In the last few years there has been an explosion in the use of an herb known as kratom here in the U.S. Kratom comes from a tree common to South East Asia where it has been traditionally used for centuries. Mitragyna speciosa comes from the same family of plants as coffee (Rubiaceae) and has been commonly used as a stimulant (in low doses), a sedative (in high doses), an analgesic, for its euphoric qualities, to reduce dependence on opioids, for increased concentration and to improve mood and wellbeing.
Kratom is easily obtainable at “head” shops and via the internet and many people are turning to this plant as an alternative to prescription based opioids , for pain relief and for recreational reasons. As a therapist and an herbalist I have increasingly worked with people who are taking this herb and have seen its effects, both positive and deleterious in the community. The internet has an enormous amount of content in the form of blogs, sales and informational sites. I also personally have an interest as I grew up partially in Thailand and the herb is from a tree that grows indigenously there.
In this article I want to explore this plant from a scientific perspective, from the vantage of a traditional herbalist and from a personal point of view as well.
Kratom is found throughout South-East Asia and IndoChina and is a deciduous tree that grows upwards of 50 feet high. On the tree, oval leaves up to 7 inches long grow opposite each other and deep yellow flowers grow in clusters at the end of leaf axils. The calyx of the inflorescence is cupped and rounded.
Traditionally, Thai people (especially from the South of the nation) take kratom by stripping the leaves of its stem and generally chewing up to 50 of them a day. This is peasant medicine and is usually consumed by laborers who work long hours in the field as a way to gain energy and to reduce pain. They have also used it in traditional medicine formulas such as teas for reducing diarrhea, as an anti diabetic, a cough suppressant, for intestinal deworming, pain management and for help in coming off of opioids.
The Thai government made kratom illegal in 1943, most likely due to its opiate like qualities and because it interfered with the illicit opium trade, of which the government made a handsome profit via levies and taxes. Thailand continues to prohibit this plant and in modern times it has become extremely popular with the Muslim community in Southern Thailand and with insurgents who commit terrorist activities. Because of this the Thai government has tried to eradicate and cut down Kratom forests in Southern Thailand, angering the local environmentalists.
It is estimated that upwards of 94 percent of teenagers now consume kratom regularly in southern Thailand and that the consumption of kratom throughout South East Asia is widespread.
Because it has not been made illegal in Europe and the U.S., kratom began to be shipped to the States in large amounts in the last decade and has made its way into Head shops and online retail stores. There has been an explosion in use just in the last few years but still remains under the radar for most people, including health care practitioners and herbalists. Though I have heard about it as a Thai herb for many years, I first started hearing about it as a popular U.S. herb in my work as a therapist in a psychiatric hospital setting. I discovered that many of the people addicted to opioids such as vicodin, percoset and heroin had also been using kratom.
One man told me how he quit heroin with the help of the herb but ended up becoming heavily addicted to kratom, consuming up to 30 grams a day (normal doses are around 2-5 grams). He said that coming off kratom lasted longer and included more anxiety that a regular opiate detox and felt that a kratom detox was equally as bad. I also met several people who extolled the virtues of kratom, saying that it had help them manage pain, anxiety and to avoid opioid dependence. The feeling I got that is if one avoided taking large doses a day, that kratom was seen as an effective medicine in lieu of western pharmaceuticals.
It is important to mention that the primary way of managing pain in this country is through the consumption of a variety of pharmaceutical drugs. Prescriptions for opioid medications such as vicodin and percoset have soared from 76 million in 1991 to 241 million prescriptions in 2014. ERs throughout the country see more than 800,000 people every year due to prescription opioid abuse. The latest statistic in 2010 show there were 16,651 deaths attributed to opioid overdosing. Over 2 million Americans abuse and/or have a dependence on prescription opioids and in 2012, we spent 8.34 billion dollars on opioid prescriptions.
In this environment, medical professionals and those in need of pain management or looking for a recreational high have been searching for alternatives to opiates that are easily addictive, often ineffective after tolerance is built and too often quite deadly. Kratom has become popular not only due to its opiate like effects but also because it appears to not be deadly, with a marked dosage “cut-off” point where it induces nausea and vomiting. There have been a handful of reported deaths associated with kratom (though these are murky cases that appear to involve alcohol and poly-pharmacy as well). Because of this, kratom is seen as a far less dangerous substances that prescription opioids. However, high doses have been shown to cause severe sedation, confusion and psychosis in some people.
There has been quite a bit of research done on kratom , its complex pharmacological constituents and effects. Over 25 alkaloids and active compounds have been isolated from kratom and many exhibit analgesic, antitussive, immunostimulant, opiate, antihypertensive and sedative properties. Two of the most active ones include the alkaloids mytraginine and 7-hydroxy-mytraginine. Both of these alkaloids have strong opiate receptor affinity. Activity here leads to strong pain relieving effects. It also blocks 5-HTP receptors and activates noradrenergic and serotonergic pathways in the spinal cord. Finally, mytraginine also stimulates adrenergic receptor sites, eliciting a sympathetic response and giving kratom its stimulating effect.
7-hydroxy-myrtaginine is found in very small amounts in kratom leaf but has 13 times the potency of morphine. Together these main constituents, along with a number of other ones help cause its analgesic effect. Interestingly, these main alkaloids have a similar morphology to the hallucinogenic trytamines (LSD, psilocybin) but work on different pathways from those chemicals.
Because of the ability of some of its constituents to bind opiate receptors, its addictive potential is also apparent. When people stop taking kratom after consuming it for a period of time, similar withdrawal problems akin to opiate withdrawal will happen, including increased anxiety, pain, insomnia, cravings and depression. Similar to opiates, kratom also causes constipation and is a traditional medicine for those who have diarrhea. The half life of these main constituents with opiate like affinity is about 3.5 hours. That means the duration of the main effect is about 5-7 hours.
Besides these psychoactive constituents, kratom also contains epicatchin, one of the most potent antioxidants also found in green tea and dark chocolate. Antioxidants are known for their ability to inhibit oxidation and reduce the risk of degenerative illnesses.
Though this has been used commonly as an herb in Thailand for many centuries, it has only become commonly known in the West in the last ten years. Because of this, herbalists have not become acquainted with it greatly and are still researching its properties. There are a number of different varieties of kratom leaf with their own specific properties. Kratom can generally be categorized into country of origin (Bali, Indonesia, Thailand) and three main groups- red , green and white leaf. Green and white leafed kratom tend to be more energizing and stimulating and some say that green is especially useful for those with anxiety and depression. Green strains tend to be powerful and long lasting. White strains tend to be the most energizing and last the shortest time. Red vein leaf varieties are more sedating and these varieties are more commonly used for detoxing off of opiates.
Most varieties will cause an effect that lasts between 3 to 5 hours. Peruse an internet site and you will find
mention of dozens of varieties. Like marijuana, each varietal is extolled for its particular virtue (longer effect, more sedating or stimulating, etc.) Popular varieties include Maeng Da, green vein Bali, white vein Thai, etc.
The herb is sold primarily in powder form where it can be consumed in capsules or added as a powder to drinks. It is also sold as a crushed leaf that is consumed as tea. Generally one adds the powder to drinks or swallows it quickly with a chaser via “toss and wash”.
Dosages range from 2-15 grams per use. 1-3 grams is a normal dose (1/2 to one teaspoon), and often causes more stimulating effects at that level. 4-6 grams is a stronger dose (about 2 teaspoons), 7-10 grams (about a tablespoon) is a very strong dose and anything after that is extremely strong. Strong doses not only tend to be sedating but can bring on heightened states of euphoria. There is also increasing potential for nausea and vomiting as the dosage increases. Tolerance to the herb grows quickly and most people do not feel its euphoric effects if taken daily.
Finally, the internet is now rife with wholesale sellers of both the powder as well as extracts, usually in resin and tincture form. Extracts are high potency concentrates usually made by boiling down, purifying and tincturing to make the kratom highly potent. Usually, the leaf is boiled in water until it is evaporated off, leaving a paste that is highly concentrated with pharmacologically active alkaloids. The extract then is made into a powder, a resin, a tincture or an oil. Those who study the pharmacology of the plant promote extracts that carry a full spectrum of the active constituents in proper balance, or what is known as a Full Spectrum Balance extract. The potencies are often designated by 1x, 5x, 10 x, 15 x and higher. 15 x would mean that the plant has been reduced from 15 grams of leaf to one gram of extract. Extracts are notably potent, addictive and often carry a much higher risk of side effects and complications, especially if taken with other drugs or alcohol.
Due to the widespread interest in this plant, I have tried a number of varieties at different doses to understand its effect. The cost of the plant is quite cheap with an ounce seeing for as little as 7 dollars to as much as 15 dollars. Considering that an average dose is about a teaspoon that weighs as little as 2 grams, each ounce carries as much as 14 doses. That comes out to about 50 cents a dose for a 7 dollar ounce of kratom. This is one of the reasons it is so extremely popular. A very small amount causes a good effect for very cheap.
I have stuck to trying mainly reds (more sedating) and greens (mildly energizing) and avoided whites (too stimulating.) Some of the varietals I have tried include green vietnam, red bali, red chocolate and green thai. In general I have taken about a teaspoon at a time but occasionally less and occasionally more. The effects include a feeling of brightness, mood lift, pain relief and energy. For some varietals there is a sense of “edginess” and a feeling of being overstimulated, similar to coffee. And for others there is a sense of cloudiness and sedation. But by and large one can easily understand why kratom is so popular as a folk medicine in South East Asia- it provides a lift and does not have a strong “come down” and does not generally impair every day function- more like coffee than a recreational drug.
When ingested orally, kratom takes effect within a half hour and starts out as low level stimulation and a feeling of smoothness and slight visual brightness, as if there was a level of gloss on the world around one. By hour two the effects are much more noticeable, with a sense of pleasure, relaxation and a heightened feeling of sensing the beauty in the world around one and some opiate like sensations. I can also sense a burgeoning but subtle feeling of euphoria that diminishes by the end of the hour. Afterwards and for the next few hours, the effect diminishes but continues to last as a sense of relaxation and general pleasure. During the experience, I do not feel inhibited cognitively, and my physical abilities are not diminished. I can easily carry on a conversation and never feel overwhelmed.
From my “experiments” I can well understand why people are interested in taking kratom as it certainly produces analgesic, gently euphoric and simultaneously calming and stimulating effects at moderate doses. At the same time, from the reports I have heard from some, I can also understand its addictive potential. Because it seems unlikely to be extremely toxic and deadly, I think it would be unwise to make it illegal, though I would be extremely cautious of extracts, which seem to me akin to much more potent and concentrated pharmaceutical drugs.
Side Effects and Contraindications
In the last couple years, kratom has come to the attention of the Drug Enforcement Agency. This is a plant that was essentially off the radar until about 5 years ago and has now skyrocketed in popularity. Because of that government officials have taken notice. The DEA were close to issuing a proclamation in 2016 making it a schedule 1 drug akin to heroin and cocaine. There was an enormous outcry from consumers who say that kratom has been instrumental in helping them wean off opioid drugs and essentially saving their lives. This led to the DEA backing off for the time being but kratom remains illegal in a number of states and watched closely by authorities.
The two main issues that people are concerned about is abuse and addiction. Both are possible with kratom. Those who use large doses continuously will become addicted and it is deeply difficult to withdraw from this plant- as it is for any opioid. Advocates will say that while potentially addictive, it does not present the threat that pharmaceutical opioids present in terms of lethality. There have been some isolated cases of deaths that involved kratom- but in all of them other medications and alcohol were involved so it is hard to assess the culprit substance. And nevertheless, the amount of fatalities is in the teens- compared to tens of thousands of pharmaceutical opioid deaths.
In terms of side effects, common complaints include nausea, restlessness, edginess, overstimulation, sweating and constipation. For a select few who are susceptible, high doses can instigate tremors, tachycardia, seizures, mania or psychosis. Those who chronically use high doses are susceptible to liver toxicity and damage as well- but this appears to be very rare. In terms of contraindications, this is not an herb to take while taking any other strong tranquilizing and sedating drug such as pharmaceutical opioids, sleep medications and benzodiazepines. It should be avoided when pregnant or breast feeding.
As someone who has worked in clinical areas and in private practice as a therapist I have seen a lot of people with high degrees of pain management issues as well addiction issues. Opioid prescription and dependence is extremely common and is a major problem in the US. As an herbalist I generally promote gentle nourishment with the help of good diet and strengthening herbs, along with lifestyle and exercise habits that promote pain relief primarily. There are also numerous analgesic, anti-inflammatory, circulatory and nervine herbs that can be helpful on a short term basis for pain without the more complex dependency and side effect issues of kratom. Some of these include jamaican dogwood, devil’s claw, turmeric, cramp bark, feverfew, ginger, licorice, and california poppy.
However, for some people, they may feel that the stronger effect of kratom is warranted and needed, especially for intermittent use as one of many tools for managing pain. Some may also choose to take it simply for recreational enjoyment. We are a culture with complex feelings about using plants and plant extracts for pleasure. While we endorse coffee ( a botanical relative of kratom), alcohol and now marijuana, we are not comfortable with addictive plant extracts like cocaine and heroin. Kratom straddles the line in being habit forming but also medicinal in nature and without the potential for a deadly overdose. I believe this is an herb that should be treated with caution and one to be taken intermittently in whole form and not daily if there is interest in its properties. I certainly don’t think the leaf should be illegal and shows quite a bit of promise as an alternative to synthetic and prescription drugs. It also presents itself as an alternative to NSAID medication with their known deleterious effects on the hepatic and digestive systems.
Though kratom potentially acts as a good (and far less potentially lethal) step down from strong opioids, it should only be considered as a stepping stone.. It should also not be seen as a replacement for the harder work of healing from pain and anxiety. If those underlying issues exist they should be examined at a root level. That means working to address underlying illness as well as complex dietary, environmental, and structural issues that are often interrelated. Simply taking kratom is a momentary bandage for addressing those underlying root concerns.
On another level, I believe kratom holds great promise for managing opioid dependence and tapering off of them as a way of harm reduction and as a step down process towards full abstinence from opioids. This has been an effective strategy in traditional Thai culture and one that is being explored on a clinical level there. We as a society need to address the perils of prescribing hundreds of millions of opioid drugs to eliminate pain and look for better, more healthy and less deadly options.
http://www.ncbi.nlm.nih.gov/pubmed/22133323 – Herbal Medicines For Management of Opioid Addiction
http://www.ncbi.nlm.nih.gov/pubmed/22018854 – HPLC Analysis of Mitragynine, Codeine, Caffeine, Chlorpheniramine and Phenylepherine
http://www.ncbi.nlm.nih.gov/pubmed/21817918 – Kratom and Hypothyroidism
http://www.ncbi.nlm.nih.gov/pubmed/21528385 – Intrahepatic Cholestasis w/ Powdered Kratom Use
http://www.ncbi.nlm.nih.gov/pubmed/21513619 – Fatal Intoxications of Mitragynine and 0-desmethyltramadol
http://www.ncbi.nlm.nih.gov/pubmed/21450536 – Metabolism Studies of Kratoms Alkaloids
http://www.ncbi.nlm.nih.gov/pubmed/21249338 – Metabolism Studies of Speciociliatine
http://www.ncbi.nlm.nih.gov/pubmed/21219704 – Fatality from Mitragynine and Propylhexedrine
http://www.ncbi.nlm.nih.gov/pubmed/21153588 – GCMS Monitoring of Kratom and Krypton Intake
http://www.ncbi.nlm.nih.gov/pubmed/21112167 – Kratom Alkaloids and 0-desmethyltramadol In Urine of Consumer
http://www.ncbi.nlm.nih.gov/pubmed/20967737 – Phase I/Phase II Metabolites of speciogynine
http://www.ncbi.nlm.nih.gov/pubmed/20857386 – Herbal Mixtures Containing Synthetic Compounds as Psychoactive Compounds
http://www.ncbi.nlm.nih.gov/pubmed/20798544 – Case Report of Inpatient Following Kratom Detoxification
http://www.ncbi.nlm.nih.gov/pubmed/20683389 – Chemistry, Pharmacology, and Metabolism of Emerging Drugs
http://www.ncbi.nlm.nih.gov/pubmed/20650576 – “Legal Highs” on the net-Evaluation UK Websites
http://www.ncbi.nlm.nih.gov/pubmed/20411370 – Seizure Following Kratom Exposure
http://www.ncbi.nlm.nih.gov/pubmed/20371282 – Neuromuscular Blockade Produced by Mitragynine and Methanol Extract of Kratom Leaves
http://www.ncbi.nlm.nih.gov/pubmed/19902190 – HPLC/MS Metabolism Study of Paynantheine
http://www.ncbi.nlm.nih.gov/pubmed/19731590 – Phytochemical Characterization of Mitragyna Speciosa Leaves Grown in the USA
http://www.ncbi.nlm.nih.gov/pubmed/19577523 – HPLC/MS Analysis of Mitragynine in Human Urine
http://www.ncbi.nlm.nih.gov/pubmed/19536806 – HPLC/MS Metabolism Study of Mitragynine in Human and Rat Urine
http://www.ncbi.nlm.nih.gov/pubmed/19393795 – Prevalence of Psychoactive Drug Among Drivers in Thailand
http://www.ncbi.nlm.nih.gov/pubmed/19294483 – The Botanical Origin of Kratom
http://www.ncbi.nlm.nih.gov/pubmed/18482427 – Self-treatment of Opioid Withdrawal Using Kratom
http://www.ncbi.nlm.nih.gov/pubmed/18259963 – Opioid Receptors and Legal Highs: Salvia Divonorum and Kratom
http://www.ncbi.nlm.nih.gov/pubmed/18191353 – Inhibitory Effects of Kratom Extract on GI Tracts in Rats
http://www.ncbi.nlm.nih.gov/pubmed/17882605 – Self-treatment of Opioid Withdrawal With A Dietary Supplement
http://www.ncbi.nlm.nih.gov/pubmed/16107269 – Inhibitory Effect of Mitragynine on Neurogenic Contraction of the Vas Deferens
http://www.ncbi.nlm.nih.gov/pubmed/15822540 – Energy Drink Consumption Among Male Construction Workers in the Chonburi Province
http://www.ncbi.nlm.nih.gov/pubmed/9061050 – Inhibitory Effect of Mitragynine on Electrically Stimulated Contraction of Iso. G-Pig Ileum
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