Helpful supplement or dangerous drug? Doctors discuss use and risks of kratom

You can find it at health food stores, gas stations and smoke shops. It is considered an opioid-like substance, and binds to one of three types of opioid receptors in the brain. In most states, it’s completely unregulated.

That’s because kratom, a product typically bought as a green powder or in capsules, is sold as an herbal supplement. 

Its popularity has been increasing over the years, with purported benefits including mood enhancement, energy boosting at low doses, and help with opioid withdrawal, pain or sleep.

Kratom powder is pictured Friday in Lewiston. (Credit: August Frank / The Lewiston Tribune)

Kratom comes from a plant from southeast Asia, which is botanically related to coffee. Kratom sellers offer different variations known as red, white and green vein kratom that offer slightly different levels of the alkaloids that affect its psychoactive properties.

Dr. Scott Phillips, the medical director at the Washington Poison Center, said although kratom is naturally derived, it can still have serious effects.

“Your brain’s receptors don’t know whether it’s man-made or whether it’s made from nature,” he said. “It just responds to that chemical structure.”

 Kratom contains two active chemical compounds, mitragynine and 7-hydroxymitragynine, that bind to opioid receptors in the brain — called mu opioid receptors. 

Kratom is considered a partial opioid agonist, meaning it activates opioid receptors, but to a much smaller degree than a full agonist. Buprenorphine is another example of a partial opioid agonist. It’s a drug used to treat opioid use disorder.

Since 2015, the Washington Poison Center has had 480 calls related to kratom, including around 39 in Spokane County, 15 in Benton County, 14 in Walla Walla County and five in Whitman County, Phillips said. The list is not comprehensive, as the center only records what they receive calls for.

A 2019 study published in the Journal of Preventive Medicine showed that other morphine-like opioids carried an overdose risk of a thousand or more times greater than kratom. 

However, some people who use kratom may be more likely to use other drugs or alcohol, which increases the risk of overdose and death.

A smoke shop on Bridgeport Way in Tacoma advertises kratom. (Credit: Lauren Gallup / NWPB)

Kratom-related overdose deaths are relatively rare, according to data from the Centers for Disease Control and Prevention, and most overdose deaths where kratom was detected also included the use of other substances. Roughly 80% of those who died of a kratom-related overdose also had a history of substance misuse.

Though kratom deaths are rare, Phillips said, there can still be significant risks associated with its use. 

One is that while kratom is less addictive than opioids like morphine, heroin, fentanyl and oxycodone, it can still cause physical and psychological dependence. According to one study that surveyed almost 3,000 respondents, 12.3% of kratom users qualified as misusing the substance.

Kratom also has the potential to interact with other drugs, including benzodiazepines, barbiturates, alcohol, opioids, antidepressants and anti-anxiety medications. Chronic use may also carry risks including liver toxicity, as well as seizures — particularly for people with epilepsy. 

Additionally, because kratom is not regulated, it can be difficult to determine whether something is what it’s marketed to be, Phillips said.

“One of the problems that has arisen is that it’s not always pure kratom,” he said. “When it’s categorized as an herbal, unregulated (substance), it really has to go through no formal (Food and Drug Administration) approval process.”

Guillermo Rojo Martinez co-owns Kratom Kings in Moscow, Idaho, with his business partner, Ty Pierce. The company sells kratom powder and capsules, in addition to cannabidiol, or CBD products. They also sell kava, a supplement with depressant effects used for treatment of issues such as anxiety and insomnia.

Kratom Kings independently sends its product for testing through Wonderland Labs in California to test for contaminants including heavy metals, E.coli and salmonella, as well as the strength of the product, Rojo Martinez said. But that testing isn’t required.

“It basically does mean that you have to develop trust with every customer,” he said. 

Rojo Martinez said he and Pierce first started their business in 2018, which is around when kratom first started gaining wider popularity. At the time, he said, there weren’t many reputable options for buying kratom. 

“A lot of people were getting into kratom because it was unregulated,” he said. “You could sell a really low-quality product and it would still sell because it was so niche.”

Rojo Martinez said he’s in favor of regulation, and standardized testing.

“The thing I’m more worried about is people that get sold ‘kratom’ that’s not anything,” he said. “They just got scammed.”

Bags of kratom sold at Kratom Kings. (Credit: Rachel Sun / NWPB)

His business offers various strains of kratom in capsules and powders, which Rojo Martinez said his customers most often use for calming and sleep aid properties. When it’s not for that, he said, the second most common reason customers use it is in low doses to help with energy. 

“A lot of people report that you just have more focus,” he said. “Drudgery, monotony, they don’t bother you as much.”

The FDA does not recognize kratom as a drug to treat any medical conditions or consider it safe as a supplement. Doctors are often wary of kratom due to its potential risks and lack of research or regulation.

Despite that, kratom has become increasingly popular to treat a litany of issues, with online forums dedicated to kratom and the many ways its users say they benefit from it.

Many users are passionate about kratom and the benefits they see from it, Rojo Martinez said.

In 2016, the Drug Enforcement Agency announced it would temporarily reclassify kratom as a Schedule I drug. But the DEA later reversed that decision following a large public outcry, including people who said they used the supplement to treat chronic pain, as well as scientists worried how a ban would affect their research.

“The thing is kratom has, like, a sort of grassroots thing to it,” Rojo Martinez said. “I’ve noticed there’s a lot of people that will talk pretty passionately about it once they realize someone else could have the same problems they’re having and that they could be possibly solved by kratom.”

Though kratom has the potential for misuse, Rojo Martinez said, it’s not something he thinks most people would find enjoyable as a recreational drug. The doses necessary to get high, he said, generally making people feel heavy and sluggish.

Capsules filled with kratom fall from a machine used to close the capsules Friday at Kratom Kings in Moscow. (Credit: Liesbeth Powers / Moscow-Pullman Daily News)

“I think a very, very small portion of the user base uses it that way, just because there are easier options for getting high,” he said.

Kratom Kings does provide some guidelines for use, Rojo Martinez said. They don’t sell to people under 18, and recommend against taking more than 10 grams per day. They also don’t recommend mixing kratom with other substances like alcohol.

“The most common way we get, let’s say complaints that we feel are misguided, is because they’ll take alcohol, they’ll take kratom, (and) they say it makes them feel just weird, bad, something like that,” he said. “There’s a pretty clear interaction there.”

Rojo Martinez said he also doesn’t recommend kratom for pregnant people, because there’s little known about how it may affect pregnancy.

In some rare cases, kratom has been associated with Neonatal Abstinence Syndrome, or NAS, a condition in which babies who were exposed to a drug in utero, often opioids, go through withdrawal symptoms.

NAS is characterized by symptoms including poor feeding, and lower birth weight, agitation, irritability, jerky movements and sweating. It is sometimes treated with morphine, methadone or buprenorphine.

Dr. Robin Sautter is a family medicine provider at Gritman Medical Center with a focus in women’s health, as well as prenatal care and newborn care. 

Sautter hasn’t personally worked with cases of NAS caused by kratom, she said, though it can happen. 

In general, she said, people should be careful not to make assumptions about the safety of herbal supplements. 

“None of those are FDA approved, meaning that they haven’t gone through the vetting process to make sure that they’re truly pure, like we know exactly all the ingredients in it,” she said.

At her practice, Sautter said, she’ll go through an extensive medical history that includes medications and supplements someone takes when they come in with a positive pregnancy test. Not all supplements, including kratom, are considered safe to take during pregnancy.

“We really want to identify and see if there’s anything that might be harmful. An example might be an iodine containing supplement, which is labeled as healthy for your thyroid. That can affect the thyroid development of a baby,” she said.

It can be hard to know how much something will affect a fetus, Sautter said. 

If a pregnant person is using kratom for pain management or opioid withdrawal, it’s safer to talk with their doctor about finding a pregnancy-safe alternative.

“There are medicines that are safe to use for opioid withdrawal in pregnancy,” she said. “We want to make sure that first and foremost, mom’s health is being addressed so that then subsequently the baby’s also going to be okay.”