• Kratom is an herbal leaf from a tropical evergreen tree that is used as a stimulant, mood enhancer, or sedative.
• As kratom use increases in young people, physicians should routinely ask patients about their kratom use, researchers say.
• Up to one-third of kratom users experience an adverse side effect, which may involve cardiac arrest, liver damage, brain bleeding, or seizures.
• In some cases, kratom use has resulted in overdose deaths.

Doctors should routinely ask their patients about their kratom use, a new research commentary suggests.

The authors argue that physicians should view kratom the same as other recreational drugs like cannabis, cocaine, methamphetamines, and heroin.

“We believe it’s time for physicians to embrace asking about kratom due to its effects, safety profile, widespread availability and largely unregulated status,” researchers from the University of New Mexico School of Medicine and WorkIt Health wrote on August 12 in Annals of Internal Medicine.

Tildabeth Doscher, MD, a clinical assistant professor of family medicine at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, who was not involved in the commentary, agreed.

“Kratom is definitely something I see in my practice because it is a substance that people do become physically and psychologically dependent on,” Doscher told Healthline.

What is kratom?

Kratom is an herbal leaf from Mitragyna speciosa, a tropical evergreen tree in the coffee family. The tree is native to Thailand, Indonesia, Myanmar, Malaysia, and other Southeast Asian countries.

People use the leaves, or extracts from the leaves, as a stimulant, mood enhancer, or sedative.

“Kratom acts as a stimulant at low doses but acts as an opioid at higher doses,” explained Natalie Klag, MD, assistant professor of psychiatry in the Department of Psychiatry & Behavioral Health at The Ohio State University Wexner Medical Center and College of Medicine. Klag was not involved in writing the new commentary.

Kratom is available in tobacco, vape, and natural product stores, among others. It comes in several forms and can be smoked, vaped, drunk, or swallowed in capsule form.

An estimated 1.9 million Americans ages 12 years or older used kratom in 2022, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). However, the authors of the new commentary said this is “likely an underestimation.”

Rates of kratom use were highest among young adults ages 18 to 25, followed by adults 26 or older, and adolescents aged 12 to 17, SAMHSA reports.

Kratom is also used to relieve chronic pain, treat anxiety and depression, or reduce opioid withdrawal symptoms, such as when stopping heroin or morphine.

There is little evidence to support the use of kratom for these purposes. The drug also hasn’t been approved for medical use.

Is kratom legal?

Although kratom is widely available in the United States, the Drug Enforcement Agency (DEA) considers it a “drug of concern.”

According to the Food and Drug Administration (FDA), “… kratom is not lawfully marketed in the U.S. as a drug product, a dietary supplement, or a food additive in conventional food.”

However, kratom remains unregulated in most states except Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin, according to the Congressional Research Service. Legislators in several of those states have introduced bills that would permit the sale of kratom products.

In Tennessee, the ban on kratom extends only to synthetic versions of the drug, not to the plant itself.

How safe is kratom?

“[Kratom’s easy] availability communicates a level of safety that is misleading,” Klag told Healthline, “and can often lead to people delaying medical management if their use is out of control.”

In the research commentary, the authors wrote that up to one-third of kratom users experience an adverse side effect.

A 2022 study links kratom use to multiple adverse events, including:

• cardiac arrest
• irregular heart rhythm
• liver and kidney injury
• brain hemorrhage
• visual disturbances
• seizures
• aphasia (language disorder)
• neonatal abstinence syndrome (when a baby is exposed to a drug in the womb)
• death

Kratom products have also been found to contain dangerous contaminants such as toxic metals and Salmonella, the authors of the new commentary write.

According to data from the Centers for Disease Control and Prevention (CDC), 91 kratom overdose deaths occurred in the U.S. between July 2016 and December 2017. These reports involved only 27 states.

Klag said kratom use can even complicate the prescribing of medications for other substance use disorder.

“Naltrexone, a medication commonly used for opioid use disorder and alcohol use disorder, would cause significant withdrawal symptoms if initiated in someone using kratom,” she said.

“Kratom has also been shown to have significant interactions with psychiatric medications, such as Seroquel,” she added.

Is kratom addictive?

There is little research on whether kratom is addictive or causes dependence.

However, “kratom has been implicated in numerous studies as a highly addictive substance,” the authors of the commentary wrote, “with reports of tolerance, dependence, and withdrawal, which is characterized by hostility, irritability, emotional lability, and delusions.”

Withdrawal from kratom is associated with psychiatric disturbances such as:

• nervousness and restlessness
• irritability and anger
• violent and intrusive thoughts
• hallucinations
• increased anxiety
• depression

A 2010 case report published in European Addiction Research found the following withdrawal symptoms in a 44-year-old man who had been using kratom:

• anxiety
• restlessness
• tremor
• sweating
• cravings

A 2016 Addiction Biology study done in rodents also suggests that mitragynine, the main psychoactive substance in kratom, may have addictive properties.

Despite this evidence, kratom use disorder is not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the commentary authors point out.

However, one survey found that 12.3% of people who use kratom would qualify as having a use disorder, the authors said.

In her practice, Doscher sees patients with symptoms of kratom use disorder. “At high doses, kratom is like an opioid — people go through withdrawal,” she said. “I have people who are kratom dependent, who I put on buprenorphine, same as if they were using fentanyl, methadone, etc.”

While there is no standard treatment for kratom use disorder, some research suggests that buprenorphine may be an effective treatment. This prescription drug is used to treat opioid use disorder.

Doscher has found that kratom addiction is easier to treat than an opioid addiction. “I’ve never had to treat someone with a kratom dependence with methadone,” she said.

Methadone is another prescription drug used to treat opioid addiction.

More physician education about kratom use needed

Given the risks of kratom use, the commentary authors write that “physicians need more education and better tools to counsel and assess patients’ kratom use.”

Klag agreed. “Physicians would need further education on how kratom works, how it is consumed, the effects of discontinuation, as well as potential medication interactions and medical complications it can cause,” she said.

Doscher thinks the education of physicians should begin as early as possible in their careers. “The opportunity to train physicians [about kratom] is small,” she said. “The bigger opportunity would be to train medical students.”

Doscher, who offers substance use treatment — and trains primary care doctors on substance use treatment — thinks the question that doctors ask patients should be more broad: “Do you take anything at all that isn’t prescribed to you?”

“Substance use treatment should be much more widespread,” she noted. Also, “people need to understand that when they are not in control of using a substance, that’s a problem.”

While Klag thinks physicians need to stay up to date on the risks of kratom, she emphasized that they need to have open conversations with their patients.

”Patients need to feel comfortable bringing this information to us so that we can provide guidance and education in a safe environment,” she said. “Otherwise, they will get information from unreliable sources.”

Takeaway

A group of physicians wrote in a commentary that physicians should routinely ask patients about their use of the herbal drug kratom, the way they ask about the use of cannabis, cocaine, and other recreational drugs.

Kratom is an herbal leaf from a tropical evergreen tree native to Southeast Asia. It has stimulant or sedative effects, depending on the dose. Some people use it to treat anxiety and depression, chronic pain, or opioid withdrawal symptoms, although there is little evidence to support these uses.

Kratom use comes with many health risks, including cardiac arrest, kidney or liver damage, brain bleeding, and seizures. Some people have also died due to kratom overdose.