Kratom Regulatory Reform
NOTE: Sober Linings Playbook is a personal website. Any views or opinions expressed herein belong solely to the website owner and do not represent those of individuals or organizations the owner may be associated with in a professional or personal capacity, unless explicitly stated.
[This piece is posted with permission from kratomsobriety.com where it appeared originally on Sept. 15, 2023]
By Charlie
Rising Concerns About Kratom Addiction
Recently, an influx of news coverage reignited a national debate about kratom's potential benefits and risks. Derived from a psychoactive plant native to southeastern Asia, kratom products range from mild beverages to capsules with ground leaves to potent extracts. Kratom is banned in six states as well as a handful of other cities and counties in the United States. Most Americans purchase kratom at local stores or on the internet, but there is a growing kratom bar scene in several major cities and in the state of Florida.
While some people find kratom improves the quality of their lives by providing calming invigoration or pain relief, other Americans struggle with kratom addiction. During the summer of 2023, Princeton University's Andrew Huberman warned about the downsides of kratom, especially for individuals with a history of substance abuse disorder.
In an academic commentary, two psychiatrists caution that kratom "retailers continue to develop higher potencies and continue to mislead their customers that it is a safe 'herbal supplement' when evidence indicates that kratom is addictive." Additionally, pending lawsuits against kratom corporations allege certain products are innocuously promoted while being "perniciously addictive", and in another case, that a company failed to warn customers.
Earlier this year, despite a strong desire to stop, I was spending over $90 a day on kratom extract shots. It was expensive and demoralizing, with many futile attempts at quitting. In late March 2023, I started meeting online with others struggling with the same issue and finally became kratom-free. As a person in recovery from alcoholism, I found kratom easily became a transfer addiction.
Since then, through weekly podcast interviews, I learned that many others have similar difficult experiences, especially dealing with kratom tolerance and withdrawals. Most slowly progress from a kratom dependency to an addiction that allows one to essentially still function while often eventually negatively affecting finances, health, work, and family. Recovering from problematic kratom use can be very isolating, and social media forums are currently the primary sources of information and support for many individuals.
While perhaps not as dangerous or severe as abusing other substances, some individuals find it very challenging to quit kratom. Many people frequently relapse on kratom multiple times because they find withdrawal symptoms or mental cravings too challenging to withstand. Kratom use can sometimes lead a person back to alcohol or other drugs, with significant consequences.
Others with no addiction history can also develop a troublesome kratom habit by finding it placed on the shelves next to the energy shots at a convenience store or through promotion as a risk-free wellness product online. Even long-term consumers who initially used kratom powder to self-treat various conditions can eventually face substantial negatives from prolonged kratom consumption, even when buying from reputable well-reviewed sources.
Exaggerating or Minimizing Kratom's Risks Must Be Avoided
A recent pilot study found there are signals that kratom addiction may cause a change in dopamine transporter levels "with similar effects to other opiate drugs such as heroin, morphine, and codeine." The scientific literature describes how Kratom Use Disorder can sometimes require medication-assisted treatment, including opiate blockers such as naltrexone and opioid replacement medications such as buprenorphine. In an analysis of adverse reports submitted to a federal database, academics found the signs of kratom "addiction or withdrawal was more than five times greater" than anticipated.
The extent of kratom addiction remains an issue of great debate, and there is a clear need for additional research. One panel of experts earlier this year formed differing conclusions and found that kratom's abuse and withdrawal potential are low. Nonetheless, recent headlines about kratom-related death lawsuits are not mere sensationalism driven by drug hysteria or moral panic.
Earlier this year a Florida court attributed the 2021 death of 39-year-old nurse Krystal Talavera to a kratom extract purchased online. According to a preprint study published by the Social Science Research Network, her death was just one of 550 kratom-related fatal incidents in the state from 2020 to 2021. Among these deaths, 353 were determined to be caused by kratom, 21 were classified as kratom-only, and most involved polysubstance intoxication, particularly with fentanyl.
During the same two years, to contextualize, these kratom-related deaths were a small portion of Florida's fifteen thousand fatal drug poisonings. Sadly though, for these 550 Floridians who died with kratom in their systems and for their surviving family members, it is clear that kratom was an ineffective harm reducer and not a successful addiction solution for them as victims of the rising polysubstance overdose-death crisis. We need a policy solution that better prevents kratom-related deaths even if there are pre-existing health conditions, dangerous substance interactions, adulterated kratom or overconsumption.
Scientists also identify potential non-fatal unhealthy "cardiovascular, gastrointestinal, neurological, and psychiatric" effects associated with kratom use. While kratom appears safer than a substance like alcohol, kratom's risk profile warrants a standalone public health policy response.
Kratom and its largely unregulated marketplace create other negative consequences for individuals and communities across America, such as in Idaho, where prosecutions for "theft crimes...related to supporting a kratom addiction" are becoming more common. Or in the recent local news segment, “My Gas Station, My Drug Dealer” describing the toll of kratom addiction in Mississippi. Kratom advocates often blame the U.S. Food and Drug Administration (FDA) and the pharmaceutical industry for this "Wild West" regulatory situation.
However, Courthouse News documented how the ugly political underbelly of kratom lobbying creates a toxic and bombastic environment for any regulator attempting to shield customers from industry excesses. The large companies dominating the estimated $1.3 billion kratom sector appear to profit handsomely from the current lack of robust regulation. When "commercial actors use a range of coordinated and sophisticated strategies to protect business interests," it often can be "at the expense of public health."
Regulating Kratom Will Improve Public Health Outcomes
The widespread mass marketing of kratom as a health or food product obscures the substance's potential side effects. At times, kratom packaging or advertising do not make it readily evident that kratom is an ingredient, a problem with first-time purchases. These practices mask the dose-dependent stimulating and sedating reactions people may experience from kratom use. Many customers are often unaware of potential interaction dangers when mixing kratom with specific prescriptions, drugs, and alcohol.
While the FDA made mistakes with its past kratom oversight plans, we need a new regulatory framework to avoid overreliance on industry self-regulation. The American Kratom Association's state-based Kratom Consumer Protection Act doesn't sufficiently prioritize public health. The Global Commission on Drug Policy issued a report, "Regulation: The Responsible Control of Drugs," with a graphic illustrating the problems with unregulated markets:
There is a growing call for new regulations such as:
Universal third-party testing of all kratom products.
Dose instructions and risk warnings.
Limiting potency of extracts.
A standardized labeling system.
Minimum age 21 sales.
Questions remain. With internet purchases, are age limits enforceable, and can a safe supply be guaranteed through online sales? Should kratom be sold at gas stations and similar locations? Would a state-based licensing and inspection system to dispense kratom improve safety? Could a modest tax on kratom fund meaningful regulation compliance oversight and support additional research on reports of seizures and other health concerns related to kratom?
The goals of any regulatory reform would be to protect the general public and convey to consumers the seriousness of the risks associated with kratom use. The greatest obstacle is such regulation would require an act of Congress or passage in state legislatures across the country. We must do more to safeguard against uninformed consumers, misleading marketing, and irresponsible vendors.
I believe banning kratom is not the right policy choice, as prohibition will likely cause the kratom supply to become dangerously compromised. Moreover, there will be too great of a human toll and wasted resources due to any enforcement of a kratom ban by police and courts. I am also in favor, alongside robust regulation, of kratom decriminalization in all 50 states and expunging the records of all people with kratom possession charges or sentences. The 18th Amendment last century did not cure alcoholism in America.
However, this comes with repercussions, as Nora Volkow, director of the National Institute on Drug Abuse, told the Boston Globe in 2018:
“The greatest mortality from drugs comes from legal drugs. The moment you make a drug legal, you’re going to increase the number of people who get exposed to it, and therefore you increase the negative consequences of its use. When you legalize, you create an industry whose purpose is to make money selling those drugs. And how do you sell it? Mostly by enticing people to take them and…to take high quantities.”
The booming kratom sector is making kratom as widely accessible as alcohol but without the corresponding regulations and guardrails and without the same near-universal cultural acceptance that the substance can be detrimental for some people. Just like you don’t need a beer to enjoy the big game, you also don’t need kratom for exercising or everyday functioning - despite all the hype from any industry.
In particular, marketing kratom to target people in recovery from drugs or alcohol is questionable at best, predatory at worst. Yes, kratom can be helpful during difficult withdrawals from other substances, and kratom may initially be a safer alternative than using illegal street drugs and alcohol. However, kratom consumption can lead to an outright difficult-to-stop addiction to kratom, and some find it a slippery slope that can result in returning to using more harmful substances again.
Normalizing Kratom Abstinence as The Best Harm Reduction Choice For Many
In 2016, the federal government initially proposed and retreated later from scheduling kratom as a controlled substance. Given this tenuous legal status, kratom advocates are extremely protective of the substance's image. Any unfavorable portrayal of kratom in the news, social media, or by public figures is often roundly dismissed as exaggeration or misrepresentation. These negative headlines and lawsuit judgements are coal-mine canaries.
Among the pro-kratom community, kratom can directly produce benefits, but all detrimental results are due to user error. A long list of deflections is typically deployed to exonerate kratom. Accordingly, a massive culture change is also needed, something that can not be legislated into reality. While partly an understandable attempt to normalize kratom consumption, this extensive push to market kratom as non-addictive creates significant stigma and barriers for people recovering from kratom abuse.
Promoting kratom as an innocuous healing herb with no side effects or health dangers is counterproductive, and certainly is not educating the public in a way that reduces adverse kratom incidents. This tactic of kratom valorization by calling it a miracle plant or a lifesaver is just as problematic as demonizing the substance. The pervasive effort to downplay kratom's health risks creates a real challenge to recovery, as many problematic kratom users often internalize all these minimizations and rationalizations.
This is in stark contrast with alcoholism. There is no debate that some individuals should not consume booze for their own good. One can openly talk about the negatives of drinking and celebrate how life has improved through sobriety. The same should be valid for kratom; abstaining from the substance is the best choice for many Americans.
This dynamic parallels the discourse on cannabis use and legalization, as deeply and thoughtfully discussed in the Recovery Review Blog's post "Portraying Abstinence Recovery as Puritanical Is in the Interest of Those Who Sell Addictive Drugs." Kratom advocates, at times, co-opt the principles of harm reduction and safe supply to oversell the substance's benefits to society and to prevent prohibition at any cost. While adopting rhetoric related to plant medicine and anti “war on drugs” advocacy, the pro-kratom community will often simultaneously assert that kratom is not a drug.
The crux of this tension between the pro kratom community and those us with histories of kratom addiction is brilliantly explained in this Addict Collectives’ “The Word Addict: Why Not PWUD (People Who Uses Drugs)”:
“I think it’s no accident that so many decriminalists—not unlike prohibitionists!—want to view the ‘drug crisis’ as monolithic, instantiating equal harms across race, class, and, yes, addict lines. I think this reflects that (1) the addict community has interests different from theirs, and (2) bringing attention to us threatens their access to the stuff they can “use responsibly” but we can’t.”
A crucial part of recovering from any addiction is self-responsibility and personal accountability. Many Americans consume kratom safely and in moderation with apparently no ill effects as a natural remedy or uplifting drink. This is not a call to impose temperance on the rest of the country. However, we live in a society where cultural influences and commercial practices impact individuals.
We have the right to expect the government to create, monitor and enforce regulations for the kratom marketplace. The public should not have to rely on retailers' goodwill or a pay-to-play “gold” certification system operated by the kratom lobby to keep everyday Americans safe, and to follow the basic tenets of consumer protection principles. While it is reasonable to be skeptical of big government, corporations are driven largely by maximizing profits and not the public good.
Hopefully, such a new regulatory system for kratom would also spark a shift in which kratom consumption's potential risks and drawbacks are more widely discussed and appreciated, and no longer ubiquitously denied and minimized to both prevent kratom prohibition and to maximize kratom sales.
Sources:
* Haden, P. (2023, July 24). Herbal supplement kratom targeted by lawsuits after a string of deaths. NPR. https://www.npr.org/2023/07/08/1186514144/kratom-herbal-supplement-lawsuits- deaths-fda
* Woolf, M. (2022, September 20). Opinion | Kratom has given me a better life. Michigan needs regulation. Bridge Michigan. https://www.bridgemi.com/guest-commentary/opinion-kratom-has-given-me-better-life-michigan-needs-regulation
* Center, M. T. (2023, July 13). Exploring the Complexities of Kratom. Psychology Today. https://www.psychologytoday.com/us/blog/from-addiction-to-recovery/202306/expl oring-the-complexities-of-kratom
* Huberman, A. (2023, July 28). AMA #9: Kratom Risks, Does Infrared Sauna Work & Journaling Benefits [Video]. YouTube. https://www.youtube.com/watch?v=HoH93judXmE
* Anand, A., & Hosanagar, A. (2021). The Addictive Potential and Challenges with Use of the “Herbal Supplement” Kratom: A Case Report and Literature Review. Pain Medicine, 23(1), 4–9. https://doi.org/10.1093/pm/pnab126
* McCroskey, K. (2023, April 17). O.P.M.S. Failed to Warn That Kratom Products Can Be Addictive, Class Action Says. ClassAction.org. https://www.classaction.org/news/o.p.m.s.-failed-to-warn-that-kratom-products-ca n-be-addictive-class-action-says
* McCroskey, K. (2023, April 17). Krave Botanicals Misled Consumers About Highly Addictive Kratom Products, Class Action Claims. ClassAction.org. https://www.classaction.org/news/krave-botanicals-misled-consumers-about-highl y-addictive-kratom-products-class-action-claims
* Kratom Sobriety Podcast. (2023, September 12). Kratom Addiction | a podcast by Charlie and Jacob. PodBean. https://kratomsobriety.podbean.com/
* Zainudin, N. a. B. (2023). A Pilot Study of the Striatal Dopamine Transporter Levels in Kratom-Dependent and Normal Subjects Using 99mTc-TRODAT-1 Single Photon Emission Computed Tomography-Computed Tomography (SPECT-CT). www.cureus.com. https://doi.org/10.7759/cureus.43251
* Broyan, V. R., Brar, J. K., Student, T. A., & Allgaier, J. T. (2022). Long-term buprenorphine treatment for kratom use disorder: A case series. Substance Abuse, 43(1), 763–766. https://doi.org/10.1080/08897077.2021.2010250
* Li, X., Ndungu, P., Taneja, S. B., Chapin, M. R., Egbert, S. B., Akenapalli, K., Paine, M. F., Kane-Gill, S. L., & Boyce, R. D. (2023). An evaluation of adverse drug reactions and outcomes attributed to kratom in the US Food and Drug Administration Adverse Event Reporting System from January 2004 through September 2021. Clinical and Translational Science, 16(6), 1002–1011. https://doi.org/10.1111/cts.13505
* Henningfield, J. E., Chawarski, M. C., Garcia-Romeu, A., Grundmann, O., Harun, N., Hassan, Z., McCurdy, C. R., McMahon, L. R., Sharma, A., Shoaib, M., Singh, D., Smith, K. E., Swogger, M. T., Vicknasingam, B., Walsh, Z., Wang, D. W., & Huestis, M. A. (2023). Kratom withdrawal: Discussions and conclusions of a scientific expert forum. Drug and Alcohol Dependence, 7, 100142. https://doi.org/10.1016/j.dadr.2023.100142
* Bendix, A. (2023, July 31). $11 million awarded to family of woman who died after taking kratom, an opioid-like herb. NBC News. https://www.nbcnews.com/health/health-news/11-million-awarded-family-woman- died-taking-kratom-opioid-herb-rcna97293
* Suriaga, A. A., Tappen, R. M. McCurdy, C. R., and Newman, D. (2023) Increased Risk of Mitragynine Drug Intoxication is Associated with Opioid Use: A Retrospective Analysis. SSRN. https://ssrn.com/abstract=4495146.
* Drug Overdose Mortality by State. (n.d.). https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_pois oning.htm
* Peppin, J. F., Raffa, R. B., & Schatman, M. E. (2020). The Polysubstance Overdose-Death Crisis. Journal of Pain Research, Volume 13, 3405–3408. https://doi.org/10.2147/jpr.s295715
* Striley, C. W., Hoeflich, C. C., Viegas, A. T., Berkowitz, L. A., Matthews, E. G., Akin, L. P., Iheanyi-Okeahialam, C., Mansoor, U., & McCurdy, C. R. (2021).
* Health Effects Associated With Kratom (Mitragyna speciosa) and Polysubstance Use: A Narrative Review. Substance Abuse, 16, 117822182210958. https://doi.org/10.1177/11782218221095873
* Colhoun, D. (2023, July 5). How kratom, a legal “herbal opioid,” tore one local family apart. Idaho Mountain Express Newspaper. https://www.mtexpress.com/news/health/how-kratom-a-legal-herbal-opioid-tore-o ne-local-family-apart/article_7d5d01a6-1767-11ee-83f5-6bb06325e72d.html
* Carter, J., & Clark, P. (2023, August 24). My Gas Station, My Drug Dealer. WLBT. https://www.wlbt.com/2023/08/24/my-gas-station-my-drug-dealer/
* Baylis, S. (2023, August 7). Herbal Supplement Kratom Is Bought and Sold in a ‘Wild West’ Marketplace. The Messenger. https://themessenger.com/health/herbal-supplement-kratom-is-bought-and-sold-in-a-wild-west-marketplace
* Ericson, E., Jr. (2022, January 12). The kratom playbook: Working the refs. Courthouse News Service. https://www.courthousenews.com/the-kratom-playbook-working-the-refs/
* Lacy-Nichols, J., Marten, R., Crosbie, E., & Moodie, R. (2022). The public health playbook: ideas for challenging the corporate playbook. The Lancet Global Health, 10(7), e1067–e1072. https://doi.org/10.1016/s2214-109x(22)00185-1
* Szalavitz, M. (2021, August 12). The FDA Shouldn’t Support a Ban on Kratom. Scientific American. https://www.scientificamerican.com/article/the-fda-shouldn-rsquo-t-support-a-ban- on-kratom/
* Kratom.org. (2022, June 11). What Is the Kratom Consumer Protection Act (KCPA)? Kratom.org. https://kratom.org/guides/kcpa/
* Regulation – The Responsible Control of Drugs. (2019, May 5). The Global Commission on Drug Policy. https://www.globalcommissionondrugs.org/reports/regulation-the-responsible-cont rol-of-drugs
* The Daily News Editorial Board. (2023, August 12). Our view | Supplement rules are a dangerous framework for kratom. Longview Daily News. https://tdn.com/opinion/our-view-supplement-rules-are-a-dangerous-framework-fo r-kratom/article_bc27e746-30af-11ee-9c64-bf06cca21b02.html
* Ledger, T. (2023, April 6). Kratom leads to trafficking charge in Ala. Tri-City Ledger. https://www.tricityledger.com/story/2023/04/06/news/kratom-leads-to-trafficking-ch arge-in-ala/5807.html
* US: Director Of Drug Abuse Institute Offers Words Of Caution On. (n.d.). Media Awareness Project. http://www.mapinc.org/drugnews/v18/n110/a08.html?7538264
* Stauffer, W. (2023, June 17). Portraying Abstinence Recovery as Puritanical Is in the Interest of Those Who Sell Addictive Drugs. WordPress.com. https://recoveryreview.blog/2023/06/17/portraying-abstinence-recovery-as-puritani cal-is-in-the-interest-of-those-who-sell-addictive-drugs
* Murthy, T. V. (2023, August 23). The Word “Addict”: Why Not “PWUD”? Substack.com https://addictcollective.substack.com/p/the-word-addict-why-not-pwud
