Kratom (Mitragyna speciosa) is a psychoactive plant in the coffee family that has been used medicinally for generations in Southeastern Asia across diverse contexts. Manual laborers use it to enhance stamina and energy; and it is widely used to relieve pain, diarrhea, and cough. In addition, kratom has long been used to relieve symptoms of opioid withdrawal. Within the past decade, the use of kratom has increased considerably in the West, and it is now estimated that millions of people in the United States take kratom regularly. The expansion of kratom use to the West has resulted in widespread curiosity, concern, and controversy.
In August 2016, the US Drug Enforcement Administration (DEA) announced its intention to place kratom on Schedule I, along with heroin and cannabis, as a substance with high potential for abuse and no currently accepted medical use. They cited anecdotal reports of “kratom-related deaths,” seizures, and liver failure, along with concerns that kratom is highly addictive and linked to psychosis. Further, the DEA warned that withdrawal from kratom is associated with hostility and aggression in addition to other mental and physiologic symptoms.
A public backlash to the DEA’s announcement was swift and furious; citizens wrote to politicians, petitioned the White House, and talked to the media about what they saw as an infringement on their right to use a helpful plant. Researchers expressed concern that the study of kratom’s potential medical uses could be crippled by the expensive and time-consuming regulatory hurdles that scientists must clear before studying Schedule I substances. In an unprecedented response, the DEA responded by withdrawing their intent to schedule, citing an effort to gather additional scientific information and to accept public comment. Over the next 6 weeks, more than 23,000 people submitted comments; over 99% expressed support for keeping kratom legal.
On November 14, 2017, the US Food and Drug Administration (FDA), citing their science-based obligation to the public, issued an advisory warning of “deadly risks” associated with kratom use, listing 36 deaths (later increased to 44) “associated with the use of kratom-containing products.” The FDA also warned of the risk for harm from adulterated kratom products and serious side effects including seizures, liver damage, and addiction.
Meanwhile, kratom advocates continue to argue that the FDA’s kratom “death count” is largely meaningless because it is anecdotal and consists primarily of individuals who took other potentially deadly substances. Advocates have organized in an effort to keep kratom legal federally and in the 44 states that have not yet banned its use. Many claim that the influence of lobbying groups (for example, the pharmaceutical industry) is behind government warnings.
Kratom is not a classical opioid; however, studies in rodents indicate that alkaloids in kratom bind to opioid receptors and have antinociceptive properties. These studies also suggest low toxicity and levels of respiratory depression that are markedly lower than those induced by classical opioids. At low doses, the plant has stimulating effects; while at higher doses, people report relaxation