Kratom and the US Opioid Crisis: A Help or a Harm?

A quick thank you , as I always do before we start to Montage Health and the Montage Health Foundation for their support of my quest , as an addiction medicine doctor , to use this podcast to produce fun and engaging education for healthcare providers on addiction . And if you're not a healthcare provider , well , I am glad you're here too .

I hope that you find this podcast educational and useful . So with that , we are going to jump right in to this podcast episode .

Hello friends , this is Dr Casey Grover from the Addiction Medicine Made Easy podcast , and I am so excited to be doing this collaborative episode on Kretum with Drs Sonia Deltradici and John Keenan from the Addiction Medicine Journal Club . I am beyond excited . That's the geek in me talking about today's episode . So let's dig in .

Addiction Medicine Journal Club is one of my favorite podcasts . Sonia and John do an awesome job of reviewing recent articles in addiction medicine and I've emailed with them a few times about various topics in addiction medicine and we've shared some thoughts on articles as fellow addiction medicine geeks and doctors .

But most recently I reached out to them to see if we wanted to collaborate on a podcast episode and we connected for a video conference and came up with so much to talk about and we're probably well , I hope we're going to be able to do more than one episode together , and the topic we picked for tonight was Kratom .

So with that , sonia and John , how are you both tonight as we get ready to discuss our experiences treating patients who use Kratom ?

There are multiple traditional medical uses for kratom , including pain relief and to stave off fatigue . It has also been used recreationally for euph kappa opioid receptors and it actually also may inhibit the cyclooxygenase enzyme to produce an anti-inflammatory effect and at lower doses it has some mild stimulant properties .

So I actually can say I was in clinic today and I talked to several of my patients about Kratom , so I'm excited to see how this conversation goes . So , sonia and John , in your practice , how are patients presenting to you when they are using Kratom ? Are they coming and saying I need help with Kratom ? Does it come up later ? What are y'all seeing ?

Yeah , it's interesting .

It's interesting . It's often kind of my patients with a previous history of substance use disorder are now using it kind of without any other medication assistance to treat symptoms that they kind of attribute to their diseases .

I was searching for a botanist who could talk to me about it , and I know apparently a lot of botanists and none of them have even heard of it .

And yet Tobacco Hut , you know two blocks from my house , has , you know , a Kratom sign with , you know , 24 inch high letters out there Like it's a huge product and I feel like there's so little publicity about it . It's , it's very , it's not really underground , but it's very kind of unknown , and so I think doctors don't know to ask about it .

I certainly didn't know to ask about it till relatively recently , but I'm going to have to be , I think . I think it's important to start asking , because you can just buy it over the counter .

My experience has also been like yours , that if people don't specifically come to me saying I need help with kratom , they don't think to bring it up . So actually I'm very grateful Our urine drug test . We now add Mitragyna that's the way the lab tests for it . So I'm now screening most of my patients to see if they're using Kratom .

I just don't think to bring it up .

Let's say we're starting buprenorphine , they don't think they're using any opiates , but they don't tell us about the kratom and we precipitate withdrawal from that . Would that be possible ?

I don't know if there's a lot of literature on this , and I feel like the two kind of phenotypes of patients I see are the one says I'm using Kratom , help me , and I just tell them to wait , you know 12 hours , and then start . Or I didn't know Kratom was an opioid . Why am I feeling so bad ? And then we started .

So I suppose , though , since it does have opioid agonism , if someone's using Kratom and you're starting buprenorphine , say for pain , not aware that they're opioid dependent , you could yeah , that's what I'd worry about , but I don't know if the opioid agonism is .

I won't say what's on the label , because there's no instructions on the label of these products , but they know they're using 10 , 20 , 30 , whatever bottles a day , and so they know they have a problem . I wonder if the person who's using just one bottle two bottles a day , if there's enough opioid agonism to worry about precipitated withdrawal .

I don't know , though . Anyone want to do a study out there ? Please let us know .

And actually what happens is it's sort of like the mirtazapine of drugs , right , it has like the stimulate-like effect at lower doses , as if you raise up you get more of an opioid-like effect and so by the time they present it to me you're right it's like 15 , 20 vials a day .

They're doing very large amounts and when they present it and using that degree , it really is kind of more of a pure mu opioid type effect . So they kind of present a lot like my classic kind of opioid withdrawal patients , at least the ones I've

seen .

And then also like agitation , anxiety , insomnia . I haven't seen the true opioid withdrawal with like diarrhea , the more physical diarrhea vomiting , fevers , shaking . But again , I haven't had a ton of patients . What about you ?

But I did have one patient and I let him know I'm researching more about kratom and he goes man , that withdrawal was awful and then my other patient said the buprenorphine withdrawal was worse than kratom withdrawal . And then my other patient said the buprenorphine withdrawal was worse than Kratom withdrawal .

The only thing I think I might notice a little bit different is maybe there's some more mood symptoms , simply because Kratom does have some stimulant effects and a lot of my patients , when they talk about stimulant withdrawal , are just really dysphoric .

The one other thing that I thought was interesting was just some of my patients couldn't really identify what was happening . They didn't know that kratom was an opioid . So they talked about symptoms and they didn't know what they were .

And then ultimately we went back and I identified them as as opioid withdrawal and kind of the milder symptom was just kind of like a vague sense of malaise or like just kind of restlessness which would probably be consistent with mild opiate withdrawal .

So I think for the most part I've seen kratom withdrawal and Casey , it sounds like you got more experience with this .

I mean , I had looked at some of the literature and people are starting to put out you know case series and kind of information from you know case series and kind of information from you know from real life practice about Kratom and , just like you said , Casey , the big symptoms were more mood , anxiety , agitation , insomnia , cravings , rather than the more physical

symptoms from sort of high dose , you know , fentanyl , heroin , withdrawal .

I think many patients with kind of a history of substance use they report kind of withdrawal , oftentimes to many different dysphoric feelings that aren't necessarily kind of substance related , and you know , I know this is still a hot topic .

I kind of wonder too if just the partial opioid agonist activity of it is more of a triggering feeling to them than anything else . It's just an interesting new product on the market .

Because I mean , I was always taught in addiction medicine it's very difficult to go back and forth and essentially they don't fear withdrawal . And I've often wondered how much of precipitated withdrawal is fear and anxiety ? And when a lot of times people have really been panicking I'm in withdrawal , I'm in withdrawal , it's really the anxiety .

So you know , withdrawal is so nuanced and what I learned to do in the emergency department was ask okay , you're in withdrawal , what specific symptom are you dealing with ? And most often it was anxiety . So it's kind of the fear of withdrawal I think is an issue we face a lot in addiction medicine , kind of the fear of getting on Suboxone for that reason .

But certainly you know my small number of Kratom patients have mentioned that their withdrawal was similar to opiate withdrawal . But again , a lot of those mood symptoms . So let's go another direction here and again maybe I have a head start , because I knew we were going to do this and had two creative patients in the last two weeks .

But what are you hearing as to why people go find Kratom ? What are you hearing as to the reasons why Kratom is what they seek out ?

I asked them this specific question and the three that I'm treating actively , they all said the same thing that basically they felt kind of run down , tired , fatigued after getting off of kind of their opioid agonist treatment and they thought this was all kind of like a way to transition to a new form of treatment .

And so I think we often hear that like people that say they're like they're feeling withdrawal because they're feeling achy , they're feeling tired .

But it just made me think , casey , you know , I did a little field trip to the Kratom store just to talk to the owner and see what his experience was . And he , you know , the experience is just very different . You know , as a patient , you can walk in . You , it's very nice , you can purchase whatever you want in whatever amount .

If you don't like it , you can go back the next day and try something else . As opposed to us , we're much more like you have to come at this time and if you don't like it , you can't come back till next month and you can't get an early refill and there's only three choices and your insurance doesn't even cover two of them . So you have to get this one .

And so I do understand patients desire to have that more kind of retail experience where they're more in control of it and try something on their own . But yeah , I just I don't think people know what they're getting into , you know .

And one of his friends was like , hey , there's this Kratom stuff . It gives you energy , and so he was using it regularly , Then went into horrible withdrawal and didn't know what was going on . Another patient of mine found it for pain and he sounds like he was kind of Googling pain treatments and specifically found Kratom .

Not for many of the manufacturers , because Sonia and I can talk about both of our experiences buying Kratom , but he basically found that you can treat your own pain with Kratom . And then the third I saw today and she has issues with both feeling like she needs energy and then also having pain . So she's a chronic pain patient .

She's now on buprenorphine because of opiate dependence from Kratom and pain . And then she said to so she's a chronic pain patient . She's now on buprenorphine because of opiate dependence from kratom and pain . And then she said to me she's like I just can't get going . I have no energy , I need to be on a stimulant .

In our practice we don't prescribe stimulants for stimulant addiction just from a regulatory standpoint . But I thought that was really interesting that she's like I need to be up and it sounds like the Kratom was for her a really good combo because it was pain relief and a mood lift Right .

It's the same kind of vague , non-specific symptoms and I'm reading about that , I'm like gosh , I would like to have more energy and I would like to think clearer . I don't want pain after like I go for a run . I was like , oh , wait a minute , Stop this is research .

Maybe I'm being inspired by the presidential election , but anyway , you know , a lot of these products , in their original botanical form , are pretty benign .

You know , like I think , if you make , I mean kratom tea , I think there were some cultural problems with it and there were complaints , even in countries that were using it just in its traditional form , that it was being misused and affecting the country's youth . And you know people were complaining about it .

But it was nothing like we see here , because we've taken that natural form and concentrated it and allowed it to be , you know , sold and taken in high doses . Concentrated it and allowed it to be , you know , sold and taken in high doses . You know I was asking the guy at my store about tea and he said no , no one makes a tea of it anymore .

And if you have to drink it as a tea , there's only so much tea you can drink before like your stomach is full and you just can't drink any more tea or you start to pee the tea out . You know it slows your consumption , Whereas in the US we don't want to .

You know we've concentrated it and it's super high dose in these powdered form sold in capsules or tinctures . And so the effects I think the traditional use of it probably isn't terrible . You know , one cup of Kratom tea a day , maybe that's not so terrible , I don't know . But we're not using it that way anymore .

We process it into crack cocaine . Um , you know sugar cane is , if you ever had it , is like my dad said it was like sucking sugar water out of balsa wood . He was right . And now we have granulated sugar . I mean , I think that's the natural evolution of how humans use things .

Um , but I was going to say I and maybe I'm jumping out of line here , but I was going to read some of the things that the kratom strains that I browsed were purported to be able to do . So there's the Amplifying Go Mode Slump Buster . That's the White Meng Da strain . There's the Bolstered Outlook Energizing Wellbeing strain . That's super green .

I can see how somebody who doesn't know what this is can easily say I want to be more productive .

So , and granted , none of us have a huge amount of experience with these folks , but the patient comes to you and says I need help with Kratom , I'm using it to manage my depression , I'm using it to manage my pain . They clearly have a reason why they're using it .

Talk me through how you're going to start that conversation with the patient and understand what your next steps are going to be would just be education .

I would just treat it like an opioid buprenorphine and withdrawal management with adjunct medications . That's all I got .

So I think that kind of mood symptoms a little more difficult , because it can kind of be vague , and certainly I think we can go off topic about some kind of the opioid agonist having like a antidepressant type effect , and I think that's going to be at our grand rounds coming up .

But certainly the chronic pain part of it I think is really important to understand especially . You know , we know that kind of chronic opioid exposure in any form does call hyperalgesia . So like I think it's really a good teachable moment for people . That kind of like that's not really a great long-term pain option for them .

And so I think a lot of times if you come at it from a point of like curiosity , like tell me what's going on , why do you feel this way , what are you trying to treat , I do think people are a little more receptive to that than kind of like like Dr Keenan lecturing them about .

You know this is not good for them and I think I've made more segue with that approach Now . Like , as I said , not all the time you're going to win that conversation , but it's a long-term relationship , right it's you , but it's a long-term relationship , right ?

They usually get told stop cannabis , but aren't instructed how to do so and no one asks them why they use cannabis and what that unmet need that cannabis is brought in to try to help is . So I usually ask people like what does meth do for you ? What does heroin do for you ?

And then I work backwards to say , okay , well , these are the issues , these are the prescriptions that I can substitute . So I've actually been trying a lot of the non-stimulant ADHD meds for people who use stimulants , because a lot of them say gosh , I'm just so much calmer on meth and for years in the ER I'd be like you're lying . That's not true .

Meth is an upper , but there's a certain subset who have unmanaged ADHD and have had some good luck with some of the ADHD medications . So I think I'd want to explore with them how they found it , why they use it , what it does for them . Kind of try to make a problem list Is there depression , is there unmanaged ADHD , is there pain ?

And then try to come up with a list of medications that I can substitute .

But because it's legal it doesn't sort of destroy your life the way that being addicted to an illegal drug can . So what if someone was addicted the way we're all probably addicted to our coffee ? But the use was manageable . You know , use it every day , it's your morning pick-me-up . If you don't have it you might feel kind of sick .

Is that a bad thing if it works for you ? You ?

They really believe it's harm reduction , they genuinely believe that lives are saved by Kratom because they're not using fentanyl .

And there's an interesting point there and I had one of my patients who used kratom , um , and then went to buprenorphine and I think he'd been on on stronger opioids previously um and then I shared some case reports of , like you know , heroin going to kratom , going to buprenorphine , and the response I got was that's a win for kratom and a win for buprenorphine

and I went . That's an interesting perspective . So what role , if any , does Kratom play in harm reduction strategies for opioid users and how can we incorporate that into conversations with our patients ? This goes back to your question , sonia . If someone's using a little bit of Kratom and they're not using fentanyl , what should we do with that ?

I mean , that's what the owner of the tobacco hut if he's listening , hi there said that he would recommend it for people who are trying to get off street drugs , trying to get off opioids . That's his recommendation . If someone were to approach him , for what could they try ? And it can't be worse than using illicit fentanyl . Right yeah , go ahead . Right yeah .

They were using Kratom and then they eventually came to be with an issue with the Kratom , but in the meantime they switched from homeless using meth and using heroin to kind of working with Kratom , had a job , had a house . I would consider that a success . I know we're not like going to be Kratom cheerleaders here , but that was a win for harm reduction .

But you know , I did read some data and it said about 16% of Kratom users used it as an opioid substitute , like to get off other opioids . So 84% are using it for something else . But there's a small segment who are using it to get off opioids and there's , you know , it seems to be implicated in a lot of overdoses , like it's present , but not a ton .

That Kratom alone seems relatively safe . It just can't be worse . Like John said , it's a sliding scale . There's also people who reported using it as an alcohol substitute , you know , and again , maybe safer , better for your body than alcohol , I don't know you know , and , again , maybe safer , better for your body than alcohol , I don't know .

The other things I found were predominantly from case reports . Kratom can cause a transaminitis , hypothyroidism , hypokinatism that's probably the opioid in it . There's some cases of cardiotoxicity , kidney injury and then babies born to mothers using Kratom can have neonatal abstinence . So it's probably relatively similar to other opioids .

I think the other thing , though , is it's unregulated , you know , and supplements are such a mess , you know . I'm going to call out a particular senator , orrin Hatch in Utah , who facilitated whatever supplement act in the 90s , allowed supplements to be completely unregulated .

I mean mean you can literally go to like gnc and buy a supplement and it contains zero of the active ingredient listed . I mean there was a , there's a study that looked at some various brands and purity , and supplements are just it's really unfortunate how unregulated they are . So , that being said , um , I mean , I think if someone's actually getting kratom .

It's not an excessive dose , um , you know , it's not causing life consequences . What would I say ? How about bup ? And then how about like bup and a non-addictive adhd med ?

But if someone came to me and were willing to engage with me and like I could , they would see them regularly and I can run meet your guide levels in my office so I could see if their use is escalating . I'm open to almost work with anybody if they have a reasonable suggestion , and I'd be open to somebody who said this actually works best for me .

I'm worried I'm going to have a problem with it . Can I see you every month and we'll do your drug screens to make sure my drug levels in my urine aren't escalating . I'd be nervous just because it is unregulated , and I think the Kratom people that I've talked to on LinkedIn really just want better regulations , so they find it's helpful .

There's as many as apparently 15 million users in the US . So if we make it illegal , what do those people do ? I don't know . It's an interesting question ethically as to what we should do in terms of a harm reduction perspective .

And if it's really working for someone and they're not experiencing any negative side effects and use isn't escalating , that's fine . I mean , I just it's an unregulated product . It could contain anything . There's no dosing .

I mean at my store you can buy it by the kilo of powdered leaf in kilo bags , and there's no instructions and there's no guarantee of purity , you know . And there's no guarantee of potency .

It's a botanical product and so potency varies based on season , age of the plant , leaf harvesting techniques , drying techniques All those things will affect the potency as well . And so you just you don't know what you're getting . It's not a pharmaceutical . You know it's different . It's , it's it's . You know the brand that I was looking at is a big warning .

The only warning on it says consult your health care professional to determine if Kratom is right for you .

We should probably talk about what it actually looks like when you walk into a store to buy it and kind of what . Maybe a better way it could be presented to consumers would be .

You know they're on papers and going to the doctor kind of feels like you're on papers , someone else is controlling you , and I think that's why a lot of my patients almost prefer to buy buprenorphine illicitly , so they just have more control , they don't have to report back to any annoying authority figure .

And I think buying your own kratom at the store is like that . You can choose what you want and nobody is on your case about it and the whole experience is set up to please you . Because you're a customer , you know the store looks nice , it's well lit , it smells nice , the salespeople are all super nice .

You know it's just a very different experience buying it at the store and that really strikes me and makes me feel bad for my patients and what we put them through to try to get treatment . You know , but no , it was .

You know , in the store I went to there's just a giant wall of Kratom products , a huge wall of different extracts , tinctures , capsules , raw powder so much .

You have to wait because most of us are always behind . Then you have to get the prescription . Then you have to go to the pharmacy . The pharmacist gives you attitude about being on buprenorphine and then the pharmacy's out . You know like there's all these other hurdles in the medical system .

And , sonia , your point is so good you walk in , you walk out , you're a consumer , they say thank you and off you go . That makes total sense to me .

So that actually worked pretty well . But that's a very atypical medical setting . That was like in our homelessness camp where we drove a van and it just put me at the table for buprenorphine .

So I'm starting to see those hit positive for my patients . So , quite honestly , you know , if somebody doesn't want bube and they're willing to engage with me and use Kratom and submit to regular drug testing , so I can make sure they're okay . You know I'd be open to it as long as they were engaged and working with me to make sure that .

I mean , fentanyl has just been like the biggest disaster . I mean , this is so funny and I think you guys can relate to this . I miss heroin . Oh my gosh , can we bring heroin back ?

It was so much easier to treat and you know if this is an alternative for people who are trying to get off of fentanyl and they're not interested in traditional medicine , you know what ? At least it's not fentanyl .

disorder and kind of engage them to see what they're thinking their opioid use disorder and kind of engage them to see what they're thinking .

All right , y'all

. And with that this concludes our first collaborative episode where the Addiction Medicine Journal Club and the Addiction Medicine Made Easy podcasts joined forces to take on a topic and , as I said at the beginning , we are hopefully going to do another one on this same topic in the future . That's much more evidence-based .

I don't feel like I get that many kind of people in my circle that have this type of meaningful conversation about topics I care about . That's awesome .