, and addictive properties. But at this time, kratom is legal and minimally regulated in the vast majority of the US and can be bought easily online. (LiverTox, 2012 ; Mayo Clinic, 2020)

Ethically, is it permissible to allow for the legal sell and purchase of kratom when we are aware of potentially fatal consequences? On the basis of autonomy, should individuals addicted to opioids to have the option to explore this ‘natural’ alternative? In respect to non-malfeasance, should the FDA work harder to put kratom behind the counter? The last thought I will leave you with is that kratom does not show up on standard drug tests – would you be comfortable with your surgeon taking kratom? Is it equitable for someone to lose their job for medical marijuana use, but a coworker who uses kratom chronically to keep theirs?

References:

Boron, W. F., & Boulpaep, E. L. (2017). Medical physiology. Philadelphia, PA: Elsevier.

Cracking Down on Kratom: FDA Investigation, Enforcement, Seizure, and Recall of Products Reported to Contain Kratom. (2018, November 30). Retrieved November 17, 2020, from https://www.fdli.org/2018/08/update-cracking-down-on-kratom-fda-investigation-enforcement-seizure-and-recall-of-products-reported-to-contain-kratom/

Giovannitti, J. A., Jr, Thoms, S. M., & Crawford, J. J. (2015). Alpha-2 adrenergic receptor agonists: a review of current clinical applications. Anesthesia progress, 62(1), 31–39. https://doi.org/10.2344/0003-3006-62.1.31

Ismail I, Wahab S, Sidi H, Das S, Lin LJ, Razali R. Kratom and Future Treatment for the Opioid Addiction and Chronic Pain: Periculo Beneficium? Curr Drug Targets. 2019;20(2):166-172. doi: 10.2174/1389450118666170425154120. PMID: 28443503

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Kratom. [Updated 2020 Apr 3]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK548231/

Mayo Clinic. Kratom: Unsafe and ineffective. (2020, June 03). Retrieved November 17, 2020, from https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/kratom/art-20402171