top of page
Search

Alert on Kratom: Information and clinical considerations

Due to recent state and federal action, the Department of Public Health (DPH) and the Bureau of Substance Addiction Services (BSAS) expects widespread disruptions in the availability of kratom products, including both natural and synthetic products. These products can act like potent opioids. Providers should anticipate a potential increase in the number of patients presenting with kratom-related withdrawal and requests for kratom-related use disorder treatment in the coming weeks. This alert provides background information, clinical considerations, and additional resources. Information on the temporary placement of kratom and resources for the public, health care providers, and municipalities, can be accessed at www.mass.gov/kratom.

Read the emergency regulation, published : 105 CMR 726.000 Temporary placement of kratom in Schedule 1 pursuant to MGL c. 94C s. 2A at the following link https://www.mass.gov/orgs/department-of-public-health 

What are kratom and synthetic kratom products?

Kratom is a plant native to Southeast Asia that contains over 40 psychoactive alkaloids, primarily mitragynine and trace amounts of 7-hydroxymitragynine (7-OH). 

Synthetic kratom-related products have emerged as manufacturers have concentrated 7-OH and mitragynine derivatives, including mitragynine pseudoindoxyl (MP), dihydro-7-hydroxymitragynine (MGM-15), and 9-fluoro-7-hydroxymitragynine (MGM-16). These synthetic products cause more intense opioid-like effects than natural kratom products, and can be highly variable in content, concentration, and potency.

·         Mitragynine interacts with multiple receptors:

o    At lower doses (1-5 g natural kratom) its serotonergic and adrenergic interactions predominate, resulting in more stimulating effects.

o    At higher doses (>5 g natural kratom), its interactions with the opioid receptor predominate, resulting in more pain-reducing and sedating effects. 

·         7-OH also interacts with these same receptors, but it has relatively stronger interactions with opioid receptors.

·         Both mitragynine and 7-OH are partial agonists of the opioid receptor, although 7-OH has greater activity at the receptor than mitragynine does.

Kratom products can be found in many different forms. It can be found in a whole-leaf form or as a powder, concentrated extract, blended with other products, or as a drink. Products can be taken as a pill, liquid extract, powder, tea, chewed leaves, chewable gummy, or inhaled. These products have been able to be purchased locally at smoke shops, convenience stores, gas stations, or online. Kratom products can vary widely in composition and potency, and consumers may not be aware of exactly what they are taking.

Are there risks associated with kratom products?

Some unwanted effects of kratom use can include dry mouth, delusional thinking, psychosis, itching, constipation, seizures, excessive urination, and sweating.

Overdose can occur, particularly when using highly potent synthetic products, using kratom products mixed with unknown substances, and/or using other substances alongside kratom products, especially opioids, alcohol, benzodiazepines, or other sedatives. While the research on kratom-involved overdoses is also limited, it is appropriate to respond to any suspected overdose with naloxone. 

Although rare, kratom-associated deaths have been reported; patients are especially at risk when combining kratom with other substances or if they have a chronic health condition. As there is no “standard” kratom product, the toxicity of the dose used may also contribute to the risk of overdose and death. 

Physical dependence, withdrawal, or kratom use disorder may develop. Many people take kratom products and do not realize that it could be harmful or that dependence can occur. 

Potential Impacts of Disruption

DPH anticipates widespread disruptions in the availability of both natural and synthetic kratom products due to state and federal action. People who use these products regularly may experience withdrawal symptoms and may need to seek medical care for withdrawal management or treatment for kratom use disorder.

The user base for kratom products is broad, ranging from people with prior opioid use disorder who have been using kratom and related products to self-manage withdrawal to people with no prior exposure to opioids who may have developed dependence or substance use disorders with regular consumption of these products.

Withdrawal from kratom products can look similar to withdrawal from opioids, including anxiety, agitation, muscle spasms, runny nose, hot flashes, loss of appetite, diarrhea, restlessness, and fever. Kratom withdrawal can also be treated similarly to opioid withdrawal. While there is limited research on kratom use disorder and no FDA-approved medication for treatment, buprenorphine has been found to be effective for some people. Counseling and mutual support groups are also ways to support recovery. The MA Substance Use Helpline is available to help individuals seeking treatment. 

Specifically, 24-Hour Diversionary Withdrawal Management Service (also known as ATS/detox), Community Behavioral Health Centers (CBHCs), Office Based Opioid Treatment (OBOT), Office-Based Addiction Treatment (OBAT) program providers, and emergency departments may see an increase in demand. 

Providers can access training and support for staff through the resources below.

Substance Use Disorder Treatment Programs 

Pursuant to 105 CMR 164.070 and 164.570, substance use treatment providers are prohibited from creating eligibility criteria that establish a category of automatic exclusion that is defined by a type of primary substance used. Providers who are able to support individuals seeking treatment for withdrawal should ensure that program staff, especially intake/admissions staff, are aware of the ability to admit patients presenting with kratom use. 

Additional Resources

·        Grayken Center for Addiction Training and Technical Assistance offers monthly trainings on kratom

·        To get connected to harm reduction, treatment, and/or recovery services, call or text “HOPE” to 800-327-5050 to reach the Massachusetts Substance Use Helpline.

·         BMC Addiction Warmline-Provides short-term rapid access to medications to treat substance use disorders including buprenorphine (Suboxone), Sublocade, injectable naltrexone (Vivitrol), linkage to treatment on demand (including methadone) and referral to long term care. Depending on time of call, callers may receive call back after leaving message. Phone number: 617-414-4175.

·         Broyan, Viktoriya R., et al. "Long-term buprenorphine treatment for kratom use disorder: a case series." Substance Abuse 43.1 (2022): 763-766. Accessible at: https://journals.sagepub.com/doi/full/10.1080/08897077.2021.2010250 

·         Kiyokawa, Miki, et al. "Kratom use disorder: case reports on successful treatment with home induction of buprenorphine-naloxone." Family Practice 40.4 (2023): 596-598. Accessible at: https://academic.oup.com/fampra/article/40/4/596/7232451 

·         Smith, Kirsten E., David H. Epstein, and Stephanie T. Weiss. "Controversies in assessment, diagnosis, and treatment of kratom use disorder." Current psychiatry reports 26.9 (2024): 487-496. Accessible at: https://link.springer.com/article/10.1007/s11920-024-01524-1 

 
 
 

Comments

bottom of page