Is Kratom a Performance Enhancer or a Lethal Opioid?

Obituaries made brief mention of Dana’s sterling reputation around Tupper, as some locals call the town. In high school, he played on the Lumberjacks football team and worked as a stock boy at the supermarket, then as a pharmacy assistant, before setting his sights on law enforcement. (Under a photo in his high school yearbook, his nickname reads Dana, PD.) Residents I spoke with remembered Dana as a rising star who specialized in anti-narcotics work and some expected him to be the next chief of police. He and his closest friends hunted rabbits, fished for northern pike, and occasionally practiced shooting at the Tupper Lake Rod and Gun Club. The club’s president, Dave McMahon, said that Dana took his job seriously and took an equally serious approach to fitness, which made his sudden death all the more unfathomable. “It was hard to understand what happened, why it happened, and so on,” McMahon said. “It was just a real unfortunate accident.” Some wondered if maybe he’d gone overboard on energy drinks or supplements.

Tupper Lake, a former logging town in the Adirondacks, hugs the eastern shore of a bright blue lake, nestled among a triad of 2,000-foot peaks. The town sits at the crossroads of Route 3 and Route 30. Neighbors keep tabs on where you park your car, and they joke about rolling up the sidewalks after 10 P.M. According to locals, it’s also a place where traffickers of drugs and humans pass through en route from Montreal to New York City. Arriving by way of Lake Placid, about 30 miles to the west, you’ll know you’ve reached the town when you see Sunmount, a state-run institution for the developmentally disabled and one of the town’s primary employers. Farther on, there’s Shaheen’s supermarket, a grocery store where you’re bound to hear grumblings about Sunmount. Along the road, you’ll see front yards decorated with American flags painted on wood pallets. I spotted several Blue Lives Matter flags fluttering in the mountain air.

Downtown there’s a one-story funeral home, run by Shawn Stuart, who also serves as one of the county’s elected coroners. About a month after Dana died, Stuart ruled his death an accident caused by pulmonary hemorrhage—the presence of blood in the lungs. An independent toxicology lab found extremely high levels of an alkaloid called mitragynine in his postmortem blood sample: 3,500 nanograms per milliliter. Stuart had never heard of mitragynine, but he soon learned that it was one of the two main active ingredients found in kratom, a tree that grows in southeast Asia.

Botanically, kratom is related to the coffee plant. Traditionally its leaves are steeped into a tea or chewed, like coca, and people use kratom’s stimulating effects to endure long hours of manual labor. Over the past two decades, though, kratom has spread across the U.S., often in powder or capsule form, thanks to numerous anecdotal reports that it can counteract fatigue and treat pain. But kratom is also used to manage withdrawal from prescription painkillers and heroin, and it has recently gained widespread attention—and notoriety—for its reputation as a potential cure for opioid addiction.

Officer Jordan Nason was among the first responders who tried to revive Dana, and he took the death particularly hard. Nason is pale and of medium build, with a crew cut, a goatee, and blue eyes. When we met early on a May morning at the village police station, Nason held a tallboy of Nos energy drink. Nason considered Dana his best friend, and when initial news reports in the Adirondack Daily Enterprise and elsewhere called Dana’s death an overdose, he felt hurt by the insinuations about drug use. Nason wasn’t sure he had much to say, but to his mind, labeling Dana as a person who used drugs could not have been further from the truth. Dana had been one year Nason’s senior, his mentor and confidant. The two men lifted weights together in college, and as much as they bulked up, he said they always prided themselves on “being natural.” Nason believed that Dana had been so overqualified for small-town police work that he should have worked for the FBI. And yet despite the long hours they’d spent together—in the squad car, running mock trials with Nason’s drug-detection dog J.D.—Dana never once brought up kratom.

“Whatever this was,” Nason said, “it was a legal substance. He was taking it with the best intentions that he had, whatever they were.” He seemed to be struggling to find the right words. He wasn’t the only one who found it almost inconceivable that a supplement killed an apparently healthy young man.

More than two million Americans consume kratom every year, and its potential lethality is central to a rancorous ongoing debate about its use. Between February 2014 and July 2016, according to the International Narcotics Control Board, law-enforcement authorities in the U.S. encountered 55 tons of kratom, which roughly translates to some 50 million individual doses. The plant’s popularity has drawn attention from federal regulatory agencies and international anti-doping officials. Six states have enacted bans. But kratom remains widely available. You can pick it up at gas stations alongside 5-Hour Energy or CBD oil, or order it online. Until 2015, a brand called Vivazen sold liquid shots containing kratom to the Red Bull and beach-volleyball crowd. People who use kratom say it functions as an effective stimulant and a calming sedative. It’s not without risk: anecdotal reports and case studies in the medical literature have documented the development of a kratom dependence. Until recently, the National Institute on Drug Abuse said, “Kratom by itself is not associated with fatal overdose.” Last year, NIDA appeared to have scrubbed that sentence from its website, suggesting that perhaps federal researchers no longer believed products sold as kratom were innocuous. Kratom contaminated with the painkiller tramadol has proven lethal, and the FDA has reported finding pathogenic strains of salmonella in kratom, but reports of fatal overdoses from eating or drinking the raw plant remain rather uncommon.

Kratom is atypical in several respects: the substance has druglike properties but it’s sold as a supplement. This means it doesn’t have to pass through federally mandated testing or clinical trials, and it’s available without a prescription. In 2016, the DEA initiated a formal process to put kratom in the same class of drugs as heroin and LSD—an illegal Schedule I drug with “no currently accepted medical use.” Following a vocal backlash from pain patients, people recovering from addiction, and other kratom supporters that summer, the DEA backed off and the regulatory hot potato landed in the hands of the FDA. In early 2018, FDA commissioner Scott Gottlieb said the agency determined that kratom was an opioid. Opioids, which have become synonymous with the national crisis, are the class of compounds that either come from or resemble alkaloids found in opium poppies. These include painkillers, like Vicodin and OxyContin, as well heroin and fentanyl. If you look at the chemical structures of mitragynine and all of the other naturally occurring compounds in kratom, chemists see nothing that resembles a typical opioid such as morphine. Rather, kratom is considered an opioid because its active ingredients appear to bind to some of the same receptors in the brain as opioids. (Endorphins, our internal opioids, also bind to these receptors.) At low doses—say, when the fresh leaves are chewed—kratom acts as a stimulant. At higher doses—for instance, when taken in a concentrated paste—it can have a sedative or narcotic effect.

When I visited the New York State Police Troop B headquarters in the nearby hamlet of Ray Brook, which handled the criminal investigation of Dana’s death, I noticed several flyers in the lobby advertising regional symposiums about opioids. One promoted a talk by Richard Jensen, a former wrestler who gives motivational speeches about taking addiction to the mat. Numerous studies have found links between contact sports and substance use. While neither the U.S. or world anti-doping agencies consider kratom a performance-enhancing drug, for decades researchers have noted the parallels between manual laborers and athletes who use kratom to increase stamina and offset fatigue in the lead-up to a race or during marathon weight-lifting sessions. According to a researcher writing in the Bulletin of Narcotics in 1975, “Five to ten minutes after kratom consumption, the user described himself as feeling happy, strong and active.”

Testimonials about the benefits of kratom also pop up regularly on bodybuilding forums. People who take kratom say the substance has many uses: to push through the pain of physical exertion, to self-medicate for injury, to transition off painkillers, and to recover from strenuous activity. A 2014 textbook on kratom, edited by Temple University pharmacology professor Robert Raffa, quotes a man identified as Jonas who describes a prototypical scenario: “The additional stamina kratom seems to provide allows me to push my workouts harder than with a vitamin/caffeine stack alone,” he wrote. “Quite possibly the mild euphoria helps me push myself. The painkilling effect may also contribute to this, allowing me to work through some of my joint pain.”

All of the self-medication and self-experimentation has come under increasing scrutiny. In 2017, the FDA released reports on 36 deaths that the agency said involved kratom. In response, Raffa and eight other scientific researchers signed a letter saying “the claims that kratom has caused the deaths of all or even most of the 36 individuals … cannot be supported by any reasonable scientific or medical standard.” Most of the deaths attributed to kratom involved some combination of substances, such as antidepressants and anti-anxiety medications. The FDA continues to highlight these deaths and has said that the tally has climbed to more than 44. In a speech last year, the head of the FDA singled out another person who, like Dana, reportedly died after taking kratom and had apparently consumed no other substances.

As news of the officer’s death in the Adirondacks spread across the country, it landed the little mountain town squarely in the crossroads of nationwide debate and added another layer to the controversy around kratom—an herbal supplement that built a reputation as being a nonlethal alternative to the illicitly manufactured opioids that kill tens of thousands of people annually. “What’s happening in the Adirondacks is what’s happening everywhere. It’s just on a smaller scale,” Frank Whitelaw, a coroner in nearby Saranac Lake, told me. Even though fatal drug overdoses are more common in the suburbs and larger metropolitan areas, Whitelaw saw firsthand how the secondary trauma hits close to home in small tight-knit communities. “It’s like dropping a huge rock into a perfectly calm pond, and it just creates one heck of a huge ripple effect.” Whitelaw felt that everyone knew everyone around town, especially among local law enforcement, and he was shocked by Dana’s death. “I was kind of blown away, and when the results of the toxicology test came back, that triple blew me away. That wasn’t anything I saw coming.”

But others saw an all-too-perfect story that almost seemed like a scheme cooked up to enact a wholesale ban on kratom. Pete Candland, head of the American Kratom Association, an advocacy organization, accused local investigators of being part of a clandestine DEA “shadow campaign.” Candland said the organization was “deeply concerned that the agency may also be seeking to encourage findings of kratom in death reports from coroners and medical examiners.” (In an accompanying report, a San Diego lawyer named Jane K. Babin, who was commissioned by American Kratom Association, specifically called into question the investigation into Dana’s death. “The Coroner and Medical Examiner erred in not analyzing blood for substances other than opioids and narcotics including cocaine and anabolic steroids, which could have caused the death.” However, the local media reported that cocaine and anabolic steroid tests were in fact conducted.) In another conspiratorial twist, some believe the war against kratom comes at the urging of big pharma, which is eager to cash in on fixes for treating addiction. For his part, county coroner Shawn Stuart claimed he had no agenda and called these allegations “ridiculous.” The death of a 27-year-old cop in his community was anything but routine. And, he told me, “There was no other explanation for his cause of death except for the substantial amount of kratom in his system. There’s a population that just doesn’t want to accept that.”

Dana’s family has not yet released the full autopsy report or his medical records. In New York, these reports can be made public only at the behest of one’s next of kin or by court order. State police denied a records request for the full criminal death investigation, saying it would be an “unwarranted invasion of the personal privacy of those concerned.” The lack of transparency irks kratom advocates. What’s certain is that the case remains an outlier: it’s one of the few dozen known fatalities in the U.S. that’s been connected to kratom, and one of the only deaths that reportedly did not involve some other substance.

The reported 3,500 nanograms of mitragynine found in Dana’s bloodstream is tremendously high. But the exact concentration of kratom he took, and the redistribution of drug compounds after death in the bloodstream, remains unknown. According to local news reports, the routine toxicology test covered 233 chemical compounds, including cocaine, and the coroner reportedly ordered a supplemental assay that was negative for anabolic steroids. But the fact that the tests turned up nothing doesn’t rule out the possibility that something else was at play.

Based on what has been publicly released, Ed Boyer, a toxicologist at Boston’s Brigham and Women’s Hospital, said that it would be impossible to definitively ascribe the death to kratom. “In general,” he said, “weightlifters ingest a whole hoard of things, including cardiotoxic substances, which could produce pulmonary edema.” Boyer added that without proper regulation, it’s best to simply avoid dietary supplements. With no assurance of their purity and potency, the controversy around supplements is unlikely to go away any time soon. Neither, it seems, is the routine sale of kratom.

Last May, when I first arrived in the Adirondacks, I spent an afternoon walking around Lake Placid, a two-time host of the winter Olympics. Not far from the big flat speed-skating oval in the center of town, I happened to notice Up in Smoke, a head shop that was selling various strains of kratom. The woman behind the counter told me several regular customers bought the powders, usually to get off harder drugs. I thought about how people pulled into kratom’s orbit seemed to occupy two distinct camps: those who were trying to treat pain or transition off addictive and potentially lethal opioids, and those who picked up a supplement as yet another way to probe the physical limits of the human body. I wondered what the Olympic coaches or trainers down the road thought of the substance. The World Anti-Doping Agency monitored kratom for “patterns of misuse” between 2014 and 2018 before deciding against a ban on its use in professional sporting events. (A spokesperson for Team USA declined to comment.)

The last morning I was in Tupper, there were a few boats out on the water, fishing in a lake that was still swollen with snowmelt. Up the hill, in the center of town, Mike Demars, Dana’s stepfather, smoked a cigarette outside a gas station and convenience store. He wore wraparound shades and a black cavalry hat. Demars told me that he’d been a police sergeant before taking on a field investigator position at Sunmount. He’d given Dana his badge when he made sergeant. His family struggled to make sense of it all, but ultimately he felt moved by the outpouring of support, which he saw as proof of the town’s resilience. “I know there’s stuff like Red Cross, but around here, honestly you almost don’t need it, the way people react.”

Demars didn’t see himself as particularly athletic, but he said he understood what it meant to be a police sergeant and the dedication and drive it takes to reach the next level. That’s what he believed his stepson had been trying to do all along. Dana once posted links about taking supplements on his Facebook page. “When he was bodybuilding, he would take all kinds of supplements,” Demars said. “I think the biggest thing is that you get very tired working these odd shifts and double shifts. I think it was used as a stimulant to keep him going. Even when you’re young, you start doing that long enough and you start wearing out. I know. I did it. You can only do it so long.”

He snuffed out his cigarette. “Speaking of work,” he said, “I need to get back or they’re going to fire me.” Demars hopped into his red Chevy pickup, and drove off. On his back window was a sticker that read: SGT M DANA. END OF WATCH 8.6.17.

Original Article: https://www.outsideonline.com/2387546/kratom-safety