April 7, 2016 | Continuing Ed with Ed Baker
"Continuing Ed" with Ed Baker: Kratom
By Ed Baker, LICSW/LADC
Burlington Labs Addiction Education Specialist
Over the past several weeks, I’ve had a number of inquiries from colleagues in my field regarding Kratom, the naturally occurring mu-opioid receptor agonist that grows abundantly in Southeast Asia.
What is this drug? Is its abuse-potential significant? Is it effective as a detoxifying agent in the treatment of opioid addiction? Is it the next drug to fly into our communities, slightly under the radar, until it causes public health problems that rise to a level significant enough to grab our collective attention?
Hoping to be able to answer some of these questions, I did my own research. For the hopeful benefit of others, I’ll summarize my findings and thoughts, from the perspective of someone who has personally experienced addiction, treatment and recovery, as well as professionally counseled many other individuals with substance use disorder over the last 3 decades. I hope you find it helpful.
What is this drug?
Kratom is Mitragyna Speciosa, a tropical tree in the coffee family. Its leaves have been chewed in Thailand and Malaysia for thousands of years; workers in monotonous or laborious positions have used Kratom to increase energy and lessen pain.
One of Kratom’s psychoactive chemical components is 7hydroxymitragynine, or “7HM” for short. 7HM is a complicated compound, simultaneously acting in three distinct ways in the brain: as a stimulant, a mood enhancer, and an analgesic or pain reliever. It is an adrenergic, which means in small doses it provides a stimulating effect. It also interacts with serotonin receptors, associated with mood, and with both mu and kappa opioid receptors, associated with pain relief and sedation.
It’s these three psychoactive effects, and the fact that Kratom is not yet fully regulated, that are causing Kratom’s popularity to begin to quickly increase in the U.S.
The U.S. Food and Drug Administration issued Import Alert 54-15 on 12/21/2015, ordering detention of ingredients containing Mitragyna Speciosa, or Kratom. This report states, “… scientific literature disclosed serious concerns regarding the toxicity of kratom in multiple organ systems. Consumption of kratom can lead to a number of health impacts, including respiratory depression, nervousness, agitation, aggression, sleeplessness, hallucinations, delusions, tremors, loss of libido, constipation, skin hyperpigmentation, nausea, vomiting, and severe withdrawal signs and symptoms… there is inadequate information to provide reasonable assurance that such ingredient does not present a significant or unreasonable risk of illness or injury.”
Although an Import Alert has been issued, Kratom is not controlled under the Federal Controlled Substances Act. The DEA (Drug Enforcement Agency) lists it as a “drug of concern” and acknowledges “addiction potential,” but due to lack of scientific data, has not given Kratom a stricter classification. Recently, DEA spokeswoman Barbara Carreno said, “We are monitoring Kratom, but so far, it has not been a big enough problem in the U.S. to control. But we are monitoring it closely.”
Lack of data
While this monitoring is going on, Kratom’s popularity appears to be increasing, both as a so-called “recreational drug” and as a potential aid in an individual’s detoxification from opioid dependence.
In my opinion, there are significant, even potentially life-threatening, problems in both of these uses.
In a recent article in the NY Times, Dr. Edward Boyer, a Professor of Emergency Medicine at the University of Massachusetts Medical School, said about Kratom: “Recreationally or to self-treat opioid dependence, beware - potentially you’re at just as much risk” as you are with an opioid.
Even the “Kratom User’s Guide,” an online site replete with recipes and purchasing guidance, states by way of warning, “…it is very important not to get into the habit of using it every day. For Kratom, like many drugs….. if used on a daily basis for a prolonged period of time, could become a habit hard to break.” And, “those dependent on it can develop weight loss, dark pigmentation of the face, and have physical withdrawal symptoms if they quit abruptly. The withdrawal symptoms may include muscle aches, irritability, crying, runny nose, diarrhea, and muscle jerking.”
Despite these dangers, interest in Kratom continues to grow, fueled more by myth, folklore and profit motive than by any reliable record of safe casual use or effectiveness for treating opioid addiction. Kratom is ahead of research and regulation, as have been other drugs, such as LSD-25, Methamphetamine, Cocaine, Cannabis, and Nicotine, to mention only a few.
Some states have banned Kratom (among them Indiana, Iowa, Louisiana, Massachusetts and Vermont), with more likely to come, but fringe bars that serve Kratom Tea continue to spring up, and the drug is also available in head shops and online.
Kratom as a treatment tool?
Unregulated social experimentation with Kratom is one thing. But perhaps more troubling to me is the growing interest in Kratom’s use as a treatment aid, as a possible detoxifying agent reducing the symptoms of opioid withdrawal.
Within the population of individuals suffering from opioid addiction, the rate of death by overdose has been alarming, and increasing steadily in recent years. Between 1999 and 2002 there was a 91.2% increase in deaths attributable to opioid use. And in 2014 there were over 28,647 deaths directly caused by opioid use; approximately two-thirds attributable to pharmaceutical opioids, and approximately one-third to heroin.
Proponents of using Kratom as an opioid substitute/detox agent point to the fact that Kratom -- although it activates the same opioid mu receptors as do heroin and prescribed painkillers -- is not classified as an opioid. Kratom supporters claim the substance rarely causes hypoventilation, which is a leading cause of opioid overdose deaths, and that therefore, Kratom is safer than opioids and is a promising new avenue for medically-assisted treatment (MAT). However, this assertion that Kratom rarely causes hypoventilation is not substantiated by research.
Given the relative lack of data so far on Kratom’s effects, and given that we are talking about a population that is highly vulnerable to addiction and overdose, it seems to me to be very ill-advised to rush to embrace Kratom at this point as a solution for opioid addiction.
Those who promote Kratom believe the substance will lessen the symptoms of withdrawal from opioid dependence, therefore helping the individual achieve abstinence, and that somehow this will result in recovery. However, treating symptoms, without addressing the underlying bio-psycho-social issues related to the disease of addiction, never results in a full recovery, and very often results in eventual relapse to the disease. Those who think “if we can cure withdrawal, we can cure the addict” are vastly oversimplifying the process.
The disease of opioid addiction is characterized by actual physiological changes in the individual’s brain functioning. One of these changes is hyper-algesia, or a hyper-sensitivity to pain, due to pain having been muted by opioids throughout the duration of the opioid use disorder. When faced with withdrawal from opioids, the brain will actually send out signals that initiate immediate drug-seeking behavior. Without strong external support, both medical and psychotherapeutic, the individual is most likely to continue their opioid use. Touting Kratom as a panacea overlooks the crucial element of professional medical and counseling support.
Even when individuals with opioid use disorder are no longer physically dependent upon the opioid to feel normal, and withdrawal is no longer an issue, there are still physiological changes that have occurred and persist in the brain which cause craving, drug-seeking impulsiveness, and distorted cognitive functioning, which very often undermine the person’s genuine resolve to maintain abstinence, and cause relapse to drug use.
For example, the process of becoming addicted always involves the dopamine, or reward-system in the brain. This system is invested with survival-value and is responsible for reinforcing behaviors which assure both survival of the individual and our species itself, such as eating and reproductive behavior. This is the system which rewards, remembers, and reinforces extremely important behaviors.
This same system, over the course of the development of opioid use disorder, becomes compromised, and engages in rewarding and reinforcing drug-seeking and drug-administering behaviors. When these behaviors are discontinued, either internal (feelings, emotions, memories), or external (people, places, things) stimuli associated with these behaviors will activate the release of dopamine which will set in motion and reinforce the drug-seeking behavior once again. Again, the need for psychotherapeutic or peer support becomes more than evident. How many times have we been perplexed by someone in recovery, after months or years of healthy living, suddenly relapsing?
No “magic bullet”
All this being said, I’ve answered those colleagues who have asked me about Kratom by saying it’s not the “magic bullet” some hope it could be.
Instead, if you or someone close to you suffers from opioid use disorder, please begin by enlisting the support of a medical or counseling professional, specifically trained and licensed to treat this specific disorder. There are Licensed Alcohol/Drug Counselors available in all states, as well as medical doctors licensed to medically manage treatment.
Fortunately, two of the biggest barriers to individuals seeking and achieving recovery – cost of treatment and the stigma associated with the disease of addiction – are starting to dissipate. Pr The support of others is also fairly readily available today, through grassroots recovery communities, recovery coaching centers, and 12-step programs.
While recovery seems like an impossible climb while viewed from the outside, once an individual enters into the process, hope begins to color perception. The brain will naturally reward behaviors supporting survival and health, as will family, friends and the community.
I truly believe recovery is stronger than addiction (and I’m living proof of that, as a person in long-term, stable recovery). I also consider myself living proof that, deep in the core of every person living with addiction, is the desire to free themselves from the substances that control their lives. When given the proper support, that freedom is absolutely possible. However, it’s not a quick and easy path, and it’s not one the individual can navigate alone (the support of trained counselors, family, friends, and peers in recovery can mean the difference between success and relapse).
Unfortunately, recovery is not a path that allows any “shortcuts,” much as the promoters of substances like Kratom would like us to believe.
I look forward to continuing the conversation about addiction, treatment and recovery.
Have a question or comment for Ed? Reach out at [email protected].
An abridged version of this article appeared in the May/June edition of our newsletter, TheBuzz.