Journal of Clinical Toxicology
Open Access

Abstract

Kratom: The Herbal Opioid

Milad Webb, Daniel S Isenschmid, Lok Man Sung, Leigh Hlavaty and Avneesh Gupta

Objective: Kratom (Mitragyna speciose) is a tropical tree used in traditional herbal medicine. It has gained popularity as an herbal remedy and recreational drug. Bioactive alkaloids isolated from kratom shows stimulant and opiate-like effects and raise concern for potential abuse, dependence, and toxicity. The intent is to characterize the association of kratom use with toxicity-related deaths, determine the profile of mixed-drug usage, characterize the demographics of those using kratom, and to identify opportunities for public health interventions.

Methods: This is a retrospective study of postmortem toxicology from suspected drug-related deaths from January 2018 to March 2019. The data was aggregated from the Wayne County and Washtenaw County Medical Examiners’ Offices, which serve Livingston, Monroe, Wayne, and Washtenaw counties in the State of Michigan. Thirty-three (33) decedents with postmortem toxicology positive for the kratom compound mitragynine were identified in suspected drug-related deaths; none were excluded.

Results: We examined the demographics and co-occurring drug profiles in mitragynine-related drug deaths. Single agent toxicity at substantially elevated concentrations causing death is reported of 33 identified cases, 31 (94%) were certified as drug toxicity-related deaths. Decedents were predominantly male (88%) and Caucasian (94%) with a median age of 36 years and with known substance abuse history (80%). Median concentration where mitragynine was determined to be contributory to death was 180 ng/mL. Co-occurrence of opioids was observed in 84% of cases with fentanyl being most common. Stimulants such as cocaine and amphetamines were found in 52%. A single-agent mitragynine death was confirmed in one decedent (2400 ng/mL).

Conclusion: In the medical examiner setting, kratom found in postmortem toxicology is rising and associated deaths are no longer esoteric. Kratom positivity has a strong association with substance abuse history and mixeddrug toxicity suggestive of recreational use. Despite backlash from consumers and advocacy groups, the known potential for abuse and increasing evidence of toxicity likely warrants some measure of regulation.