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Vicknasingam B, Karunakaran T, Chawarski MC. Research and publication gaps on kratom and kratom products: a scoping review of current literature. Curr Opin Psychiatry 2024; 37:282-291. [PMID: 38818826 DOI: 10.1097/yco.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
PURPOSE OF REVIEW Kratom plant, products derived from the plant, and plant phytochemicals are of great interest among researchers, clinicians, and consumers. However, there is a paucity of rigorously collected scientific data on their risk/safety profile and public health impact. This scoping review discusses original research articles published between 2022 and 2023. It focuses on identifying publication gaps on topics related to epidemiology, public health, and risk/safety profiles comparing evidence collected by researchers from Southeast Asia and the West. RECENT FINDINGS Our review of the Scopus database identified a total of 55 publications, including clinical case reports and case series reports, surveys, studies enrolling human participants, and publications based on large-scale national surveys or large-scale national or international health system database records. SUMMARY Overall, there is dearth of reliable data on key epidemiological factors, including the prevalence rates, and on objective and reliable indices of the risk/safety profiles. Rigorous and systematic studies including improved epidemiological surveillance, human laboratory, and controlled clinical studies are urgently needed to advance our understanding of public health consequences of consuming kratom and kratom-derived products and to improve our understanding of their risk/safety profile and additional analytical studies to better inform development of needed regulatory oversight.
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Affiliation(s)
| | | | - Marek C Chawarski
- Departments of Emergency Medicine and Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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2
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Rogers JM, Weiss ST, Epstein DH, Grundmann O, Hill K, Smith KE. Kratom addiction per DSM-5 SUD criteria, and kratom physical dependence: Insights from dosing amount versus frequency. Drug Alcohol Depend 2024; 260:111329. [PMID: 38788532 DOI: 10.1016/j.drugalcdep.2024.111329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/15/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Kratom products are widely used in the United States, with inadequate understanding of how dosing amounts/frequencies relate to outcomes. METHODS Between July-November 2022, we enrolled 395 active US adult kratom consumers into a remote study with a baseline survey. We examined self-reported typical dose amounts and frequencies across people and product types, and their associations with outcomes: multiple regression was used to examine whether amounts and frequencies (doses/day) were associated with acute effects, withdrawal symptoms, scores on the Subjective Opioid Withdrawal Scale (SOWS), and addiction (operationalized as DSM-5-based symptoms of kratom-use disorder, KUD). RESULTS Participants were 54.9% male, aged 38.1 on average, and 81.3% White. Mean length of kratom use was 5.7 years. Most (95.9%) reported regularly using whole-leaf kratom products; 16 (4.1%) reported regular extract use. SOWS scores were mild to moderate on average (13.5, SD 11.9). KUD symptom counts were mostly in the mild/moderate range (80.7%). Withdrawal and KUD symptoms were more closely associated with dose frequency than dose amount. Men reported more acute effects, withdrawal symptoms with cessation, and KUD symptoms than women. CONCLUSIONS Greater dose amount and frequency were systematically related to the number of withdrawal symptoms upon cessation and to KUD symptoms; the relationship was stronger for dose frequency than amount. Men may have more acute effects and more withdrawal and KUD symptoms than women. Although kratom may be used nonproblematically by some consumers, physical dependence (tolerance, withdrawal, or use to avoid withdrawal) and KUD become more likely with increasing dose frequency.
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Affiliation(s)
- Jeffrey M Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States
| | - Stephanie T Weiss
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - David H Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Katherine Hill
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
| | - Kirsten E Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Smith KE, Feldman JD, Dunn KE, McCurdy CR, Grundmann O, Garcia-Romeu A, Panlilio LV, Rogers JM, Sharma A, Fernandez SP, Kheyfets M, Epstein DH. Novel methods for the remote investigation of emerging substances: Application to kratom. Exp Clin Psychopharmacol 2024; 32:215-227. [PMID: 37213182 PMCID: PMC10663387 DOI: 10.1037/pha0000656] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The botanical product commonly called "kratom" is still relatively novel to the United States. Like other natural products marketed as supplements, kratom is highly variable, both in terms of the alkaloids naturally occurring in kratom leaves and in terms of processing and formulation. Kratom products sold in the United States are not well-characterized, nor are daily use patterns among regular users. Surveys and case reports have comprised most of the literature on kratom use among humans. To advance our understanding of real-world kratom use, we developed a protocol for the remote study of regular kratom-using adults in the United States. Our study had three aspects implemented in one pool of participants nationwide: an in-depth online survey, 15 days of ecological momentary assessment (EMA) via smartphone app, and the collection and assay of the kratom products used by participants during EMA. Here, we describe these methods, which can be used to investigate myriad drugs or supplements. Recruiting, screening, and data collection occurred between July 20, 2022 and October 18, 2022. During this time, we demonstrated that these methods, while challenging from a logistical and staffing standpoint, are feasible and can produce high-quality data. The study achieved high rates of enrollment, compliance, and completion. Substances that are emerging or novel, but still largely legal, can be productively studied via nationwide EMA combined with assays of shipped product samples from participants. We discuss challenges and lessons learned so other investigators can adapt these methods. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Kirsten E. Smith
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Jeffrey D. Feldman
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Albert Garcia-Romeu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leigh V. Panlilio
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Jeffrey M. Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Salma-Pont Fernandez
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Marina Kheyfets
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - David H. Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
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Zamarripa CA, Spindle TR, Panlilio LV, Strickland JC, Feldman JD, Novak MD, Epstein DH, Dunn KE, McCurdy CR, Sharma A, Kuntz MA, Mukhopadhyay S, Raju KSR, Rogers JM, Smith KE. Effects of kratom on driving: Results from a cross-sectional survey, ecological momentary assessment, and pilot simulated driving Study. TRAFFIC INJURY PREVENTION 2024; 25:594-603. [PMID: 38497810 DOI: 10.1080/15389588.2024.2327827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/01/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES Despite widespread kratom use, there is a lack of knowledge regarding its effects on driving. We evaluated the self-reported driving behaviors of kratom consumers and assessed their simulated-driving performance after self-administering kratom products. METHODS We present results from: 1) a remote, national study of US adults who regularly use kratom, and 2) an in-person substudy from which we re-recruited participants. In the national study (N = 357), participants completed a detailed survey and a 15-day ecological momentary assessment (EMA) that monitored naturalistic kratom use. For the remote study, outcomes were self-reported general and risky driving behaviors, perceived impairment, and driving confidence following kratom administration. For the in-person substudy, 10 adults consumed their typical kratom products and their driving performance on a high-fidelity driving simulator pre- and post-kratom administration was evaluated. RESULTS Over 90% of participants surveyed self-reported driving under the influence of kratom. Most reported low rates of risky driving behavior and expressed high confidence in their driving ability after taking kratom. This was consistent with EMA findings: participants reported feeling confident in their driving ability and perceived little impairment within 15-180 min after using kratom. In the in-person substudy, there were no significant changes in simulated driving performance after taking kratom. CONCLUSIONS Using kratom before driving appears routine, however, self-reported and simulated driving findings suggest kratom effects at self-selected doses among regular kratom consumers do not produce significant changes in subjective and objective measures of driving impairment. Research is needed to objectively characterize kratom's impact on driving in regular and infrequent consumers.
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Affiliation(s)
- C Austin Zamarripa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tory R Spindle
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leigh V Panlilio
- Real-World, Assessment, Prediction, Treatment Unit, Intramural Research Program, National Institute on Drug Abuse, Baltimore, Maryland, USA
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey D Feldman
- Real-World, Assessment, Prediction, Treatment Unit, Intramural Research Program, National Institute on Drug Abuse, Baltimore, Maryland, USA
| | - Matthew D Novak
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David H Epstein
- Real-World, Assessment, Prediction, Treatment Unit, Intramural Research Program, National Institute on Drug Abuse, Baltimore, Maryland, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher R McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Michelle A Kuntz
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Sushobhan Mukhopadhyay
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Kanumuri Siva Rama Raju
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jeffrey M Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
| | - Kirsten E Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Smith KE, Rogers JM, Sharma A, McCurdy CR, Weiss ST, Dunn KE, Feldman JD, Kuntz MA, Mukhopadhyay S, Raju KSR, Taylor RC, Epstein DH. Responses to a "Typical" Morning Dose of Kratom in People Who Use Kratom Regularly: A Direct-Observation Study. J Addict Med 2024; 18:144-152. [PMID: 38174871 PMCID: PMC10939942 DOI: 10.1097/adm.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Use of kratom has outpaced systematic study of its effects, with most studies reliant on retrospective self-report. METHODS We aimed to assess acute effects following kratom use in adults who use regularly, and quantify alkaloids in the products, urine, and plasma. Between July and November 2022, 10 adults came to our clinic and orally self-administered their typical kratom dose; blinding procedures were not used. Physiological measures included blood pressure, respiratory rate, heart rate, pulse oximetry, temperature, and pupil diameter. Subjective outcomes included Subjective Opioid Withdrawal Scale, Addiction Research Center Inventory, and Drug Effects Questionnaire. Psychomotor performance was also assessed. RESULTS Participants were 6 men and 4 women, mean age 41.2 years. Nine were non-Hispanic White; 1 was biracial. They had used kratom for 6.6 years (SD, 3.8 years) on average (2.0-14.1). Sessions were 190.89 minutes on average (SD, 15.10 minutes). Mean session dose was 5.16 g (median, 4.38 g; range, 1.1-10.9 g) leaf powder. Relative to baseline, physiological changes were minor. However, pupil diameter decreased (right, b = -0.70, P < 0.01; left, b = -0.73, P < 0.01) 40-80 minutes postdose and remained below baseline >160 minutes. Subjective Opioid Withdrawal Scale pre-dosing was mild (5.5 ± 3.3) and decreased postdose (b = [-4.0, -2.9], P < 0.01). Drug Effects Questionnaire "feeling effects" increased to 40/100 (SD, 30.5) within 40 minutes and remained above baseline 80 to 120 minutes (b = 19.0, P = 0.04), peaking at 72.7/100; 6 participants rated euphoria as mild on the Addiction Research Center Inventory Morphine-Benzedrine-scale. Psychomotor performance did not reliably improve or deteriorate postdosing. CONCLUSIONS Among regular consumers, we found few clinically significant differences pre- and post-kratom dosing. Alkaloidal contents in products were within expected ranges.
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Affiliation(s)
- Kirsten E. Smith
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey M. Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Stephanie T. Weiss
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey D. Feldman
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Michelle A. Kuntz
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Sushobhan Mukhopadhyay
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Kanumuri Siva Rama Raju
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Richard C. Taylor
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - David H. Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
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Faucher MA, Morillos S, Cordova P, McNeil-Santiel J, Onisko N, Adhikari EH, Nelson DB. Kratom (Mitragyna speciosa): A Case Review of Use Before and During Pregnancy. J Midwifery Womens Health 2024; 69:144-149. [PMID: 37679866 DOI: 10.1111/jmwh.13558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Kratom (Mitragyna speciosa) is a plant-based substance with psychoactive properties similar to opioids but is not currently classified as an opioid. One of its more prevalent uses is to treat opioid dependency and withdrawal symptoms. Opioid use disorder is a leading cause of pregnancy-associated maternal mortality, and pregnant women may be using kratom as a substitute or alternative to opioids. Prevalence of kratom use is increasing rapidly, but scientific evidence specific to therapeutic and adverse effects is lacking overall, and the implications of its use in pregnancy and on the fetus-newborn are limited to a few case reports. Kratom is a legal substance by federal law, although some states have banned its use. The lack of regulation is concerning. Significant illness and associated deaths have been reported with kratom use. Lack of disclosure by people using kratom and limited laboratory testing options are major challenges for health care providers and public health.
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Affiliation(s)
- Mary Ann Faucher
- Women & Infants Specialty Health, Parkland Health, Dallas, Texas
| | | | - Polly Cordova
- Women & Infants Specialty Health, Parkland Health, Dallas, Texas
| | | | - Nancy Onisko
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Emily H Adhikari
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Hossain R, Sultana A, Nuinoon M, Noonong K, Tangpong J, Hossain KH, Rahman MA. A Critical Review of the Neuropharmacological Effects of Kratom: An Insight from the Functional Array of Identified Natural Compounds. Molecules 2023; 28:7372. [PMID: 37959790 PMCID: PMC10648626 DOI: 10.3390/molecules28217372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Kratom (Mitragyna speciosa Korth. Havil) has been considered a narcotic drug for years, barred by the law in many parts of the world, while extensive research over the past few decades proves its several beneficial effects, some of which are still in ambiguity. In many countries, including Thailand, the indiscriminate use and abuse of kratom have led to the loss of life. Nonetheless, researchers have isolated almost fifty pure compounds from kratom, most of which are alkaloids. The most prevalent compounds, mitragynine and 7-hydroxy mitragynine, are reported to display agonist morphine-like effects on human μ-opioid receptors and antagonists at κ- and δ-opioid receptors with multimodal effects at other central receptors. Mitragynine is also credited to be one of the modulatory molecules for the Keap1-Nrf2 pathway and SOD, CAT, GST, and associated genes' upregulatory cascades, leading it to play a pivotal role in neuroprotective actions while evidently causing neuronal disorders at high doses. Additionally, its anti-inflammatory, antioxidative, antibacterial, and gastroprotective effects are well-cited. In this context, this review focuses on the research gap to resolve ambiguities about the neuronal effects of kratom and demonstrate its prospects as a therapeutic target for neurological disorders associated with other pharmacological effects.
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Affiliation(s)
- Rahni Hossain
- School of Allied Health Sciences, College of Graduate Studies, Walailak University, Nakhon Si Thammarat 80160, Thailand; (R.H.); (M.N.); (K.N.)
- Research Excellence Center for Innovation and Health Product (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Abida Sultana
- Department of Biochemistry & Molecular Biology, University of Chittagong, Chittagong 4331, Bangladesh;
| | - Manit Nuinoon
- School of Allied Health Sciences, College of Graduate Studies, Walailak University, Nakhon Si Thammarat 80160, Thailand; (R.H.); (M.N.); (K.N.)
- Hematology and Transfusion Science Research Center, Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Kunwadee Noonong
- School of Allied Health Sciences, College of Graduate Studies, Walailak University, Nakhon Si Thammarat 80160, Thailand; (R.H.); (M.N.); (K.N.)
- Research Excellence Center for Innovation and Health Product (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Jitbanjong Tangpong
- School of Allied Health Sciences, College of Graduate Studies, Walailak University, Nakhon Si Thammarat 80160, Thailand; (R.H.); (M.N.); (K.N.)
- Research Excellence Center for Innovation and Health Product (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Kazi Helal Hossain
- Angiogenesis and Brain Development Laboratory, Department of Neurosciences, Huntington Medical Research Institutes (HMRI), Pasadena, CA 91105, USA;
| | - Md Atiar Rahman
- School of Allied Health Sciences, College of Graduate Studies, Walailak University, Nakhon Si Thammarat 80160, Thailand; (R.H.); (M.N.); (K.N.)
- Department of Biochemistry & Molecular Biology, University of Chittagong, Chittagong 4331, Bangladesh;
- Research Excellence Center for Innovation and Health Product (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand
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Arhin M, Mobley J, Hamad H, Remick P. Successful Management of Kratom Use Disorder With Buprenorphine and Naloxone. Cureus 2023; 15:e41146. [PMID: 37519540 PMCID: PMC10386870 DOI: 10.7759/cureus.41146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Kratom is an unregulated herbal supplement that is growing in popularity in the United States. Its primary active ingredients, mitragynine, and 7-hydroxymitragynine, are partial agonists that act on mu- and delta-opioid receptors in the central nervous system, producing analgesia and a sense of euphoria. Kratom use can lead to addiction and adverse side effects, such as seizures, hallucinations, and coma. This case report presents a male in his 40s with a history of kratom use, who presented to the clinic seeking help for his addiction. The patient had been using kratom for several years to self-medicate for his anxiety and depression and gradually developed a kratom addiction. The patient was successfully treated with buprenorphine/naloxone, which helped alleviate his withdrawal symptoms and allowed him to abstain from kratom. This case underscores the growing issue of kratom addiction in the United States and the critical need for physician awareness in treating withdrawal.
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Affiliation(s)
- Martin Arhin
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Julian Mobley
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Hamad Hamad
- Family Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Paul Remick
- Family Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
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Prevete E, Kuypers KPC, Theunissen EL, Esposito G, Ramaekers JG, Pasquini M, Corazza O. Clinical Implications of Kratom ( Mitragyna speciosa) Use: a Literature Review. CURRENT ADDICTION REPORTS 2023; 10:317-334. [PMID: 37266188 PMCID: PMC10177737 DOI: 10.1007/s40429-023-00478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 06/03/2023]
Abstract
Purpose of Review This work aims to provide an up-to-date review of the preclinical and clinical scientific literature on the therapeutic value of kratom to better understand the underlying mechanisms related to its use and inform future therapeutic applications. Recent Findings A growing number of studies, mainly of cross-sectional nature, describe the widespread use of kratom by individuals to self-treat pain, psychiatric symptoms, and substance use disorders (SUD) outside a controlled clinical setting. Preclinical evidence suggests kratom is effective as an analgesic agent and might decrease the self-administration of other drugs. A randomized controlled trial has further supported kratom's therapeutic value as an analgesic. Investigations in nonclinical samples of long-term kratom users also indicate its therapeutic benefit in managing SUD symptoms (e.g., craving) and long-term or acute symptoms (e.g., withdrawal) for alcohol, opioids, and other illicit drugs. However, episodes of kratom-related intoxications have also been reported, often due to the adulteration and the contamination of kratom products mainly sold online or mixed toxicities when consumed outside clinical and traditional settings. Summary Evidence on the clinical implications of kratom use is still limited and uncertain, with kratom research constantly evolving. Therefore, further randomized trials are needed.
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Affiliation(s)
- Elisabeth Prevete
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell’Università 30, 00185 Rome, Italy
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands
| | - Kim Paula Colette Kuypers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands
| | - Eef Lien Theunissen
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands
| | - Gianluca Esposito
- Department of Psychology and Cognitive Science, University of Trento, Corso Bettini, 84, 38068 Rovereto, Italy
| | - Johannes Gerardus Ramaekers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell’Università 30, 00185 Rome, Italy
| | - Ornella Corazza
- Department of Psychology and Cognitive Science, University of Trento, Corso Bettini, 84, 38068 Rovereto, Italy
- Department of Clinical, Pharmacological and Biological Sciences, University of Hertfordshire, College Lane, Hatfield, AL10 9AB UK
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Smith KE, Feldman JD, Dunn KE, McCurdy CR, Weiss ST, Grundmann O, Garcia-Romeu A, Nichels J, Epstein DH. Examining the paradoxical effects of kratom: a narrative inquiry. Front Pharmacol 2023; 14:1174139. [PMID: 37214465 PMCID: PMC10196254 DOI: 10.3389/fphar.2023.1174139] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction: Surveys and case reports have documented kratom use in the United States (US) for over a decade. However, those reports have generally not examined in depth the role kratom plays in the lives of those who use it regularly for sustained periods. Until there are controlled studies of the pharmacology and subjective effects of kratom alkaloids in humans, one of the best sources of insight on kratom-product use remains qualitative data with nuanced descriptions of kratom effects from those who use it regularly. Method: We conducted semistructured qualitative interviews with adults who regularly use kratom products, as part of a laboratory study of kratom-product self-administration. This qualitative component of the study was conducted as a narrative case-report series (n = 10). Results: Despite some differences among participants, all experienced acute combination effects that were largely, even simultaneously, analgesic and stimulatory. Most participants had decreased their dosages over time, and one planned to quit. Five of the 10 participants met DSM-5-based criteria for kratom-use disorder (3 mild, 1 moderate, 1 severe, by symptoms counts). When kratom was inadvertently taken in larger than intended doses, participants described a constellation of symptoms that they called "the wobbles" (a jittery feeling accompanied by what seemed to be nystagmus); this was rare, but could be of scientific and clinical interest as a possible manifestation of serotonin syndrome. Most participants described tolerance but considered kratom generally safe at low-moderate doses, providing perceived benefits with less potential risk for adverse effects compared to pharmaceuticals or illicit drugs. Discussion: In-depth interview data like these help confirm and clarify findings from larger survey studies and clinician-driven case reports. They are needed to inform the policy practice regarding kratom and may also help inform future experimental designs.
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Affiliation(s)
- Kirsten E. Smith
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Jeffrey D. Feldman
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Stephanie T. Weiss
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Albert Garcia-Romeu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Janeen Nichels
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - David H. Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
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Smith KE, Rogers JM, Feldman JD. Kratom's Emergence and Persistence Within the US Polydrug Epidemic. CURRENT ADDICTION REPORTS 2023; 10:262-271. [PMID: 37266191 PMCID: PMC10111073 DOI: 10.1007/s40429-023-00476-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 06/03/2023]
Abstract
Purpose of Review Use of "kratom" products, derived from the bioactive botanical Mitragyna speciosa have increased amidst US polydrug use epidemics. Kratom alkaloids interact with opioid, serotonergic, adrenergic, and other receptors and regular users have described experiencing a wide range of effects. Some with polydrug use histories have reported using kratom as a substitute for other drugs or to nonmedically self-manage substance use disorder (SUD) symptoms. Data describing this remain scare and come from self-report. We review this literature describing kratom use as a drug substitute, or as a nonmedical "self-treatment" for attenuating dependence or SUD symptoms. Recent Findings Kratom products have been documented as being used as a licit and illicit opioid substitute. Use to reduce alcohol or stimulant consumption is less well documented. Although prior and current polydrug use appear common among a some kratom users, it is unclear if co-use is contemporaneous or concomitant. Temporal order of use initiation is typically undocumented. Use for energy and recreation are also increasingly reported. Summary Data on kratom consumption come primarily from self-report with significant limitations. Until controlled human laboratory studies have been conducted, we can presently only describe what is known about human kratom use based on self-report. Such data describe real-world kratom use, leaving unaddressed human abuse liability or therapeutic potential of kratom alkaloids. Clinicians should be mindful of use motivations among people with SUD histories, sensitively assessing use. The paucity of data highlights the urgent need to increase funding and research for understanding kratom's effects in humans.
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Affiliation(s)
- Kirsten Elin Smith
- Real-world Assessment, Prediction, and Treatment Unit, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, 251 Bayview Blvd., Suite 200, Room 01B340, Baltimore, MD 21224 USA
| | - Jeffrey M. Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA USA
| | - Jeffrey D. Feldman
- Real-world Assessment, Prediction, and Treatment Unit, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, 251 Bayview Blvd., Suite 200, Room 01B340, Baltimore, MD 21224 USA
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Smith KE, Feldman JD, Schriefer D, Weiss ST, Grundmann O, Dunn KE, Singh D, McCurdy CR, Butera G, Epstein DH. Diagnostic Ambiguities and Underuse of Clinical Assessment Tools: A Systematic Review of Case Reports on Kratom Addiction and Physical Dependence. CURRENT ADDICTION REPORTS 2023. [DOI: 10.1007/s40429-023-00474-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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13
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Mukhopadhyay S, Gupta S, Wilkerson JL, Sharma A, McMahon LR, McCurdy CR. Receptor Selectivity and Therapeutic Potential of Kratom in Substance Use Disorders. CURRENT ADDICTION REPORTS 2023. [DOI: 10.1007/s40429-023-00472-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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14
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Feldman JD, Schriefer D, Smith KE, Weiss ST, Butera G, Dunn KE, Grundmann O, McCurdy CR, Singh D, Epstein DH. Omissions, Ambiguities, and Underuse of Causal Assessment Tools: a Systematic Review of Case Reports on Patients Who Use Kratom. CURRENT ADDICTION REPORTS 2023. [DOI: 10.1007/s40429-023-00466-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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15
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Leksungnoen N, Andriyas T, Ngernsaengsaruay C, Uthairatsamee S, Racharak P, Sonjaroon W, Kjelgren R, Pearson BJ, McCurdy CR, Sharma A. Variations in mitragynine content in the naturally growing Kratom ( Mitragyna speciosa) population of Thailand. FRONTIERS IN PLANT SCIENCE 2022; 13:1028547. [PMID: 36388525 PMCID: PMC9648690 DOI: 10.3389/fpls.2022.1028547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 06/16/2023]
Abstract
We analyzed the content of mitragynine (MG) found in kratom leaves (Mitragyna speciosa) and the influence of different environmental conditions (air and soil variables) on the yield in various regions of Thailand. The content of MG in kratom leaves ranged from 7.5 - 26.6 mg g-1 of dry leaf weight. Canonical correspondence analysis showed that the most significant environmental variables affecting the MG content among the various regions were light intensity, relative humidity, soil volumetric water content (VW), soil pH, and calcium. This study is a first step towards providing information about environmental conditions suitable to maximize the quality and quantity of bioactive alkaloids in kratom. Future studies should focus on leaf collection and the post-harvest processes in order to assure the desired alkaloidal content in finished products, when produced under suitable environmental conditions identified in this study.
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Affiliation(s)
- Nisa Leksungnoen
- Department of Forest Biology, Faculty of Forestry, Kasetsart University, Bangkok, Thailand
- Kasetsart University Research and Development Institute (KURDI), Kasetsart University, Bangkok, Thailand
- Center for Advance Studies in Tropical Natural Resources, National Research University-Kasetsart University, Kasetsart University, Bangkok, Thailand
| | - Tushar Andriyas
- Department of Forest Biology, Faculty of Forestry, Kasetsart University, Bangkok, Thailand
| | | | - Suwimon Uthairatsamee
- Department of Forest Biology, Faculty of Forestry, Kasetsart University, Bangkok, Thailand
| | - Phruet Racharak
- Department of Forest Biology, Faculty of Forestry, Kasetsart University, Bangkok, Thailand
| | | | - Roger Kjelgren
- The University of Florida (UF)/Institute of Food and Agricultural Sciences (IFAS) Department of Environmental Horticulture, Mid-Florida Research and Education Center, Institute of Food and Agricultural Sciences, University of Florida, Apopka, FL, United States
| | - Brian J. Pearson
- The University of Florida (UF)/Institute of Food and Agricultural Sciences (IFAS) Department of Environmental Horticulture, Mid-Florida Research and Education Center, Institute of Food and Agricultural Sciences, University of Florida, Apopka, FL, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, University of Florida, Gainesville, FL, United States
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Stanciu C, Ahmed S, Gnanasegaram S, Gibson S, Penders T, Grundmann O, McCurdy C. Kratom as an opioid alternative: harm, or harm reduction? A systematic review of literature. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2022; 48:509-528. [PMID: 36001875 DOI: 10.1080/00952990.2022.2111685] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: Kratom (Mitragyna speciosa Korth.) products are increasingly endorsed for self-management of multiple ailments, including as opioid substitution. The FDA has expressed that there is no evidence to indicate that this botanical is safe or effective for any medical use.Objective: We systematically review the current state of the literature concerning the impact of kratom and its alkaloids in all paradigms that involve opioids.Methods: A keyword search of online literature databases identified 16 preclinical studies, 25 case reports, and 10 observational studies meeting our pre-selected criteria.Results: All rodent models support alkaloids' action on opioid receptors, translating in their ability to mitigate opioid withdrawal. Some studies found mitragynine (MG) to have less reinforcing properties than morphine, and possessing tolerance-sparing properties when coadministered with morphine. Two studies that assessed 7-hydroxymitragynine (7OHMG) found it to substitute for morphine with potential for tolerance and dependence. Aside from addiction development, case reports outline a variety of confounding toxicities. Ten surveys of users, some conducted with assistance from pro-kratom lobbying organizations, find a high self-reported efficacy as an opioid substitute, with minimal reported adverse effects.Conclusion: With no reported controlled human clinical trials, in the light of rising concerns surrounding kratom's liabilities, there is insufficient evidence to allow any conclusions to be drawn. Case reports and observational studies carry significant bias toward harm and efficacy, respectively. Existing animal studies are heterogeneous in methodology and ultimately findings, with concern for interspecies variability and human translatability. Further research should investigate the safety and efficacy of using kratom alkaloids as opioid substitutes.
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Affiliation(s)
- Cornel Stanciu
- New Hampshire Hospital, Psychiatry at Dartmouth's Geisel School of Medicine, Concord, NH, USA
| | - Saeed Ahmed
- Department of Psychiatry, Rutland Regional Medical Centre, Rutland, VT, USA
| | | | - Stephen Gibson
- Pharmacy Department, New Hampshire Hospital, Concord, NH, USA
| | - Thomas Penders
- Department of Addiction, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Christopher McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
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Public Health Implications and Possible Sources of Lead (Pb) as a Contaminant of Poorly Regulated Kratom Products in the United States. TOXICS 2022; 10:toxics10070398. [PMID: 35878303 PMCID: PMC9320411 DOI: 10.3390/toxics10070398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023]
Abstract
Kratom (Mitragyna speciosa) is a tropical tree that is indigenous to Southeast Asia. Kratom leaf products have been used in traditional folk medicine for their unique combination of stimulant and opioid-like effects. Kratom is being increasingly used in the West for its reputed benefits in the treatment of pain, depression, and opioid use disorder (OUD). Recent studies from the United States Food and Drug Administration (FDA, Silver Spring, MD, USA) and our laboratory have shown that many kratom products being sold in the United States are contaminated with potentially hazardous levels of lead (Pb). In this commentary, we discuss the public health implications of the presence of Pb in kratom products, particularly as they relate to the predicted levels of Pb exposure among kratom users. We also considered the specific toxic effects of Pb and how they might relate to the known physiologic and toxicologic effects of kratom. Finally, we consider the possible sources of Pb in kratom products and suggest several areas for research on this issue.
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