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Getting Familiar with Kratom

Whether you pronounce it “CRAT-em” or “CRATE-em,” kratom has emerged recently as a drug of concern in the United States. Legal in some states, illegal in others, this drug may have the potential to be an effective medication in the future, but is also being widely used recreationally without any control on dose or purity, “and that is cause for significant concern,” said Quest Diagnostics Senior Medical Advisor Jeff Gudin MD in a recent “Topics in Drug Testing” podcast from Quest Diagnostics. He spoke with Quest Diagnostics Medical Science Liaison, Jack Kain, PharmD about kratom: what it is, how it works, how it is used, and the role of testing for kratom in keeping patients safe.

Kratom is still under the radar for most physicians, Dr Kain said. It is an herb derived from the leaves of the kratom tree (Mitragyna speciosa), indigenous to Southeast Asia. The leaves have traditionally been chewed as a stimulant to combat fatigue. In the United States in recent years, it is sold as an “herbal supplement” with claims that it boosts mood and energy, and relieves pain.

“In the pain management world, we hear about kratom all the time,” Dr Gudin pointed out. The leaf contains multiple plant alkaloids, the most abundant of which is mitragynine, which is similar in structure to opioids and is a mu-opioid receptor agonist, just like opioids.

The Drug Enforcement Agency originally proposed classifying it as a Schedule 1 drug, meaning it had no potential medical value and would have outlawed it, but backlash from the public convinced them to instead list it as a “drug of concern,” which kept it legal at the federal level.

“To me, that was a positive development,” Dr Kain said, as Schedule 1 drugs are very difficult to do research on as potential therapeutics. With appropriate research, Dr Gudin added, “This could be a medicine in the future.” Some patients with substance use disorder report using kratom to reduce their use of strong opioids, for instance.

The problem with the drug as it is currently sold, Dr Gudin said, is that as an “herbal supplement,” there is no regulation of strength or purity. “Kratom leaves have different levels of different alkaloids, just as marijuana does,” he said. This is one of the dangers of walking into a ‘head shop’: you don’t know what you are getting. It’s not that I would label it a ‘bad’ drug, but it is a drug, and it needs to be studied the way all drugs are,” and manufactured consistently and safely.

There have been documented cases of liver toxicity from kratom, Dr Kain noted. The drug is sometimes combined with tramadol, which can also cause liver damage.

“Most packets say, ‘Not for human consumption,’ which probably tells you something, that it is not necessarily safe,” Dr Gudin added.

To keep patients safe, it may be advisable to include a test for kratom in the panel of tests a physician chooses for their patients undergoing prescription drug monitoring. Kratom is not nearly as widely used as opioids, and so testing every patient may not be cost-effective, but if the drug paraphernalia shops in your area “have big signs for kratom, there may be a locally high rate of use,” Dr Kain said.

“I ask my patients if they know about kratom,” Dr Gudin added. “Ninety-nine percent say ‘What’s that?’ But if they know about it, I often put it on the panel. Quest offers a two-step approach, with presumptive identification of the possible use or non-use of the tested drugs, followed by reflex definitive testing when positive. “That is likely to be the most economical choice while balancing clinical benefit,” Dr Kain said.

You can listen to the full podcast and download a copy of the slides as well.

Published date: Nov. 3, 2020