Kratom and Opioids

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drusso

drusso

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We have a local naturopath in the area who is recommending a lot of Kratom to patients--advocating it for opioid withdrawal, depression, etc. How do you handle Kratom? Treat it like a herbal remedy or an ilicit botanical (cannabis, cocca teas, etc)...

"Valerie is a 56 y of, generally medically healthy, but with multiple Mental Health Diagnosis, including Bipolar D/O, Anxiety, Depression, ADD, with pain following both Failed Back (L2 to Sacral Fusion) as well as Failed Neck surgeries (C5-C7 Fusion).

Tapered and discontinued her Fentanyl 25mcg patch about one month ago and began taking Kratom. We have continued her on Hydrocodone 5/325, budget of 4 per day. Pt feels she has less depression on Kratom and thinks that it is helping nerve pain. Psychiatric NP is in support of her continued use."

Today she requests to go up to Hydrocodone 5/325, from 4/day to 5/day. Request declined.."

https://en.wikipedia.org/wiki/Mitragyna_speciosa

The U.S. Drug Enforcement Administration has issued a "Drugs of Abuse Resource Guide", which states "Kratom is not controlled under the Federal Controlled Substances Act; however, there may be some State regulations or prohibitions against the possession and use of kratom... In addition, DEA has listed kratom as a Drug and Chemical of Concern."[36] There is no FDA-approved medical use for kratom in the United States.
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lord_jeebus said:
Mitragynine is a mu agonist so I would place Kratom in the same botanical category as opium.
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Yup, and it's also regularly written about on the drug abuse forums as a means to get high(bluelight). It, like all herbals, isn't standardized or tested so you don't know what you are getting. I would not recommend this to anyone.
 
Just saw a young patient in my clinic woth opioid use disorder. He started taking Kratom as a replacement of taking non prescribed opioids off the street. He states that he has been off opioids for 4 weeks by now. He couldn't afford to continue buying prescription opioids, since this was consuming his entire paycheck. Close friends already started shooting heroin and he wants to avoid this. He started using Kratom as a last resort prior to heroin.
He states his use of Kratom (once to twice a day) gives him minimal euphoria/pleasure, no cravings and minimal cognitive impairment.
I agree with Steve about not prescribing scheduled meds if someone is actively using, but this could be a potential therapy for maintenance of patients with opioid use disorder (of course in conjunction with NA/psych interventions).
 
drusso said:
My concern is managing the relationships between the patient, the naturopath, and the psych NP. I suppose I could just tell her that her NP or ND needs to take over prescribing the Norco...
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You could call the ND a wackaloo, tell the psych np to address addiction, and tell the patient the truth. As well as what you think about their other "providers".
 
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by your post, since the DEA believes it is a drug of concern, you could tell the patient that you can no longer prescribe Norco, or she has to stop the Kratom.

there are some tox screens that look for kratom. ill have to call the lab that does mine to see if it is included in the LC/GS...
 
ND's need more restrictions in their license. To say their training is equivalence "practice as primary care" (from your prior post and now this) is not reasonable, is there any way to involve the state medical board?
In my are I see them rx "hormonal therapy" in the non-deficient patient and have thought this to be questionable. they are sliding down an already slippery slope
 
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olafa said:
ND's need more restrictions in their license. To say their training is equivalence "practice as primary care" (from your prior post and now this) is not reasonable, is there any way to involve the state medical board?
In my are I see them rx "hormonal therapy" in the non-deficient patient and have thought this to be questionable. they are sliding down an already slippery slope
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Medical board regulates doctors, not naturopaths.
 
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Doesn't the medical board also serve to protect /establish the boundary of practicing medicine among those w training and credentials to so. I can't imagine the ND board wanting to limit their ability to do more
 
Nope
ND board fights for encroachment on legitimate care. Same with nursing boards. Only if someone claims to be a doctor does the medical board step in.
 
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1) sadly, the term "doctor"has been usurped by PTs, chiros, etc. We should have defended it, but didn't.

2) Medical boards will deal aggressively with those who "practice medicine", not just those who call themselves medical doctors.

Here is what the DEA says about Kratom: http://www.dea.gov/druginfo/factsheets.shtml
 
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Glad I read this thread. I'll start being on the lookout.
 
Does it show up on immunoassay? On LCMS?
 
Yup, we have millennium and can test, haven't seen it come back positive yet
 
A patient asked about this last week, and said that he was considering ordering online since he had read a lot about it. Patient is post fusion x 3. My response to him was that it was his choice -- if he chose to order, then not to bother coming to his next appointment.
 
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mazinger said:
Just saw a young patient in my clinic woth opioid use disorder. He started taking Kratom as a replacement of taking non prescribed opioids off the street. He states that he has been off opioids for 4 weeks by now. He couldn't afford to continue buying prescription opioids, since this was consuming his entire paycheck. Close friends already started shooting heroin and he wants to avoid this. He started using Kratom as a last resort prior to heroin.
He states his use of Kratom (once to twice a day) gives him minimal euphoria/pleasure, no cravings and minimal cognitive impairment.
I agree with Steve about not prescribing scheduled meds if someone is actively using, but this could be a potential therapy for maintenance of patients with opioid use disorder (of course in conjunction with NA/psych interventions).
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The article linked to by Steve (post above this one) states at the end of the article that methadone and suboxone cannot be prescribed for kratom detox because kratom is not considered an opioid by the DEA and abuse of this herb is not strictly considered "opioid addiction."
 
kratom now Schedule 1.

https://www.dea.gov/divisions/hq/2016/hq083016.shtml

DEA Announces Intent to Schedule Kratom
SE Asian drug is imminent hazard to public safety

AUG 30 (WASHINGTON) - The Drug Enforcement Administration (DEA) today announced its intention to place the active materials in the kratom plant into Schedule I of the Controlled Substances Act in order to avoid an imminent hazard to public safety. Mitragynine and 7-hydroxymitragynine are found in kratom, which is a tropical tree indigenous to Thailand, Malaysia, Myanmar, and other areas of Southeast Asia. The announcement was made in the U.S. Federal Register and can be found by following this link.

Kratom is abused for its ability to produce opioid-like effects and is often marketed as a legal alternative to controlled substances. Law enforcement nationwide has seized more kratom in the first half of 2016 than any previous year and easily accounts for millions of dosages intended for the recreational market, according to DEA findings. In addition, kratom has a high potential for abuse, has no currently accepted medical use in treatment in the United States, and has a lack of accepted safety for use under medical supervision. These three factors constitute a Schedule I controlled substance according to the Controlled Substances Act passed by Congress in 1970.

Kratom has been seized by law enforcement in various forms, including powder, plant, capsules, tablets, liquids, gum/resin, and drug patch. Because the identity, purity levels, and quantity of these substances are uncertain and inconsistent, they pose significant adverse health risks to users.

From February 2014 to July 2016, over 55,000 kilograms of kratom material were encountered by law enforcement at various ports of entry within the United States. Additionally, another 57,000+ kilograms of kratom material offered for import into the United States between 2014 and 2016 are awaiting an FDA admissibility decision. Together, this material is enough to produce over 12 million doses of kratom. The FDA has also warned the public not to use any products labeled as containing kratom due to concerns about toxicity and potential health impacts. In addition, FDA has issued and updated two import alerts related to kratom products. Kratom has been on DEA’s list of drugs and chemicals of concern for several years.

The American Association of Poison Control Centers identified two exposures to kratom from 2000 and 2005. Between 2010 and 2015, U.S. poison centers received 660 calls related to kratom exposure. The Center for Disease Control (CDC) found that kratom abuse leads to agitation, irritability, tachycardia, nausea, drowsiness, and hypertension. Health risks found in kratom abusers include hepatotoxicity, psychosis, seizure, weight loss, insomnia, tachycardia, vomiting, poor concentration, hallucinations, and death. DEA is aware of 15 kratom-related deaths between 2014 and 2016.
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Isn't this the substance that we are seeing these occasional news reports about someone suddenly acting abnormally and going berserk, attacking people with super human strength that it takes multiple police officers to subdue said person?
 
melancholy said:
Isn't this the substance that we are seeing these occasional news reports about someone suddenly acting abnormally and going berserk, attacking people with super human strength that it takes multiple police officers to subdue said person?
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Perhaps you are thinking of Krakodil? One of my favorite patients, is an ex con, ex gang member, and recovering drug addict 15 years sober, who has recently graduated with a masters in clinical social work. He is a drug counselor and surveillance coordinator. I call him whenever I have questions. Recently, he mentioned that they are watching krakodil, kratom, and a synthetic type marijuana called "spice." Krakodil is the one that they are most concerned about, and it causes all sorts of strange behavior.
 
jettavr6 said:
Perhaps you are thinking of Krakodil? One of my favorite patients, is an ex con, ex gang member, and recovering drug addict 15 years sober, who has recently graduated with a masters in clinical social work. He is a drug counselor and surveillance coordinator. I call him whenever I have questions. Recently, he mentioned that they are watching krakodil, kratom, and a synthetic type marijuana called "spice." Krakodil is the one that they are most concerned about, and it causes all sorts of strange behavior.
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Not to nit pick here but krakodil is a morphine derivative created by "cooking" codeine with phosphorous from match heads and household cleaning agents. It is big in Russia and the former soviet states. It's name derives from crocodile because users skin turns rough in the areas they inject it. It causes necrosis of the skin and there are pics of some horrifying wounds that develop as a result.

I believe you are thinking of spice, flaka and/or K2. These are synthetic drugs that are smoked and make the user hallucinate. These drugs are involved in the instances of people randomly attacking others and biting their faces off.
 
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Agreed on above. Spice is synthetic marijuana/bath salts. Schedule 1.

Keaton is most commonly purchased - at least until now - via online pharmacies that had labelled it as a natural alternative to opioids. Plant derived. (Like cocaine and opium).


Sent from my iPhone using SDN mobile
 
Ducttape said:
Agreed on above. Spice is synthetic marijuana/bath salts. Schedule 1.

Keaton is most commonly purchased - at least until now - via online pharmacies that had labelled it as a natural alternative to opioids. Plant derived. (Like cocaine and opium).


Sent from my iPhone using SDN mobile
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Keaton = Kratom. Or Batman.
 
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sorry, spellcheck changed it to Keaton.

I like the Bales Batman the best, then Will Arnett. Adam West 3rd. Keaton 4th, then Kilmer and finally, way back in the distance, Clooney. I don't really want to add Affleck yet - seems only a role player (tho one might say the same about Will Arnett...)
 
Ducttape said:
sorry, spellcheck changed it to Keaton.

I like the Bales Batman the best, then Will Arnett. Adam West 3rd. Keaton 4th, then Kilmer and finally, way back in the distance, Clooney. I don't really want to add Affleck yet - seems only a role player (tho one might say the same about Will Arnett...)
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The Lego movie Batman was amazing. "Darkness....no parents...." Haha
 
PainDrain said:
Not to nit pick here but krakodil is a morphine derivative created by "cooking" codeine with phosphorous from match heads and household cleaning agents. It is big in Russia and the former soviet states. It's name derives from crocodile because users skin turns rough in the areas they inject it. It causes necrosis of the skin and there are pics of some horrifying wounds that develop as a result.

I believe you are thinking of spice, flaka and/or K2. These are synthetic drugs that are smoked and make the user hallucinate. These drugs are involved in the instances of people randomly attacking others and biting their faces off.
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By all means, nit pick -- I just learned something new -- thank you. A lot of new drugs out there that it's tough to keep up.
 
jettavr6 said:
By all means, nit pick -- I just learned something new -- thank you. A lot of new drugs out there that it's tough to keep up.
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The scariest part is we cannot test for the new synthetics such as spice, k2 and flaka. Often the chemical is so new there isn't a reliable test.
 
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Ferrismonk said:
I know this is an older thread, but I just had a patient show up positive for it as well (Kratom). I'll be discussing it with her and won't prescribe opiates while she takes it, similar to what I do with marijuana.

Also, for what it's worth, the DEA backed down and it's not going to be schedule 1 for now. Seems the herbalists cried loud enough to make them back down.

The DEA Changes Its Mind on Kratom

Drug policy experts and advocates implore DEA to keep opiate-like plant legal
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Apparently some naturopaths are recommending it in teas.
 
Good to know. Recently have had several of my chronic pain patients asking about it, was wondering about why this had become popular again
 
Had my first experience with kratom in a patient. Patient swears that it helps, and that when he stopped it his pain was significantly worse (withdrawal) and thus it must have helped.

Is the messaging that this is essentially another opioid and all the issues that we have and educate our patients about opioids should be done with kratom or is the messaging that this is a herb with abuse potential that we do not have enough evidence about to be able to recommend for or against?
 
The DEA backed off...kratom is not a scheduled drug although the the two most active ingredients are opioids. It can be obtained mail order as a powdered leaf or you can grow the trees yourself or can get it at kratom shops here in Fl.
 
kstarm said:
Had my first experience with kratom in a patient. Patient swears that it helps, and that when he stopped it his pain was significantly worse (withdrawal) and thus it must have helped.

Is the messaging that this is essentially another opioid and all the issues that we have and educate our patients about opioids should be done with kratom or is the messaging that this is a herb with abuse potential that we do not have enough evidence about to be able to recommend for or against?
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Like cannabis, Kratom is not just one thing. It's a potpourri of alkaloids. Some of them are active at opioid receptors, but are not technically considered "opioids." They are opioid-ergic...Can also have withdrawal from it. There have been reported deaths attributable to Kratom toxicity. Albeit, if you're using Kratom you're probably using a lot of other stuff too...
 
"A combination of morphine and amphetamine" is how an addictionologist described it in a lecture.
 
2017-11-02 16.19.47.jpg


Timely. Patient brought this in and asked what I thought.
 
I suppose it depends on the definition of opioid. The one I am most familiar with states any drug, similar pharmacologically or structurally to morphine that acts on the opioid receptors is an opioid. Kratom contains hydroxymitragynine and mitragynine, both of which have activity on the opioid receptors. (A Review on the Antinociceptive Effects of Mitragyna speciosa and Its Derivatives in Animal Model. - PubMed - NCBI , Mitragynine/Corynantheidine Pseudoindoxyls As Opioid Analgesics with Mu Agonism and Delta Antagonism, Which Do Not Recruit β-Arrestin-2. - PubMed - NCBI ) These alkaloids are opioids but not opiates, since the term opiate means structurally similar to morphine with activity on the opioid receptors. Methadone is an opioid but not an opiate.
 
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drusso said:
There have been reported deaths attributable to Kratom toxicity. Albeit, if you're using Kratom you're probably using a lot of other stuff too...
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Fair enough. Another way of putting that is
"According to a 2016 review, "Although death has been attributed to kratom use, there is no solid evidence that kratom was the sole contributor to an individual's death."

The kratom=amphetamine+morphine combo description is somewhat absurd. Fear-mongering, to be honest. I'm sure people get addicted to it, but it's weak stuff. Coffee is to Stimulants what Kratom is to opioids. Though I guess some people report stimulating effects as well, but plenty of people feel that way about tramadol if you check out the recreational drug forums.

Not saying anyone should be prescribing opiates to kratom users or anything like that. Obviously there could be interactions and it strikes me as unwise to have people using uncontrolled substances in combination with controlled substances when it's your license on the line. You could get blamed for something when they really just got a 'tainted product' or something stupid. Though I'm not sure how likely that is, I understand wanting to avoid the risk.

Also, it wasn't just herbalists that cried for the DEA not to make a new plant illegal. Plenty of people who just don't want to see more people in prison for plants than we already have... but our non-violent offender population is a whole different argument.
 
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