Kratom Use: What Does It Mean for Our Patients?

Katherine M. Mahon, MD
Posted on February 19, 2024

Dr. Mahon is a faculty member at the Crozer Family Medicine Residency Program, Springfield, Pennsylvania.

A 23-year-old man recently presented to our family medicine residency continuity clinic requesting help with his kratom use. He had used kratom for three years, which he was purchasing legally at local smoke shops and gas stations. Before, he had been misusing oxycodone that he had obtained illicitly starting at 16 years of age. He had attempted to stop using kratom and experienced withdrawal symptoms of anxiety, sweating, nausea or vomiting, malaise, and body aches. The resident and I admitted we were familiar with kratom mostly from seeing advertisements outside of local stores. Despite experience with treating patients with medications for their opioid use disorder, I knew very little about kratom’s effect on patients or its implications for misuse and dependence.

Kratom, or Mitragyna speciosa, is a plant indigenous to Southeast Asia. It has traditionally been used by manual laborers for increased energy and pain relief; however, it is also seen in Thailand and Malaysia, with use in cultural ceremonies, as an alcohol alternative, or easing opiate withdrawal. 

Starting in 2007, use of kratom in the United States has risen and continues to rise, with use increasing 10-fold from 2010 to 2015.  Currently, kratom is fairly easy to obtain in most parts of the United States and is sold primarily at smoke shops, gas stations, or on the internet.

Kratom contains more than 25 alkaloids, with mitragynine and 7-hydroxymitragynine being the predominant active compounds. Mitragynine has a complex pharmacology; it acts as a partial agonist of the mu opioid receptor in addition to having activity at many other central nervous system and peripheral receptors. At lower doses, kratom is reported to have a stimulatory effect, and higher doses elicit opioid and euphoric effects.

Based on a cross-sectional study from data collected in 2019, the estimated prevalence of kratom use in the last 12 months for U.S. adults is 0.8%, and estimated lifetime prevalence was 1.3%. Users of kratom report multiple motivations for use, with the most commonly endorsed reasons being treatment of anxiety or depression, pain relief, treatment of fatigue or low energy, and treatment of chronic pain. 

Information about the safety profile and risk of toxicity from kratom and its metabolites is still emerging.  There were 2,312 kratom exposures that led to reports to the U.S. National Poison Data System from 2011–2018, with 935 of the cases being due to a single substance (kratom) exposure. The most common adverse effects reported were agitation, tachycardia, drowsiness, and vomiting. Serious adverse effects were rarely reported but included seizure, withdrawal, hallucinations, and cardiovascular and respiratory depression and arrest. 

Kratom is not federally scheduled as a controlled substance, although some states have limited its availability or banned its use (Alabama, Arkansas, Indiana, Vermont, Wisconsin). The U.S. Drug Enforcement Agency intended to list kratom as Schedule I in 2016 but postponed the action because of pressure from kratom advocacy groups and letters from members of Congress. However, the U.S. Food and Drug Administration has repeatedly expressed concern about potential harm and abuse. 

Cross-sectional studies performed in Malaysia and case reports worldwide suggest that some patients who chronically use kratom experience withdrawal and dependence similar to other opioids. No formal guidelines are available for treatment of kratom dependence or misuse, and only a paucity of evidence is available regarding long-term outcomes and success of treatment in primary care. To date, several case reports have described the use of buprenorphine for medication-assisted treatment in individuals reporting kratom dependence or use disorder.  

Because of its increasing use and potential for misuse and withdrawal, family physicians should understand the effects of kratom use and consider them during their differential diagnosis. Physicians should also be aware that patients may not consider kratom use as something necessary to discuss during an office visit, or they may be reluctant to disclose use. The AFP article “Common Herbal Dietary Supplement-Drug Interactions” contains information on how to best screen for and discuss herbal supplement use with patients.