Kratom Drug of the Month: download

Transcript and Sources

Introduction

And now it’s time for the Drug of the Month, where we take a closer look at the background, science, history, and recent trends in a different drug each month. For our last drug of the month, we talked about Ritalin, a commonly prescribed drug that’s faced controversy for both its prescribed and off-label uses. This month, we’ll be examining a drug that was a relatively obscure plant-based medicine until recently, when a proposal to add it to Schedule 1 of the Controlled Substances Act sparked wide outrage. This month, of course, we’ll be discussing Kratom.

So Kratom’s scientific name is Mitragyna (mitt-ra-guy-na) speciosa. It is a tropical evergreen tree from the same family as coffee, native to Southeast Asia. The tree can grow up to 80 feet tall and three feet wide. The leaves are dark green and glossy, and can grow to over 6 inches in length when fully open. It is indigenous to Thailand, Indonesia, Malaysia, Myanmar, and Papua New Guinea.

In English, its name is also sometimes pronounced krah-tom. I’ve heard it both ways about 50/50, so I’m going to say Kray-tom just because that’s easier for me to pronounce, personally. If you feel strongly that we’re saying it wrong, you can take it up with us on Facebook or Twitter, or you can email us as thisweekindrugs@gmail.com. Sam might even change it up next week and pronounce it krah-tom. Who knows?

Anyway, moving on. Back to Kratom. In cultures where the plant grows, it has been used in traditional medicine since “time immemorial.” The leaves are chewed to relieve pain, and increase energy, appetite, and sexual desire in ways similar to coca. The leaves or their extracts can also be used as a local anesthetic, and to treat coughs and diarrhea. It is a unique substance in that, at low doses, kratom acts more as a stimulant, traditionally used by manual laborers to increase their energy and improve their spirits to get through long days in the field. However, at higher doses, kratom has a more sedative, opioid-like effect. This is because the active alkaloids of kratom, mitragynine and its derivatives, have a pharmacology very similar to morphine. That may also be why, today, many users of kratom have reported success using kratom teas and extracts as a non-addictive substitute to treat opioid dependency.

Unfortunately, little medical or scientific research has been done on kratom’s health effects, with most papers I’ve seen coming out in the past two years alone, and nothing really from before the early 2000s, which is surprisingly recent. As of January 2015, neither the plant itself nor its alkaloids were listed in any of the Schedules of the United Nations Drug Conventions. Surprisingly, however, or maybe not surprisingly, kratom has been illegal in Thailand and Malaysia since the 1940s and 1950s, respectively. Reliable information about the origins or history of kratom are hard to come by, at least on English / American internet, but according to one website, kratomnation.com, kratom has been used for thousands of years in South East Asia, which doesn’t really narrow it down. Several widely cited articles, including one in the International Journal of Legal Medicine, says kratom has a [quote] “long history” of traditional use. So that’s about as precise as it gets.

In its native region, kratom leaves are often chewed fresh (usually after removing the stringy central vein), but dried leaves can also be chewed. More often, dried leaves are crushed or powdered to mix into drinks so they’re easier to swallow. Powdered kratom can be mixed with water or other beverages like fruit juice, milk, or kefir to mask the bitter taste. Apparently, chocolate milk works best for this. Dried kratom leaves are also often made into a tea. Some people like to mix kratom tea with ordinary black tea, or other herbal teas, or mixed with honey, again, to mask the flavor.Kratom leaves can be smoked, but doing so is impractical because the amount of leaf that constitutes a typical dose is too much to be smoked easily.

At the stimulant level, the mind becomes more alert, physical energy (and sometimes sexual energy) is increased, motivation, mood, and productivity may be improved, and the user may become more talkative, friendly, and sociable. The stimulant effects of kratom are different from typical Central Nervous System stimulants, such as caffeine or amphetamine drugs. Kratom has more of a cognitive stimulant effect than a physical one.

At higher doses, the primary effects become more sedative, euphoric, and analgesic. The user may become less sensitive to physical or emotional pain, feel calmer and more relaxed, and have a general feeling of comfortable pleasure. They may even enter a state of pleasant dreamy reverie. Side effects may include itchiness, sweating, or nausea.

Kratom skyrocketed into national attention last month, when the US Drug Enforcement Administration or DEA announced it would be moving Kratom to schedule I as early as Friday, September 30, citing an “imminent hazard to public safety.” As of today, September 30, when I’m recording this segment, the DEA has not yet made its move, but a spokespersons for the DEA have told several publications that it will not rule out publishing a final order to ban kratom at an indeterminate time in the future. The DEA is currently facing immense political pressure from thousands of kratom users who have testified that using kratom helped them overcome their opiate addiction, an epidemic that has been sweeping the country, driven largely by an over-prescription of pharmaceutical opioids in recent years. A petition to the White House asking the Obama administration to stop the DEA from scheduling Kratom has gathered more than 140,000 signatures, and more than 50 Congressmen have signed onto a bipartisan letter to the same effect.

According to the letter from Congress to the White House: “The DEA’s decision to place kratom as a Schedule I substance will put a halt on federally funded research and innovation surrounding the treatment of individuals suffering from opioid and other addictions — a significant public health threat.”

This should be an interesting Drug of the Month for October, as we follow along with the progress of the battle over Kratom’s scheduling. So that’s all for this week’s segment, an introduction to Kratom. Sam will be back next week with the science behind Kratom and how it interacts with the human body.

Science

Now it’s time for the drug of the month, where we go into the science, history, and current events in a different substance each month. For October, that drug is Kratom, which Rachelle gave an introduction to last week. For this, the second installment, I’ll be explaining a bit about the science behind kratom: how it interacts with the body, along with some of its beneficial and harmful effects.

As Rachelle discussed last week, kratom comes from a tree in Southeast Asia whose scientific name is Mitragyna speciosa. The leaves are the important part, and people can consume them in a variety of ways, from chewing on the raw leaves, to drying them out in order to create a powder that can then be added to drinks. Depending on the dosage, kratom can have a range of effects that’s wider than that of most other drugs. This is somewhat similar to cannabis, and may also have something to do with one other thing they have in common: that rather than being specific compounds, both cannabis and kratom are plant matter that contain a wide variety of compounds, that form something referred to as the “entourage effect.”

Kratom, which again, is the leaf of the tree, contains over 40 different compounds, but the two most abundant ones are mitragynine and 7-hydroxymitragynine (which is also known as 7-HMG for short). These are both alkaloids, along with about 25 of those 40 other compounds. As we’ve mentioned on the show before, alkaloids are a large category of compounds that include a wide variety of drugs including morphine, cocaine, theobromine, and nicotine. While they can be stimulants, narcotics, or many other types of drugs, alkaloids almost universally taste bitter, which is why kratom is so often combined with drinks in order to mask its bitter taste.

An interesting thing about kratom is that while its use goes back centuries if not millenia, it is relatively new to Western society – while this has led to it remaining unscheduled by the DEA and its equivalents in other governments for a long time, this also means that it was generally overlooked by academics who were studying the effects of drugs through the lens of Western medicine. What all that means is we actually don’t know that much about the pharmacology of kratom – like nitrous oxide, we have a decent understanding of its effects, but some of the mechanisms of action still remain a mystery.

A few of the things we do know is that mitragynine and 7-HMG are both agonists of the μ-opioid receptor. As a quick refresher, if something is an agonist that means it binds to a receptor and causes a reaction, while an antagonist blocks a reaction. This is the same receptor acted on by drugs like morphine, which is responsible for some of kratom’s more narcotic effects, but may also be the reason there are anecdotal reports of people using it to help them fight addictions to heroin or prescription painkillers (though we’d like to emphasize that there isn’t research to back this up yet, since kratom is pretty new to academia and is just starting to be studied).

While we are not sure exactly why, generations of accumulated experience have shown us that kratom has different effects at different dosages. When taken in small amounts, like when chewing the leaf, it can help relieve pain, and increase your energy and appetite. Because of this, it has long been used in a manner similar to coca, where farmers and other manual laborers will chew the leaves during the day to keep them going. Users start feeling effects within 5 to 10 minutes and they can last about 2 to 5 hours. Like a typical stimulant, the side effects at these small doses can include anxiety, agitation, and nausea.

When taken in larger doses, kratom starts to behave more like an opiate, acting like a painkiller and sedative but also coming with side effects like constipation, dizziness, and sweating. While it can be used to stave off withdrawal symptoms from opiates, if used frequently enough it will cause its own withdrawal symptoms, so it may be more of a substitute (albeit a possibly safer one) than a cure. One data point that shows it may be safer is that while mitragynine acts on the same receptor as other opiates, in animal studies at very high doses, mitragynine caused respiratory depression, but less than morphine or codeine. Respiratory depression is the main cause of death in opiate overdoses, so this is a very important metric for drug safety. However, reduced risk does not mean no risk, and in addition to a few hundred hospitalizations in the US, kratom has been linked to one death. In this case, it was interacting with other drugs, so as always, do your research before mixing drugs because that drastically increases your risk.

So that’s all for this segment, where wethe scratched the surface of the science of kratom. Hopefully much more research will be on its way, and of course, we’ll be providing updates in the news segment as any papers are published. Rachelle will be back next week with a look into the history of kratom.

History

And now it’s time for the Drug of the Month, where we take a closer look at the background, science, history, and recent trends in a different drug each month. October’s Drug of the Month is Kratom, which the DEA recently proposed to ban. Last week, Sam went over the science of Kratom and how it interacts with the human body. This week, I’ll go over the history of kratom, which has been used in SouthEast Asia as a common pain relief remedy and stimulant for generations.

As Sam and I have both mentioned, while kratom is a commonly used herbal medicine in certain parts of the world, its introduction to the “Western” world and particularly North America is a relatively recent development. That’s why not much in the way of either scientific research or cultural history has been written about kratom, or at least not in English. Of course the word “kray-tom” or “krah-tom” itself comes from the Malaysian word for the plant, ketum.

According to some online sources, the use of Kratom was likely first introduced into western civilization by early Dutch traders; and, may have been first described in Western literature during the early 19th century by Pieter Willem Korthals, a botanist for the East India Company. Many sources also point to an 1836 article by James Low as the first authoritative record on kratom. In his “dissertation on the soil & agriculture of the British settlement of Penang,” Low writes that “ the peasants and rural workers in Malaysia used [kratom] as a substitute when opium was unavailable or not affordable.” In 1895, kratom was given its botanical name, Mitragyna speciosa, by a man named E.M. Holmes, who was Curator of the Materia Medica Museum of the Pharmaceutical Society at the time. Holmes also referred to Kratom’s use as an opium substitute. Two years later H. Ridley recorded the use of kratom to wean people off of opium (and its extracts).

It’s clear from these early records that kratom’s use as a substitute or treatment for opiate use has been well-documented for centuries and likely dates back much farther than Western civilization’s contact with it suggests.

In 1907, a researcher named L. Wray described how kratom could be smoked, chewed or drunk as an infusion with opium-like effects regardless of the method of administration. He expressed the hope that an active principle would soon be isolated and its usefulness to medicine assessed. Samples of the leaves were sent to the University of Edinburgh where, 14 years later, mitragynine, one of its most abundant alkaloids, was isolated.

On August 3, 1943, the government of Thailand passed the Kratom Act, which made possession and sale of Kratom illegal and even included cutting down kratom trees in order to enforce the law. Some sources claim that the ban on kratom was not driven by public health concerns, but rather because it was being used a substitute for opium, which the government relied on as a legal narcotic product to generate taxes from, and therefore kratom was its competitor. This may sound pretty familiar to anyone who may believe that the Pharmaceutical lobby may have been behind the DEA’s emergency proposal to ban kratom here in the United States.

Kratom was also made illegal in Malaysia in 1952.

There was a resurgence of interest in its research in the 1960s, which was spurred by a search for non-opiate analgesics. Researchers found mitragynine to be comparable with codeine as an analgesic and cough suppressant, and that, unlike codeine at equivalent doses, it did not cause vomiting or shortness of breath. They also found kratom to have no opiate-like addiction symptoms, and to be much less of a respiratory depressant than codeine. Chemically unrelated to any known analgesic, it also appeared to be significantly less toxic. A 1988 Letter to the Editor in the Journal of Ethnopharmacology concludes, “we are left with a drug which is claimed to be both a narcotic and a stimulant – two effects generally regarded as opposite. Even more intriguing is the connection of these effects with a chemical structure resembling a psychedelic hallucinogen rather than an opiate.” The letter even predicts “While the market now has many non-opiate analgesics, kratom may have a special role as a replacement for methadone in addiction treatment programs.”

In 1975, a study of 30 Thai kratom users was published. These were mostly older, married men who had been using the drug for more than 5 years. Ninety percent chewed the fresh leaf or took it as a powder. The leaves were chewed three to ten times a day with stimulant effects beginning 5-10 min later. Almost all of the subjects said that they had become addicted because they sought to increase their work out-put. The drug was also said to “calm the mind”. The kratom habit was noted to be a largely ritualistic, rural phenomenon, with village society accepting male users who worked to support their families, but not female users. In 2001, the Thai Narcotics Control Board indicated that kratom was still the second most widely abused illegal drug in the country, particularly in the rural and sub-urban areas.

The drug is currently on the DEA’s “drugs of concern” list, but the agency has maintained for years that kratom should be a Schedule 1 substance, as the agency claims that it has a high potential for abuse, that it has no currently accepted medicinal use, and that there is a lack of evidence of safety when used under medical supervision. The Centers for Disease Control and Prevention reported in July that the number of calls to poison control centers related to kratom had increased tenfold, from 26 in 2010 to 263 in 2016. Only forty-nine of all cases over the past six years were considered life-threatening.

Health problems related to kratom use are difficult to evaluate due to the apparently conflicting nature of reports from Asia and the West. In many of the poison control cases reported, kratom was used in conjunction with other drugs. Because such reports are statistically insignificant in Southeast Asia, where the plant is primarily grown and commonly used, adulteration of extracts sold on the internet are likely behind many reports of kratom toxicity. Even if the poison control calls were purely attributable to kratom overdose, 263 in one year (of which only 49 were life-threatening in over six years) is nothing compared to the nearly 19,000 overdose deaths caused by pharmaceutical prescription opioids in 2014, and more than 10,000 more caused by heroin.

As of January 2015 neither the plant nor its alkaloids were listed in any of the Schedules of the United Nations Drug Conventions. However, as of today, it is illegal in Australia, Thailand, Malaysia, Myanmar, Romania and the US states of Indiana, Mississippi and Louisiana*.

Kratom is also a controlled substance in Denmark, Latvia, Lithuania, Poland, Sweden, and New Zealand.

That’s all for the history of Kratom. Next week, Sam will be back for our fourth and final installment of October’s Drug of Month, where he’ll discuss recent news and trends in kratom.

Trends

Now it’s time for the drug of the month, where we bring you an introduction and the science, history, and recent trends in a different drug each month. For October, that drug is kratom, and for this, the fourth and final installment, I’ll be talking about trends and current events in the world of kratom.

So this is going to be an unusual episode, because this is the first drug that we’ve covered while it’s currently IN the scheduling process. We’ve covered this a bit during our weekly news, so I’m going to give a bit more context for all of these happenings, and an update for where things now stand. This is going to be a bit longer than our usual segment because there’s so much happening – but this also means that this segment could become outdated pretty soon, so keep listening to the news to see what happens next.

As Rachelle explained in the history segment, while kratom is native to Southeast Asia and is quite popular in countries such as Thailand, it has actually been illegal in Thailand since 1943. It’s also banned in Malaysia, Myanmar, Australia, and Bhutan. However, it’s not very strictly enforced, and the culture in Thailand seems to be similar to that surrounding coca in many South American countries.

So exactly how popular is kratom, in the areas it’s native to? A survey from 2007, with over 26,000 respondents, found that 0.81% of people in Thailand had used it in the past year. While this sounds small, it’s actually higher than the rate for cannabis, making it the most widely consumed illegal drug in the country. One interesting thing is that while fewer people had used cannabis in the past year, more people reported having tried it at some point in their lives, indicating that there are more long-term kratom users than cannabis users.

Kratom does seem to have become more popular in Thailand since that survey, with reports that kratom-related treatment admissions almost tripled between 2007 and 2011. This is likely driven by the increasing popularity not of chewed kratom leaves, but of various drug cocktails collectively referred to as “4×100,” which usually contain a caffeinated soda, cough syrup, and kratom powder. This is particularly popular among young Muslim men, whose religion forbids them from drinking alcohol, so they seek substitutes – kind of demonstrating the silliness of banning individual drugs rather than trying to avoid abuse, just as legally banning cannabis can lead people to try more dangerous but legal synthetic drugs.

As we’ve talked about before, kratom is relatively new to the Western world, and particularly new to the United States. Because of this, it’s not included in Monitoring the Future or any of the other major American drug surveys. One source of data we do have is from poison control centers who respond to people worried about overdose or other drug problems. From 2000 to 2005, the American Association of Poison Control Centers only identified 2 exposures to kratom. A recent CDC report says there were 26 calls to poison control related to kratom in 2010, and 263 in 2015. While this is a huge proportional increase, it’s worth putting it into perspective: also in 2015, there were over 12,000 calls related to laundry detergent pods, so 45 times that of kratom.

This increase in poison control calls is certainly linked to an increase in use, as kratom itself has not been getting more dangerous. In the past five years or so, kratom has blown up in Western drug culture, particularly online. Many message boards and other communities have come together to discuss using kratom as a substitute to get people off of opiates like heroin, and others using it as a way to get pain relief while avoiding starting on opiates. This has now translated to a lot of books being written about the topic, which is a new phenomenon in the US. For example, on Amazon.com there are only 67 books that mention Kratom in the title or text. The vast majority were published in 2015 and 2016, with two in 2012 and one in 2009. Most of these are touting it as a cure or treatment for addiction – with the same range of sensationalism and science that we see with marijuana or many other drugs. However, that first book to mention kratom in 2009 was titled, “Legally Stoned: 14 Mind-Altering Substances You Can Obtain and Use Without Breaking the Law,” so it’s clear that not all kratom use is medicinal. From an admittedly outsider perspective, the culture surrounding kratom in America seems very similar to that surrounding ayahuasca, with a majority of users interested in its medicinal and life-improving properties, and psychonauts or even casual users who are just seeking a legal, easy-to-obtain drug.

Many online stores have popped up to meet this small but growing demand, and the novelty and easy access have led to the same sort of media sensationalism seen with salvia divinorum or bath salts. The earliest news article I could track down was from 2011 in the Phoenix New Times, which actually treated it quite reasonably, saying there were a growing number of people seeking treatment for it, but that we shouldn’t base all of our judgment on the people who are having the worst experiences with it, as many are using it responsibly and even getting medical benefit from it. Then in 2012, the fear started drumming up, with one example being an NBC headline, “Asian leaf kratom making presence felt in US emergency rooms,” and many more beginning to focus on the large increase in poison control calls without noting the small scale of the problem or the large community using it medicinally.

The increased reporting on kratom, itself fueling its popularity which fuels more reporting, has brought the attention of lawmakers and law enforcement. As we said earlier, kratom is already banned in some Southeast Asian countries, and it’s considered a controlled substance in a few European ones like Denmark, Latvia, Lithuania, Poland, Romania, and Sweden.

In the US, it remains unscheduled, but not for long. When it first started attracting attention, groups like the Kratom Association pushed for industry self-regulation, trying to be honest about its medical effects and negative side effects, and shaming sellers who advertised it as a legal high rather than an herbal medicine. However, this wasn’t enough for the Drug Enforcement Administration, who put it on their list of “drugs and chemicals of concern.” Then, on August 31, 2016, the DEA filed a notice of intent to use its emergency scheduling powers to add kratom to the list of schedule 1 substances under the Controlled Substances Act, calling it an “imminent threat to public safety” and saying they could make the ban permanent as soon as September 30. However, the administration only cited 15 kratom-related deaths in the entire country, 14 of which involved combinations with other drugs – hardly an imminent threat to public safety, especially in comparison to the deaths caused by other legal drugs.

This caused an uproar among the kratom using community, as well as drug policy reformers who have long been fighting against fear-mongering and knee-jerk reactions in drug scheduling. Thousands upon thousands of people contacted the DEA, from users to researchers to policymakers, telling them not to put kratom into this incredibly restrictive legal category.

Then on October 13, in a move that shocked even those fighting against the ban, the DEA reversed course and published a withdrawal of that notice of intent – meaning they would not be emergency scheduling kratom, and would instead be seeking input from the public before making a decision. This was unprecedented – the DEA has always just gone ahead with its decisions, ignoring the protests of researchers and responsible drug users. Since this is such a momentous announcement, I’ll just read the DEA’s own summary:

“On August 31, 2016, the Drug Enforcement Administration (DEA) published in the Federal Register a notice of intent to temporarily place mitragynine and 7-hydroxymitragynine, which are the main psychoactive constituents of the plant Mitragyna speciosa, also referred to as kratom, into schedule I pursuant to the temporary scheduling provisions of the Controlled Substances Act. Since publishing that notice, DEA has received numerous comments from members of the public challenging the scheduling action and requesting that the agency consider those comments and accompanying information before taking further action. In addition, DEA will receive from the Food and Drug Administration (FDA) a scientific and medical evaluation and scheduling recommendation for these substances, which DEA previously requested. DEA is therefore taking the following actions: DEA is withdrawing the August 31, 2016 notice of intent; and soliciting comments from the public regarding the scheduling of mitragynine and 7-hydroxymitragynine under the Controlled Substances Act.”

So that means that kratom is still legal and those comments are still open: they’ll remain open until December 1, 2016. And that means we’re at a pivotal moment in the history of kratom: after they review the comments, the DEA could still move forward with their plan to put it in schedule 1, or they could put it into schedule 2, 3, or even lower. So if you have anything to say about kratom, please submit a public comment! You don’t have to be an expert, any personal experiences or just your thoughts and feelings are important to share. If they get an avalanche of public comments opposing a ban, then we’re more likely to end up with a sensible policy on kratom.

But, while it remains legal at the federal level, unfortunately many states have already banned kratom, and some others are considering it. According to Speciosa.org’s map of kratom’s legality, it’s banned in 5 stateS: Arkansas, Indiana, Tennessee, Vermont, and Wisconsin. Other states have seen legislation that didn’t pass, or currently have legislation pending, so it’s my hope that at the very least, they’ll hold off on any additional bans while the DEA figures out what it’s doing nationally.

So as I said, this is the first time we’ve reported on current trends while a drug is being scheduled, so it’s too bad that this will be outdated so soon, but it’s also great to have this opportunity to play a part in that process. So if you care about the legality of kratom, please submit comments to the DEA, and keep an eye on what your state government is doing so you can fight back against prohibition there too.

Thanks for listening, and we’ll be back next week with the introduction to November’s drug of the month.