Kratom: Deadly Supplement or Supplementing Death?

Last month, the Centers for Disease Control (CDC) reported on what appear to be unintentional drug overdose deaths with kratom.

The CDC study suggests kratom can be deadly, especially when used with other drugs. The analysis found that there were 152 drug overdose deaths from July 2016 to June 2017 in which the deceased tested positive for kratom. Of these deaths, kratom was listed as a cause of death for 91 people, including seven who tested positive for no other substance, although researchers cautioned that "the presence of additional substances cannot be ruled out.'

Maybe we are witnessing a justification for the concerns that more than one agency has expressed over the last several years.

As many readers might know, kratom (Mitragyna speciosa), a plant native to Southeast Asia, contains the alkaloid mitragynine, which can produce stimulant effects in low doses and some opioid-like effects at higher doses when consumed. As I wrote in a prior post, the use of kratom has recently increased in popularity in the United States, where it is usually marketed as a dietary or herbal supplement.

Past research suggests kratom has the potential for dependence and abuse. As of April 2019, kratom was not scheduled as a controlled substance. However, since 2012, the United States Food and Drug Administration (FDA) has taken a number of actions related to kratom, and in November 2017 issued a public health advisory. The FDA has actually warned consumers not to use kratom, as the agency is concerned that kratom, which affects the same opioid brain receptors as morphine, appears to have properties that expose users to the risks of addiction, abuse, and dependence.

There are no FDA-approved uses for kratom, and the agency has been the recipient of concerning reports about the safety of kratom. Since identifying kratom on an import alert for unapproved drugs in 2012 and on a second import alert in February 2014 regarding kratom-containing dietary supplements and bulk dietary ingredients, the FDA has taken a number of additional actions:

• In September 2014, U.S. Marshals, at FDA’s request, seized more than 25,000 pounds of raw kratom material worth more than $5 million from a facility in Van Nuys, California.
• In January 2016, U.S. Marshals, at FDA’s request, seized nearly 90,000 bottles of dietary supplements labeled as containing kratom and worth more than $400,000.
• In August 2016, U.S. Marshals, at FDA’s request, seized more than 100 cases of products labeled as containing kratom and worth more than $150,000 from a company located in Grover Beach, California.

The Drug Enforcement Administration (DEA) has also identified kratom as a drug of concern. And from 2011–2017, the national poison center reporting database documented 1,807 calls concerning reported exposure to kratom.

To assess the impact of kratom, the CDC analyzed data from the State Unintentional Drug Overdose Reporting System (SUDORS). The CDC funds 32 states and the District of Columbia to enter into SUDORS detailed data on unintentional and undetermined-intent opioid overdose deaths from death certificates and medical examiner and coroner reports, including postmortem toxicology results. Although kratom is not an opioid, overdose deaths involving kratom are included in SUDORS.

The CDC analyzed overdose deaths in which kratom was detected on postmortem toxicology testing and deaths in which kratom was determined by a medical examiner or coroner to be a cause of death in 11 states from July 2016-June 2017 and in 27 states from July-December 2017.

Data on 27,338 overdose deaths that occurred from July 2016-December 2017 were entered into SUDORS, and 152 (0.56%) of these decedents tested positive for kratom on postmortem toxicology (kratom-positive). (It should be noted that postmortem toxicology testing protocols were not documented and varied among and within states.) Kratom was determined to be a cause of death (i.e., kratom-involved) by a medical examiner or coroner for 91 (59.9%) of the 152 kratom-positive decedents, including seven for whom kratom was the only substance to test positive on postmortem toxicology, although the presence of additional substances could not be ruled out.

In approximately 80% of kratom-positive and kratom-involved deaths in this analysis, the decedents had a history of substance misuse, and approximately 90% had no evidence that they were currently receiving medically supervised treatment for pain. Postmortem toxicology testing detected multiple substances for almost all decedents. Fentanyl and fentanyl analogs were the most frequently identified co-occurring substances; any fentanyl was listed as a cause of death for 65.1% of kratom-positive decedents and 56.0% of kratom-involved decedents. Heroin was the second most frequent substance listed as a cause of death (32.9% of kratom-positive decedents), followed by benzodiazepines (22.4%), prescription opioids (19.7%), and cocaine (18.4%).

Kratom-positive deaths accounted for <1% of all SUDORS overdose deaths from July 2016-December 2017. However, identification of kratom is method-dependent; therefore, these data might underestimate the number of kratom-positive deaths, although the extent cannot be determined. Because SUDORS records results of jurisdiction-specific postmortem toxicology testing, as well as overdose-specific circumstances, the CDC believes that it is possible to ascertain that kratom was present primarily in deaths that occurred as a result of overdoses related to substance misuse and that kratom was most often detected in combination with multiple other substances.

Addiction Essential Reads

A Vaccine Against Fentanyl!

Substance Use Prevention in Teens With ADHD

The type and number of substances detected in kratom-involved deaths can inform overdose prevention strategies. Documentation of postmortem toxicology testing protocols is needed to further clarify the extent to which kratom contributes to fatal overdoses.

In the meantime, with all this smoke, perhaps we should assume that there is a fire here, and consider that kratom may indeed cause death in addition to all the other substances of abuse out there.

And maybe a life here and there will be saved.