Expert Offers Advice on Kratom Addiction Treatment

Over the past several years, an increasing number of Americans have been turning to kratom to self-treat pain, mental health symptoms like anxiety, and opioid withdrawal. But while the health benefits of this southeast Asian plant remain debatable, the potential for adverse events and addiction are documented. At a session today, Cornel Stanciu, M.D., the director of addiction services at New Hampshire Hospital, provided a comprehensive overview of this burgeoning botanical along with current evidence on managing patients with kratom addiction.

Kratom (Mytragyna speciosa), an evergreen shrub in the same family as the coffee plant, has been used as an herbal medicine in countries like Thailand and Indonesia for centuries without much trouble, Stanciu said, though its potential for tolerance and dependence has been known for a while. Since arriving in North America, however, the traditional use of kratom—typically chewing the leaves or brewing them as a tea—has been replaced by potent extracts and capsules that come with little quality control, he continued.

Stanciu, who is also an assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine, noted that many people turn to kratom as an opioid substitute, but it is risky to classify it as such. The most abundant chemical in kratom is an alkaloid called mitragynine, which has analgesic, adrenergic, anti-congestion, and antidiarrheal properties, but the leaves contain over 40 active chemicals; the result is that kratom can produce both calming and stimulating effects.

In fact, many clinically relevant effects of kratom involve interactions with adrenergic receptors. Kratom overdoses, for example, typically resemble a stimulant overdose rather than an opioid overdose. Nausea and rapid heartbeat are the predominate symptoms, whereas respiratory depression is quite rare. Likewise, animal studies of kratom withdrawal suggest that clonidine (used to treat high blood pressure) offers better symptom control than methadone or buprenorphine.

However, given that commercial kratom products vary greatly in their exact composition of active chemicals, and since users commonly ingest other substances (based on poison control data, polysubstance use is found in over 80% of kratom-related poisonings), Stanciu said the effects of kratom misuse vary from person to person and require individualized care.

The first step to managing kratom addiction is to identify if patients are using it, Stanciu said. Standard drug screens will not pickup kratom, but many patients are willing to disclose use of the drug, so psychiatrists should ask about kratom and other herbal products in a nonjudgmental way. Getting a history is valuable, as data suggest that the degree of withdrawal symptoms is associated with the frequency and duration of kratom use.

Physicians should then encourage kratom cessation. A majority of patients, particularly those without a substance use history and/or those using it for mood symptoms, can likely taper kratom without pharmacotherapy, Stanciu noted. Withdrawal symptoms typically emerge 12 to 24 hours after the last dose and resemble mild opioid withdrawal, though as noted adrenergic symptoms may also show up. Patients taking large amounts or those using kratom as an opioid substitute could benefit from opioid medications like buprenorphine, and case studies in the literature suggest it is well tolerated among kratom users. However, there are very few data on optimal dosage and duration, so physicians should monitor patients carefully.

“If you look at larger trends in medicine, the U.S. population is moving toward greater interest in natural remedies, so I think we will continue to see a rise in kratom use,” Stanciu said. “Psychiatrists should be willing and able to have discussions with their patients about this substance.” ■

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