I attended a medical student presentation recently and learned some interesting facts about kratom.

What is it?
Kratom is a natural substance derived from the Mitragyna speciosa tree, native to Southeast Asia. Its main active compound is 7-hydroxymitragynine (7-OH), an opioid. In 2020, about 2.1 million people in the U.S. reported using kratom. It is more commonly used by adults than adolescents, and more by men than women. Some individuals try it to manage opioid withdrawal, and it is sold in smoke shops and convenience stores without a prescription.

Why use kratom?
Kratom has been used for centuries in religious ceremonies, social rituals, and as a visitor gift. At low doses, it can act as a mild stimulant; at higher doses, it produces pain relief and euphoria. Use often escalates over time. A 2020 study reported that 90% of users take it for pain relief, 60% for anxiety, 40% for opioid withdrawal, and 25% for depressive symptoms.

Legal status
Kratom’s legality varies by state. In 2016, the DEA proposed classifying it as a Schedule I substance, but this did not pass. In 2018, the FDA categorized kratom as an opioid. The Kratom Consumer Protection Act (2019) aimed to provide consumer safeguards, but regulations differ widely. In Nevada, buyers must be 18 or older. More than 10 states have no protections, and 6 states have outright bans.

Forms
Kratom is available as powdered leaves, capsules, teas, extracts, gummies, or even ice cream. It contains 25 alkaloids, with four responsible for most effects. Traditionally, leaves were chewed. Red vein kratom has the highest mitragynine content with strong opioid effects. Green strains are more associated with pain relief, while white strains fall in between.

How does it work?
Mitragynine binds to mu-opioid receptors, similar to morphine or heroin but in a slightly different manner. Naloxone (Narcan) may be less effective for kratom overdoses compared to traditional opioids.

How long does it work?
Effects begin within 1–2 hours, and the half-life is about 23 hours, so it may remain in the system for more than a day. Kratom does not appear on routine urine drug screens.

Side effects
Kratom decreases GI motility, leading to constipation and nausea. By affecting serotonin receptors, it can cause euphoria but also dizziness. Reported risks include liver injury, seizures, coma, lung or cardiac complications, and in pregnancy, neonatal withdrawal. Contamination with heavy metals or additives has also been documented. Physicians may be unaware of a patient’s use unless specifically disclosed.

Patterns of use
A local Reno physician notes that typical users are 20–40-year-old white males self-treating fentanyl or heroin dependence. Many spend large sums on kratom and may dose every hour to control symptoms.

Kratom use disorder and withdrawal
Stopping kratom can be difficult. Withdrawal begins 12–48 hours after cessation and lasts 1–3 days. Symptoms include aggression, irritability, restlessness, nervousness, mood swings, delusions, lethargy, insomnia, hot flashes, GI upset, hepatitis, and cardiac arrhythmias. Some patients require hospital admission for safe withdrawal. Always tell your doctor if you use kratom—include the dose, frequency, and duration.

Important note
Kratom should not be used to treat opioid withdrawal. Far safer and more effective medications exist to support recovery from opioid use disorder.