The green powder from Southeast Asia could help fight addiction—but is that the whole story?
Last night's episode of Hamilton’s Pharmacopeia looked at kratom, a drug known in the US mostly as a green powder you can find in gas stations or head shops. It has a variety of uses, but according to toxicology and emergency medicine doctor Kavita Babu—who’s studied kratom for 12 years—the drug developed a higher profile in the mid 2000s as a DIY method for weaning people off opioids. You still need willpower, users say, but kratom can cut down on opioid cravings and withdrawal symptoms, allowing them to get back to their lives with few, if any, side effects. But as kratom’s usage and visibility have expanded in recent years—to the point that a sub shop in Arizona installed a kratom vending machine last year—the government has taken notice. On November 14, the FDA issued a public health advisory warning that kratom acts like opioids, carrying similar risks of abuse and even death. The agency stated that it would be working to block imports of the substance to head off a possible escalation of America's opioid epidemic, or the development of a parallel health crisis. So who’s right about kratom? Could it actually have a place in opioid addiction treatments? Kratom is a plant from the same family as the coffee shrub that grows in Southeast Asia, where locals have eaten it raw, brewed it as tea, or turned it into liquids or powders for centuries. The drug's effects set in quickly and last for several hours, depending on the dose taken. In low doses, say two to three grams of powder in water, it acts like a stimulant, providing a mild buzz users liken to caffeine; in higher doses, it can relieve pain, relax muscles, reduce inflammation, and lead to mood improvements. It can be used for anything from a mild pick-me-up to serious self-administered chronic pain, depression, anxiety, or addiction management. Experts estimate that 4 to 5 million Americans used kratom as of 2016; a survey of thousands of users conducted last fall by pharmacologist and kratom researcher Oliver Grundmann suggests two-thirds of respondents used it to treat chronic pain or emotional or mental stress. Only a little more than a third—mostly younger people with self-insurance, Medicare, or no insurance—said they used it for opioid addiction issues. Many respondents also told Grundmann that they used kratom for pain management to avoid opioids, using just three to five grams at a time— far below the 10 to 15 grams suggested to really get high. But the Botanical Education Alliance (BEA), which works to protect herbal substances from over-regulation, thinks people using kratom to treat addiction are actually overrepresented in the media. The BEA argues that most users use it “similar to St. John’s wart for a patient with depression, or valerian root for a patient with anxiety.” Furthermore, scientists have identified two key ingredients in kratom—mitragynine and 7-hydroxymitragynine—that interact with opioid receptors in cell and animal studies. So you can consider them opioids, but they seem to trigger the positive effects of opioids in the brain, triggering less negative side effects than other opioids as well. It takes longer to build up a tolerance to kratom than to traditional opioids, and when one does develop a dependency, the withdrawal symptoms are reportedly far milder than those associated with mainstream opioids. These facts certainly suggest kratom could be an innovative, if not ideal, pain killer; some researchers also claim it would be a good replacement for methadone or buprenorphine, opioids that stay in the body longer than heroin or most prescription drugs and don’t lead to as strong of a high. Despite being used to blunt cravings and control withdrawal, those substances still have side effects, and can be abused; kratom might be kinder and safer. But there’s still a lot we don’t know about kratom, and how it might affect humans. “At some point,” Grundmann states, “we need to conduct studies that are done on standardized extracts containing standardized amounts of mitragynine so we can compare the effect of doses and how patients react over time.” “I'm very concerned with the increased use of opioids resulting in overdose and death,” said emer