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FDA declares Kratom an opioid
- Thread starter lobelsteve
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Start asking your labs to test for mitragynine. Since we've started looking for it, we've picked it up more frequently that we ever expected: Little old lady's using it in teas and tinctures. Potheads smoking it. It is also a contaminant in Traditional Chinese Medicine remedies.
It's a schedule I and grounds for dismissal in our practice.
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There will be a massive pushback if the DEA tries to make it a Schedule I. You can grow these plants in your house and there are at least 100,000-500,000 users in the US. Or it may go the way of marijuana with the states simply carving out their own laws to allow for its use. Below is a monograph I put together on Kratom:
KRATOM
Kratom (aka Thom, Thang, and Biakis) is the US name of the drug obtained from the leaves of the Mitragyna speciosa tree, growing up to 50' high in Indonesia, Malaysia, Thailand, and Bali. In these environments it grows leaves quickly but it can be grown in subtropical climates, although the leaves die if the temperature dips below 50 deg F. Its leaves contain 25 active alkaloids including the major components mitragynine and 7-hydroxymitragynine. Other active alkaloids include ajmalicine, mitraphylline, mitragynine pseudoindoxyl, and Rhynchophylline. The major components are metabolized in the liver to 16-carboxy mitragynine, and 9-O-demethyl mitragynine. (Anal Biochem. 2017 Dec 14;543:146-161). The compounds mitragynine, 7-hydroxymitragynine, and MGM-9 are active stimulating the mu and kappa opioid receptors (Curr Drug Targets. 2017 Apr 25) and the alpha-2 adrenergic receptors, while inhibiting the 5-HT2A receptors (Pain Physician. 2017 Jan-Feb;20(1):E195-E198). It is taken orally by chewing the leaves (common in Southeast Asia),crushed dried leaf, capsule, or powder mixed as a slurry in water, drank as tea to make it more palatable, smoked (Front Psychiatry. 2017 Apr 24;8:62), liniment, balm, or tincture (J Ethnopharmacol. 2017 Apr 18;202:302-325). Long term usage of Kratom does not reportedly cause any unusual blood chemistry or hematologies with the exception of elevated HDL and LDL cholesterol. (J Ethnopharmacol. 2018 Mar 25;214:197-206.). Other species of mitragyna have been used for pain as a topical agent, for anxiety, fever, and infections (J Ethnopharmacol. 2017 Apr 18;202:302-325).
Kratom is used both for pain in 68% of those taking it, as a mood elevator in 66%, and as a drug to control the withdrawal symptoms from other opioids in 30%. (Drug Alcohol Depend. 2017 Jul 1;176:63-70), but has been used for centuries as a stimulant in laborers at doses of 1-5 g, as an opioid agonist at 5-10 g dosage (pain control, blunting of withdrawal symptoms, constipation, euphoria, muscle relaxation and treatment of diarrhea), and sedation at high dosage (10-15 g) (Pain Physician:January 2017; 20:E195-E198). It also creates a "sense of well-being". It is also used as a substitute for opioids in both addiction and pain treatment, and acts to reduce anxiety while increasing generalized well-being (Drug Alcohol Depend. 2017 Dec 7;183:134-140). The 7-hydroxymitragynine was found to be the most effective substance in kratom for the treatment of pain. Kratom is unregulated in the US currently and is freely imported, but has no quality control, no assay or analysis for either the content or purity and one study found many commercial products are adulterated (Suspected Adulteration of Commercial Kratom Products with 7-Hydroxymitragynine. - PubMed - NCBI). It operates on the opioid receptors in the human body, the alpha 2 receptor, and as an anti-inflammatory drug (Am J Health Syst Pharm. 2017 Dec 18). It reportedly has a low abuse potential (Psychopharmacology (Berl). 2017 Dec 23). Withdrawal from Kratom is usually well tolerated by most but may be severe in a few (Drug Alcohol Depend. 2017 Dec 7;183:134-140). Kratom does cause constipation that may be significant. At low doses it is well tolerated, producing a stimulant effect, whereas with high doses it produces euphoria and an anesthetic effect. At even higher doses it may produce psychosis, seizures or death. (A A Case Rep. 2017 Oct 26). A growing number of people are treated in Emergency Departments in the US for overdose symptoms associated with Kratom including nausea, difficulty sleeping, irritability, restlessness, mood swings, diarrhea, running nose, muscle aches, and joint pain. Overdoses on Kratom produce seizures, psychosis, coma, hallucination, extreme paranoia, severe vomiting, respiratory depression and in the worst scenarios, death (Pain Physician. 2017 Jan-Feb;20(1):E195-E198).
Kratom grows in red vein, green vein, and white vein leaves, each reported to have different properties. For instance, red vein is reported to have more pain killing properties while green is more "pep". The usual dosage of Kratom is 1-3g of leaves (yes, some people eat the leaves) or powder or capsules. The powder and capsules may be cut with other substances and may not be pure. Kratom is reported to be 13 times as potent as morphine. The green vein kratom has a mixture of opioid effect and increasing "pep" or stimulation while white vein kratom is primarily a stimulant.
Kratom addiction has been shown in chronic users. More than half of the regular users (>6 month of use) developed severe Kratom dependence problems, while 45% showed a moderate Kratom dependence. Physical withdrawal symptoms commonly experienced include muscle spasms and pain, sleeping difficulty, watery eyes/nose, hot flashes, fever, decreased appetite, and diarrhoea. Psychological withdrawal symptoms commonly reported were restlessness, tension, anger, sadness, and nervousness. The average amount of the psychoactive compound, mitragynine, in a single dose of a Kratom drink was 79mg, suggesting an average daily intake of 276.5mg. Regular users who consumed ≥3 glasses Kratom per day, had higher odds of developing severe Kratom dependence, withdrawal symptoms, and inability to control Kratom craving. (Drug Alcohol Depend. 2014 Jun 1;139:132-7)
The drug is most quickly absorbed by chewing the leaves, requiring 5-10 minutes to have an effect.
The most potent effects of the drug are felt for one hour with up to 3-5 hours at higher dosages.
The peak levels of kratom in the blood are at 0.83 hours and the terminal half life is 22 hours.
The treatment for kratom intoxication is naloxone that reverses most of the effects of the drug. However, longer term treatment may find responsiveness to hydroxyzine and clonidine (WMJ. 2016 Feb;115(1):49-52; quiz 53)
LEGAL STATUS: In the typical no-mans land of DEA and FDA regulations of supplements, herbals, etc., kratom remains a quasi-legal drug, widely available online and in Kratom shops in most states. The amount of use increased progressively in the US beginning in the year 2000 and reports of overdose began accelerating in 2011. In 2013, the DEA declared “There is no legitimate medical use for kratom in the United States.”, setting the stage for making it a Schedule I drug. In 2014, the FDA removed it from the list of accepted supplements. In 2016, the DEA planned to make kratom a Schedule I drug, but a firestorm of protest from the estimated 100,000 users in the US caused the DEA to back off. The drug remains in limbo with both the FDA and DEA failing to give any guidance, regulation, or legal status clarification, just as with marijuana. There are several states where kratom remains illegal including Alabama, Arkansas, Indiana, Tennessee, Vermont, Wisconsin and Louisiana.
Kratom is difficult to detect in urine drug testing. There are no standardized dosings of the drug, and frequently the drug remains without laboratory analysis for content, impurities, heavy metals when sold over the internet nor online. A 2016 study of 15 kratom products purchased over the internet were analyzed and found to have no hydroxymitragynine, the most potent of the alkaloids. All samples contained mitragynine. (J Psychoactive Drugs. 2016 Nov-Dec;48(5):330-3350
Kratom's major side effect is nausea on dosing of the drug.
KRATOM
Kratom (aka Thom, Thang, and Biakis) is the US name of the drug obtained from the leaves of the Mitragyna speciosa tree, growing up to 50' high in Indonesia, Malaysia, Thailand, and Bali. In these environments it grows leaves quickly but it can be grown in subtropical climates, although the leaves die if the temperature dips below 50 deg F. Its leaves contain 25 active alkaloids including the major components mitragynine and 7-hydroxymitragynine. Other active alkaloids include ajmalicine, mitraphylline, mitragynine pseudoindoxyl, and Rhynchophylline. The major components are metabolized in the liver to 16-carboxy mitragynine, and 9-O-demethyl mitragynine. (Anal Biochem. 2017 Dec 14;543:146-161). The compounds mitragynine, 7-hydroxymitragynine, and MGM-9 are active stimulating the mu and kappa opioid receptors (Curr Drug Targets. 2017 Apr 25) and the alpha-2 adrenergic receptors, while inhibiting the 5-HT2A receptors (Pain Physician. 2017 Jan-Feb;20(1):E195-E198). It is taken orally by chewing the leaves (common in Southeast Asia),crushed dried leaf, capsule, or powder mixed as a slurry in water, drank as tea to make it more palatable, smoked (Front Psychiatry. 2017 Apr 24;8:62), liniment, balm, or tincture (J Ethnopharmacol. 2017 Apr 18;202:302-325). Long term usage of Kratom does not reportedly cause any unusual blood chemistry or hematologies with the exception of elevated HDL and LDL cholesterol. (J Ethnopharmacol. 2018 Mar 25;214:197-206.). Other species of mitragyna have been used for pain as a topical agent, for anxiety, fever, and infections (J Ethnopharmacol. 2017 Apr 18;202:302-325).
Kratom is used both for pain in 68% of those taking it, as a mood elevator in 66%, and as a drug to control the withdrawal symptoms from other opioids in 30%. (Drug Alcohol Depend. 2017 Jul 1;176:63-70), but has been used for centuries as a stimulant in laborers at doses of 1-5 g, as an opioid agonist at 5-10 g dosage (pain control, blunting of withdrawal symptoms, constipation, euphoria, muscle relaxation and treatment of diarrhea), and sedation at high dosage (10-15 g) (Pain Physician:January 2017; 20:E195-E198). It also creates a "sense of well-being". It is also used as a substitute for opioids in both addiction and pain treatment, and acts to reduce anxiety while increasing generalized well-being (Drug Alcohol Depend. 2017 Dec 7;183:134-140). The 7-hydroxymitragynine was found to be the most effective substance in kratom for the treatment of pain. Kratom is unregulated in the US currently and is freely imported, but has no quality control, no assay or analysis for either the content or purity and one study found many commercial products are adulterated (Suspected Adulteration of Commercial Kratom Products with 7-Hydroxymitragynine. - PubMed - NCBI). It operates on the opioid receptors in the human body, the alpha 2 receptor, and as an anti-inflammatory drug (Am J Health Syst Pharm. 2017 Dec 18). It reportedly has a low abuse potential (Psychopharmacology (Berl). 2017 Dec 23). Withdrawal from Kratom is usually well tolerated by most but may be severe in a few (Drug Alcohol Depend. 2017 Dec 7;183:134-140). Kratom does cause constipation that may be significant. At low doses it is well tolerated, producing a stimulant effect, whereas with high doses it produces euphoria and an anesthetic effect. At even higher doses it may produce psychosis, seizures or death. (A A Case Rep. 2017 Oct 26). A growing number of people are treated in Emergency Departments in the US for overdose symptoms associated with Kratom including nausea, difficulty sleeping, irritability, restlessness, mood swings, diarrhea, running nose, muscle aches, and joint pain. Overdoses on Kratom produce seizures, psychosis, coma, hallucination, extreme paranoia, severe vomiting, respiratory depression and in the worst scenarios, death (Pain Physician. 2017 Jan-Feb;20(1):E195-E198).
Kratom grows in red vein, green vein, and white vein leaves, each reported to have different properties. For instance, red vein is reported to have more pain killing properties while green is more "pep". The usual dosage of Kratom is 1-3g of leaves (yes, some people eat the leaves) or powder or capsules. The powder and capsules may be cut with other substances and may not be pure. Kratom is reported to be 13 times as potent as morphine. The green vein kratom has a mixture of opioid effect and increasing "pep" or stimulation while white vein kratom is primarily a stimulant.
Kratom addiction has been shown in chronic users. More than half of the regular users (>6 month of use) developed severe Kratom dependence problems, while 45% showed a moderate Kratom dependence. Physical withdrawal symptoms commonly experienced include muscle spasms and pain, sleeping difficulty, watery eyes/nose, hot flashes, fever, decreased appetite, and diarrhoea. Psychological withdrawal symptoms commonly reported were restlessness, tension, anger, sadness, and nervousness. The average amount of the psychoactive compound, mitragynine, in a single dose of a Kratom drink was 79mg, suggesting an average daily intake of 276.5mg. Regular users who consumed ≥3 glasses Kratom per day, had higher odds of developing severe Kratom dependence, withdrawal symptoms, and inability to control Kratom craving. (Drug Alcohol Depend. 2014 Jun 1;139:132-7)
The drug is most quickly absorbed by chewing the leaves, requiring 5-10 minutes to have an effect.
The most potent effects of the drug are felt for one hour with up to 3-5 hours at higher dosages.
The peak levels of kratom in the blood are at 0.83 hours and the terminal half life is 22 hours.
The treatment for kratom intoxication is naloxone that reverses most of the effects of the drug. However, longer term treatment may find responsiveness to hydroxyzine and clonidine (WMJ. 2016 Feb;115(1):49-52; quiz 53)
LEGAL STATUS: In the typical no-mans land of DEA and FDA regulations of supplements, herbals, etc., kratom remains a quasi-legal drug, widely available online and in Kratom shops in most states. The amount of use increased progressively in the US beginning in the year 2000 and reports of overdose began accelerating in 2011. In 2013, the DEA declared “There is no legitimate medical use for kratom in the United States.”, setting the stage for making it a Schedule I drug. In 2014, the FDA removed it from the list of accepted supplements. In 2016, the DEA planned to make kratom a Schedule I drug, but a firestorm of protest from the estimated 100,000 users in the US caused the DEA to back off. The drug remains in limbo with both the FDA and DEA failing to give any guidance, regulation, or legal status clarification, just as with marijuana. There are several states where kratom remains illegal including Alabama, Arkansas, Indiana, Tennessee, Vermont, Wisconsin and Louisiana.
Kratom is difficult to detect in urine drug testing. There are no standardized dosings of the drug, and frequently the drug remains without laboratory analysis for content, impurities, heavy metals when sold over the internet nor online. A 2016 study of 15 kratom products purchased over the internet were analyzed and found to have no hydroxymitragynine, the most potent of the alkaloids. All samples contained mitragynine. (J Psychoactive Drugs. 2016 Nov-Dec;48(5):330-3350
Kratom's major side effect is nausea on dosing of the drug.
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Firstly, you don’t “smoke it” Kratom becomes inert when it’s burned. It’s only way to be used is to ingest it.
Secondly, has it ever occurred to you that there are alterior motives for scheduling Kratom? Only 40+/- deaths EVER associated with its use, and each one of those cases involved a myriad of other potentially fatal prescription conglomerations and comorbidities.
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Correction: there are 40 DOCUMENTED deaths associated with kratom- most lab tests used by coroners and emergency room toxicology testing will completely miss kratom. The actual number of deaths is probably much higher.
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Our UDS company is going to include this on their profile (if requested) next month. However, I’m not sure how often I would screen for this
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1. Kratom is not schedule I - it was proposed for emergency scheduling in August 2016 by the DEA which postponed and later removed it from consideration pending FDA investigation after 21,000 comments were received by the DEA of which over 99% were against a ban.
2. There are 44 documented links between kratom and death. One of which involved a gunshot to the chest, another which involved a hanging. All but one involved polypharmacy situations with many having drugs known to cause death including heroin.
3. There are an estimated 3-5 million users
4. 8 factor analysis by Dr. Henningfield of Johns Hopkins concluded it does not meet the DEA criteria
5. While human clinical trials have not been performed, surveys and animal studies have shown promise
6. Re: Salmonella, of 28 people, 8 were found to have used kratom in the preceding 4 months and the recommendation was to stop ALL kratom use. Even more recently an outbreak of salmonella linked to chicken salad did not produce the same recommendation.
7. Letter to DEA/Opioid commission regarding kratom
I cannot post links due to forum restrictions at this time, but would be happy to provide them if requested.
2. There are 44 documented links between kratom and death. One of which involved a gunshot to the chest, another which involved a hanging. All but one involved polypharmacy situations with many having drugs known to cause death including heroin.
3. There are an estimated 3-5 million users
4. 8 factor analysis by Dr. Henningfield of Johns Hopkins concluded it does not meet the DEA criteria
5. While human clinical trials have not been performed, surveys and animal studies have shown promise
6. Re: Salmonella, of 28 people, 8 were found to have used kratom in the preceding 4 months and the recommendation was to stop ALL kratom use. Even more recently an outbreak of salmonella linked to chicken salad did not produce the same recommendation.
7. Letter to DEA/Opioid commission regarding kratom
I cannot post links due to forum restrictions at this time, but would be happy to provide them if requested.
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I currently use kratom as an rx replacement for mild nerve pain. No pecuniary interests.
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My UDS company already has kratom on their LC/MS testing. I've been checking the box. Haven't found a single patient taking it yet, which is surprising, since in my area there's tons of these "smoke shops" that openly advertise selling it. Picking up more THC positives due to CDB (so the patients say) than Kratom.
