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"Kratom is a rare gem, a psychoactive substance which can be used readily for pleasure or personal growth, but still remains legal throughout the world (with the exception of in Thailand, Myanmar, and Australia). Please help keep it this way."

Sounds too good to be true, doesn't it? Do you feel a little bit suspicious? Ding ding ding, you win! It's too good to be true!

Ok, hello, so if it works at the opioid receptor as an agonist, then you are NOT surprised that it is 1. sedating 2. acts like an opiate 3. is addictive. 4. causes GI problems and constipation. An agonist is a key that fits in the lock (the opiate receptor) and turns it (has opiate effects). An antagonist fits in the lock and blocks it. Nalaxone is an antagonist. Buprenorphine is a partial agonist/antagonist -- at higher doses it blocks and there is no additional opioid effect.

Now, why aren't there any SE Asian wonderful plants that are being sold that are antagonists? Like narcan or nalaxone. That is, they block the receptor. They could be sold to reverse overdoses and save lives. Somehow I don't think it will sell, do you?

Kratom is currently a 250 billion dollar industry. The DEA made it a schedule one drug in 2016 but the backlash from the American Kratom Association and Congresspeople made the DEA back down after two months. At this point the DEA is seizing kratom and asking for volunteer recalls because of a salmonella outbreak involving 36 states. Kratom is still legal but the DEA came out this year saying that it does work as an opioid. There have been a number of deaths as well as addicted newborns that require a morphine withdrawal schedule. Kratom is sold over the counter and on the internet and unfortunately the amount of opioid effect is variable and not controlled. A gram of kratom is approximately equivalent to 2 grams of morphine.

Kratom is touted on the internet as helpful for pain and for getting off opioids. Unfortunately people are trading one addictive drug for another and for a not well controlled drug. We don't know what the hell it will do long term or side effects or drug interactions. Overdose and death are still risks, especially if combined with other sedating substances: alcohol, soma, barbituates, benzodiazepines, sleep medicines, and illegal drugs.

Go ahead, you've always dreamed of being a guinea pig.

I have one patient who has self weaned from oxycodone to kratom. The person (P) used a jeweler's scale, in grains. We did clinic math to get from grains to grams to morphine dose equivalents. Interestingly P got it right. P's dose of kratom is a bit more than the oxycodone in morphine dose equivalents. It's legal, so I said my concerns are that it may not stay legal, we don't know the side effects or if it's toxic, there's a huge recall going on because it's been contaminated with salmonella and the usual You Could Die. P has gut problems already, so it's guinea pig home science, and I expressed large concern that P would up the dose. Follow up is soon.

Now I am adding kratom to my warning to patients and testing for it more. Another patient (P2) disappeared for a couple months. No show for chronic pain visit for oxycodone, morphine dose equivalent at 75 mg daily. P2 would definitely go through withdrawal. Various emergency room notes filled me in a bit and then I saw P2 with fever and problems. I refused to add oxycodone to it and sent out the urine. P2 did not look like P2 was in withdrawal. I was suspicious and yes, kratom in the send out urine. My clinic dipstick doesn't test for it. Yes, it's legal. BUT that does not mean safe nor can I safely prescribe oxycodone with it. So, I notified the specialist (GI again) and sent P2 a letter (phone often does not work in chronic pain and addiction folks) and now have to revise my chronic pain medicine contract and my opioid overuse contract. No kratom, no spice, no supplements without discussing with me first, I can't prescribe safely if you are on these substances. Damn it. Oh, made by "pure encapsulations" so you KNOW it's safe? Snort. I have had at least five patients taking kratom so that's the tip of the iceberg. Time to send out urines on all chronic pain and all addiction patients on controlled substances. But you say, it's legal. Right. So is alcohol. I do test people and offer them inpatient if they are drinking or using meth or using cocaine or what-the-hell ever with their opioids. Got benzodiazepines from their behavioral health person that I don't know that they are seeing and so the risk of overdose rises by 20 times. First do no harm and I do take that seriously.

Don't be a guinea pig. Warn your kids and friends. Have a nice day.

salmonella outbreak: https://www.fda.gov/food/recallsoutbreaksemergencies/outbreaks/ucm597265.htm
maternal newborn kratom withdrawal: http://www.cfp.ca/content/cfp/64/2/121.full.pdf