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KRATOMBiak – Herbal Speedball – Kakuam – Ketum

Krathom – Thang – Thom

Opioid, Addiction, and Pain ECHOApril 18, 2019

Paula Cook, MDMikayla Mills, PharmD Candidate

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OBJECTIVES

• Discuss a patient case• Outline the history of Kratom • Review the pharmacology and

mechanism of action• Summarize the laws surrounding

Kratom use

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CASE

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CASE

• HPI: 20 year old Caucasian male presented to ED 5 days PTA for 1st time seizure

• SH: Studying music production at SLCC, lives with his parents, works at Macey’s grocery store

• Medical and Psychiatric History– ADHD diagnosed in childhood – Left foot fracture May 2018– Fell while wearing walking boot and fractured right ankle 2

months after left foot fracture

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CASE (CONTINUED) • Substance History

– Opioids• Started using Kratom 10 grams/day at age 16 and increased use

last year with fractures to 20-30 grams/day• Prescribed opioids in 2018 (was taking Percocet 80mg/day)• Currently taking Percocet 40mg/day

– Marijuana• Started smoking at age 13, continues daily high dose use

(hourly)

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CASE (CONTINUED) • Substance History (continued)

– Stimulants• Prescribed Adderall in middle school and began abusing as a

freshman in high school• Methamphetamines, cocaine

• Other Drug Use– Ketamine (4 days PTA)– LSD– Xanax– Spice

– PCP– Peyote– GHB– DXM

– Ecstasy (MDMA)– Whippets– Nicotine

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CASE• BP: 137/80• HR: 71• Temp: 97.0• SpO2: 97%

• UDS positive for Oxycodone and Marijuana

Medications• Celecoxib• Gabapentin• Robaxin• Percocet• Sertraline• Straterra

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SEIZURE• Current Use:

– Marijuana– Opioids– Kratom

– Episodic dabbles– Rx

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KRATOM

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DESCRIPTION

Kratom refers to Mitragyna speciose, a tree native to tropical regions of Southeast Asia (Thailand, Malaysia, and Indonesia) that is in the coffee family.

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EPIDEMIOLOGY • The national poison center reporting database documented

1,807 calls concerning reported exposure to kratom from 2011–2017

• 152 out of 27,338 overdose deaths that occurred from 2016–2017 tested positive for kratom on postmortem toxicology reports

• Kratom was determined as the cause of death in 91 of the 152kratom-positive cases, 7 for whom kratom was the only substance to test positive on postmortem toxicology

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HOW IT’S USED • Leaves are chewed• Leaves are dried to be:

– Brewed as a tea– Smoked– Crushed into powder to fill capsules

• “4x100”– Cocktail of kratom leaves, codeine cough

syrup, Coca-Cola, and ice– Popular in Thailand

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USES • Energy / Reduce fatigue• Anxiety • Pain• Addiction (Alcohol and

Opioid Withdrawal)

There are no approved medical uses for kratom, but it is often used in Malaysian folk medicine. It is currently under FDA review for significant safety concerns. There are no human studies, but some animal data are available.

• Antitussive• Anti-diarrheal• Libido• Mood enhancement

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PHARMACOKINETICS • Effects

– Opioid (mu)– Stimulant– Sedative (alpha-2-andrenergic)– Sensory suppressive

• Inhibits CYP3A4, 2D6, 1A2

• Onset: 5-10 minutes • Duration: 2-5 hours• Urine Drug Screen

– POC: No– GC/MS: Yes

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PHARMACOLOGY • More than 25 alkaloids have been identified in the leaves

of kratom. Mitragynine and 7-hydroxymitragynine (7-HMG) are the main psychoactive alkaloids

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MITRAGYNINE• Makes up 60% of kratom's alkaloid content • A partial mu-opioid receptor agonist that is about 25% as

potent as morphine• Also affects the adrenergic, serotonergic, and

dopaminergic pathways• Mitragynine is also a central stimulant• Half-life is about 3.5 hours

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7-HYDROXYMITRAGYNINE• Makes up 2% of kratom's alkaloid content• A highly selective mu- and kappa-opioid receptor agonist

that is estimated to be 14 times more potent than morphine

• 7-HMG has CNS stimulant and depressant effects that are 4 times that of mitragynine

• Half-life is about 2.5 hours

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EFFECTS • Higher doses (5-15 grams) have opioid-like effects

– Sedation, pleasure, and decreased pain

• Lower doses (1-5 grams) have stimulating effects– Euphoria, energy, talkativeness, and alertness

• The full mechanism is not understood, as other alkaloids found in Kratom may be causing stimulating effects.

• Effects may also vary depending on strain (color of vein)

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ADVERSE REACTIONS

Opioid• Nausea/Vomiting• Constipation• Withdrawal• Respiratory depression• Addiction

• Liver toxicity*• Death

Stimulant• Hypertension• Tachycardia• Psychosis• Seizure• Addiction

• Death

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WITHDRAWAL SYMPTOMS• Muscle/bone aches• Insomnia• Irritability• Aggression• Runny nose• Jerky movements

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TREATMENT OF USE DISORDER AND OVERDOSE• Not yet studied, no evidence based guidance

• Use naloxone for overdose

• Symptomatic treatment for stimulant effects• Treat opioid withdrawal symptoms• Medication for OUD (buprenorphine, naltrexone) • Behavioral therapy

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LEGALITY• Kratom is not federally controlled in the United States,

but it is a “drug of concern.”• It is controlled/banned in many regions of Southeast Asia

– Australia, Denmark, Germany, Malaysia, New Zealand, Romania, etc.– Kratom Act 1943 banned use in Thailand

• States including Alabama, Arkansas, Indiana, Tennessee, Vermont, and Wisconsin have banned the plant in various forms, while others have legislation pending

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DEA/FDA• DEA (2013): “No legitimate medical use”• FDA (February 2018): “Not safe or effective for any

medical condition”

– Feb. 2014: FDA began seizing shipments due to increase in poisonings

– Aug. 2016: DEA > CS I of Controlled Substance Act due to 44 Kratom related deaths

– Oct. 2016: DEA withdraws announcements due to public protest, 51 Congress people and 9 Senator response

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LAWS – UTAH • FDA recall for Salmonella (2018)• Utah concern for safety (2019) • https://le.utah.gov/~2019/bills/static/SB0058.html

– Kratom Consumer Protection Act – “Requires a person that prepares, distributes, sells, or offers to

sell a kratom product to follow certain labeling requirements”

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WHERE TO GET KRATOM?

• Kratom Bars/Kava Bars serve Kratom as a brewed beverage– Colorado, New York, North Carolina, Florida

• Head shops• Convenience stores• Online

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CASE

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CASE• 20 year old patient with new onset single generalized

seizure• $$$$ work up• Thought to be 2/2 Kratom• Referred to UNI• Put on Bupropion-Naloxone 12mg daily for OUD• Supportive care for CUD (continue gabapentin) • IOP

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CONCLUSION• There are no approved uses for

Kratom. Further studies need to be conducted to show safety and efficacy for its proposed uses

• Kratom poses a risk for addiction, abuse, and dependence

• Deaths have been associated with the use of kratom-containing products

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QUESTIONS?

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REFERENCES• National Institute on Drug Abuse. DrugFacts:

Kratom. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/df_kratom_2_2016.pdf. Published February 2016. Accessed December 20, 2016.

• Warner ML, Kaufman NC, Grundmann O. The pharmacology and toxicology of kratom: from traditional herb to drug of abuse. IntJ Legal Med. 2016;130(1):127-138.[PubMed 26511390]

• National Institute on Drug Abuse. Commonly abused drugs. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/commonly_abused_drugs_3.pdf. Published January 2016. Accessed December 20, 2016.

• https://www.cdc.gov/mmwr/volumes/65/wr/mm6529a4.htm• FDA Adverse Event Reporting System: Kratom Deaths. February 6, 2018.

https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/CDERFOIAElectronicReadingRoom/UCM595575.pdf. Accessed March 6, 2018.

• Statement from FDA Commissioner Scott Gottlieb, M.D., on the agency's scientific evidence on the presence of opioid compounds in kratom, underscoring its potential for abuse. FDA Statement. February 6, 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm595622.htm. Accessed 4/18/2018.

• http://www.emcdda.europa.eu/publications/drug-profiles/kratom• Olsen EO, O’Donnell J, Mattson CL, Schier JG, Wilson N. Notes from the Field: Unintentional Drug Overdose Deaths with Kratom

Detected — 27 States, July 2016–December 2017. MMWR Morb Mortal Wkly Rep 2019;68:326–327. DOI: http://dx.doi.org/10.15585/mmwr.mm6814a2