Introduction
Kratom might be the most popular herbal product you’ve never heard of. Touted as an energy booster and mood enhancer, it is ubiquitous in convenience stores and gas stations across the U.S. But why does the FDA list it as a “drug of concern”?
Almost two million Americans used kratom in 2021, according to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health. Although it is banned in seven states, kratom is available at many U.S. gas stations, convenience stores, and online.
Sourced from an Asian tree’s leaves, kratom produces weak opioid-like effects. It’s touted as an energy-boosting stimulant, a euphoric mood enhancer that can help anxiety or depression, and a treatment for chronic pain. But does it really work? Is it safe?
“It’s amazing how little information is out there given how many people use it,” says Peter Grinspoon, a physician at Massachusetts General Hospital and Harvard Medical School.
Understanding Kratom: An Overview
The Origins of Kratom
The Kratom Tree The kratom tree (Mitragyna speciosa) is an evergreen in the coffee family, grown in Southeast Asia. In its native region, fresh leaves are chewed as a mild stimulant, and teas are brewed as medicine to treat pain, diabetes, diarrhea, and other ailments, including opium withdrawal.
Kratom's Journey to the U.S.In the U.S., kratom is sold in dried, powdered form that’s typically brewed in tea or taken in capsules. Gummies and liquid kratom doses are also available, often with very high potency.
Kratom's Active Compounds
Mitragynine Among kratom’s many chemically active compounds is mitragynine, which targets the same pain-reducing receptors that are stimulated by opioids like heroin, morphine, and fentanyl.
7-Hydroxymitragynine Another key compound is alkaloid 7-hydroxymitragynine, which has far more potent opioid-like impacts. Kratom plants contain very small amounts of 7-hydroxymitragynine, but the amounts vary wildly in kratom supplements—some of which are adulterated with artificially high levels of this more addictive compound.
How Kratom Works in the Body
Dual Nature: Stimulant and Sedative Kratom is a stimulant at lower doses but, paradoxically, at higher doses, it induces drowsiness or sedative reactions more akin to those produced by opiates.
Interaction with Receptors Kratom also binds to serotonin receptors, which regulate mood and anxiety, and impacts dopamine release. These systems can also help reduce pain, making it difficult to parse out which compounds are really at work. “We just don’t understand exactly how they are playing together,” says Christopher McCurdy, a professor of medicinal chemistry at the University of Florida who has studied kratom use for over a decade.
The Potential Benefits of Kratom
Claims of Health Benefits
Pain Relief Though no randomized, controlled clinical trials have rigorously assessed pain relief in patients, some kratom research shows promise for short-term pain relief. However, some chronic kratom users do experience increased pain and sensitivity when they stop taking it.
Mood Enhancement and Anxiety Reduction McCurdy and colleagues’ surveys show the majority of kratom users believe it relieves their anxiety or chronic pain. “They say I take my two or three grams of powder, morning and evening, and it helps me function or gives me energy,” McCurdy says. “Of course, we can’t say if it actually works because we don’t have the scientific studies to prove that.”
Opioid Withdrawal Kratom use is common among those with opioid use disorder. Although no randomized, controlled trials prove its merit for addiction treatment, many people argue that using kratom helps keep them from more dangerous illicit opioids.
Expert Opinions on Kratom's Efficacy
Lack of Robust Evidence C. Michael White, a distinguished professor of pharmacy practice at the University of Connecticut, emphasizes that data on kratom use for anxiety, alertness, reducing fatigue, or any other purpose is very scant.
Potential Role in Healthcare“ This is where kratom may actually have a role in our healthcare system,” White says. “If you have access to addiction treatment, definitely try the proven options first. However, if you are unable to afford treatment, you are unwilling to out yourself and admit you have addiction, or you are not being provided sufficient treatment and will relapse to illicit opioid use, kratom is likely a much better option.”
The Risks and Concerns Surrounding Kratom
FDA's Stance and Warnings
Drug of ConcernThe U.S. Food and Drug Administration lists kratom as a “drug of concern,” citing addiction and side effects like seizures, liver toxicity, and, in rare cases, even death. Other adverse reactions to kratom use can include drowsiness, confusion, vomiting, or racing heartbeats.
Variation in Potency and Safety
Differences in Product Potency Studies have shown Western users often consume very different stuff—with huge, unknown variations in the amount of active chemical ingredients. “There’s a variety of products that are called kratom, but I compare it to the range from a Miller Light to Everclear,” McCurdy says. “We know there is a spectrum from safe to toxic, but we don’t know where the break point is.”
Synthetic Variants and Adulteration Then, at the extreme end, there are kratom supplements that McCurdy says are essentially synthetic 7-hydroxymitragynine products. “Some things being marketed as kratom are so far removed from the plant that they are basically pharmaceuticals,” McCurdy cautions.
Regulatory and Legal Issues
Lack of Regulation Kratom has a nebulous regulatory status and can be sold in many places to those as young as 13. Some kratom products aren’t labeled either, so buyers may not be able to tell how potent they are—and since kratom isn’t regulated or tested, it can be adulterated with lead and other heavy metals, or even other chemicals.
State Legislation Numerous states have pending legislation to limit concentrations of mitragynine or 7-hydroxymitragynine in kratom products, impose age restrictions on who can buy them, and require products to be labeled and tested.
Is Kratom Addictive?
Comparative Addiction Risks
Lower Risk Compared to Strong Opioids Compared to strong opioids like morphine, heroin, and oxycodone, the risk of becoming addicted to kratom is relatively low; however, the FDA warns that people can become addicted after taking it for long periods of time for pain, anxiety, or to boost mood or energy.
Dependence and Withdrawal“ You start out voluntarily taking it, but at a certain point you need to take it just to feel regular,” White says. “Then if you don’t take it instead of going back to your normal state you feel worse.”
Potential for Misuse
Overconsumption Risks Some kratom products are marketed with exaggerated potency, leading to potential overconsumption. “Unfortunately, it doesn’t work like that,” McCurdy says. “All of a sudden you have a huge amount of exposure into your system and could be suddenly in the ER experiencing very negative side effects.”
User Experiences and Reports
Perceptions of Safety and Efficacy While some users report benefits such as pain relief and mood enhancement, the lack of consistent regulation and quality control raises concerns about the safety and efficacy of kratom products available in the market.
Conclusion
Kratom presents a complex picture with its mix of potential benefits and significant risks. While it has a long history of traditional use in Southeast Asia, the variability in product quality and potency in the U.S. market, coupled with a lack of robust scientific evidence, makes it a controversial supplement.
In a perfect world, there would be a safe, regulated supply of kratom, as it may offer benefits to some people. However, the current regulatory landscape leaves much to be desired, putting many users at risk.
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