Kratom, controversy and harm reduction

February 2, 2016 10:23 AM

It's a legal, natural plant that has been used in Asian medicine for centuries. Indeed, a growing number of Americans are finding it to be a useful alternative to heroin and prescription pain relievers. But of course, there's a catch. Like the opioid drugs it is used to replace, this stuff can be addictive, and it can also cause serious nausea. Unlike other opioids, however, it seems to have an extremely low overdose risk, which has caught the eye of people working to fight the record high level of overdose deaths. It's called kratom. MeFi's Own Maia Szalavitz for Vice News.

Recent coverage in the New York Times and elsewhere has focused on it primarily as a drug of abuse. As a result, kratom may soon be prohibited, rather than properly studied. The data so far, however, suggests that banning it might do more harm than good— and that new more flexible ways of regulating drugs may be needed in order to truly protect the public.

posted by porn in the woods (32 comments total)

Heroin was originally a "replacement drug" for morphine, right?
posted by Halloween Jack at 10:32 AM on February 2, 2016 [1 favorite]

I would certainly like it to be studied, but since it can't be patented and profited, it won't be.
posted by SecretAgentSockpuppet at 10:40 AM on February 2, 2016 [3 favorites]

My understanding is that the majority of the current opioid epidemic is driven by two things:

* Lack of other effective options for managing chronic pain
* Really, really awful withdrawal effects

Seems to me like kratom should at least be studied for its effectiveness in pain management, because there's a strong need for a safer alternative to the oxy family. Marijuana, of course, is already a promising option for that purpose, but it couldn't hurt to expand the pharmacopeia to include something that might be better at handling more severe forms of chronic pain.
posted by tobascodagama at 10:56 AM on February 2, 2016 [1 favorite]

I would certainly like it to be studied, but since it can't be patented and profited, it won't be.
Get it into the hands of the supplement industry with vague promises about reducing pain and you're good to go.

How addictive/harmful is this compared to maintenance medications? If less or equally so, that's fantastic. (An the anecdotes seem to promote this, while acknowledging anecdotes are not data.)
posted by Hactar at 11:32 AM on February 2, 2016

the current opioid epidemic is driven by two things

The epidemic is driven by the post-industrialized and post-globalisation economies leaving large portions out of decent work and prospects. Drug addiction in people with chronic pain is certainly an issue, but the people that turn to opiates and meth because of societal pain rather than physical pain are huge drivers of what we think of as the opiate epidemic, and they'll need a societal rather than chemical fix in the long run.
posted by Candleman at 11:34 AM on February 2, 2016 [29 favorites]

I can't speak to public health implications, but it freaks me out that something so potentially dangerous to addicts is available so readily at our local tea house.

Hate to break it to you but there's a guy out back behind the tea house selling heroin.
posted by atoxyl at 11:35 AM on February 2, 2016 [11 favorites]

If kratom were a newly developed synthetic addiction medication, no one would dream of allowing it on the market without clinical testing. But because it's a supplement with a long history of use in herbal medicine, the rules are different.

And there's the rub. Letting products stay on the shelves because they're "herbal" and thus grandfathered in is a really spectacularly bad fucking idea. Just because it's derived from a plant doesn't mean it's safe. (c.f. the coca leaf or hemlock) You would be amazed at the number of over-the-counter products that have horrifying side effects, or are contraindicated with scores of prescription medicines, but that people merrily keep taking because folk wisdom. The FDA could probably do something about it, if they weren't horribly underfunded and subject to political football.
posted by Mayor West at 11:52 AM on February 2, 2016 [9 favorites]

Yeah, a friend of mine was really into this stuff. Took it pretty regularly. I tried it once. Thought to myself, "Yup, it's like Vicodin." Turned to my friend and was like, "You know they're going to make this illegal, right?" He didn't seem concerned for whatever reason. But yeah, I could only assume this stuff would be habit-forming. Dunno what my friend was thinking, but I for one wouldn't want to get hooked on something that was bound to be made illegal.
posted by panama joe at 12:01 PM on February 2, 2016

I would certainly like it to be studied, but since it can't be patented and profited, it won't be.

Well, no shit. What company is going to spend the $1billion USD to get it to market, just to let any asshole sell it?
posted by sideshow at 12:09 PM on February 2, 2016

But procuring a psychoactive substance from any of those black-gray market venues takes a tiny bit more effort--and forfeits your plausible deniability

Effort, AKA risk of arrest. Thanks.

Sorry I'll drop the snark I have some personal investment in the general issue if it wasn't clear. I don't think experienced opioid users are likely to be impressed by Kratom at head shop/herb shop prices. I was not. It might be a better deal in Internet bulk but I see it more being a comedown/maintenance drug for people who've had the good shit. Might it be an early step toward classical opioids for some people? Sure but lots of things are.

I would be a little worried about the people who do cultivate a full-time Kratom habit 'cause I don't know that anyone knows it's safe to take an ounce of it a day you know? Like with the guys eating six packs of Imodium a day to get through WDs.
posted by atoxyl at 12:20 PM on February 2, 2016 [1 favorite]

As long as the medical profession as a whole, and especially the all too aptly named 'pain clinics', persist in their absolute refusal to treat patients suffering from chronic pain conditions as anything other than wheedling junkies, there will be a market for -- and indeed a crying need for -- things like kratom.

Only recently have doctors begun to prescribe adequate pain medication for terminal cancer patients, for God's sake, and they had to shamed into it at that.
posted by jamjam at 12:28 PM on February 2, 2016 [10 favorites]

Don't forget clinical depression. A member of my family is on a couple anti-depressants and they still don't quite do the job. But a couple glasses of wine or vodka sours level her out. Medical marijuana is not legal is this state so that's out. We had talked about kratom and frankly are quite relieved we never pulled the trigger.
posted by Ber at 12:32 PM on February 2, 2016 [1 favorite]

As someone who has long used a low level of opiate for pain relief (through my doctor), I am incredibly frustrated that "potential for abuse" is so often prioritized above treating people. My life has been dramatically improved, and without any obvious problems/side-effects (I have stayed at the same level for a long time, it makes me able to work, etc). Its gotten much more annoying to actually get/fill prescriptions recently (doctor has to give me a physical prescription every time, no refills, etc) thanks to worry about abuse. And many people have trouble getting the prescription in the first place. Hydrocodone works _really well_.

Which is not to say there is no abuse, but the drug war has proven (to me at least) that you're _always_ going to have abuse, so shutting out legitimate medical use doesn't help anyone. Americans would rather err on the side of people being in pain.
posted by thefoxgod at 1:36 PM on February 2, 2016 [19 favorites]

Heroin was originally a "replacement drug" for morphine, right?

Yeah, there was massive abuse of morphine and Bayer AG sought to create an opioid (for the treatment of pain and as a cough suppressant - there was a lot of coal smog and tuberculosis in Victorian times) with less addictive potential.

Their initial idea was to acetylate codeine (the acetylation of salicylic acid by Bayer AG in 1897, a year before marketing heroin, created aspirin - which was just as effective as salicylic acid but had less intestinal tract side effects) to make a better cough suppressant (antitussive).

The active ingredients in opium are primarily morphine and codeine. Morphine was really popular because (well, aside from that it's abusable) it's a purified substance so exact doses can be given, whereas with opium it was more of a crap shoot, it being a fairly minimally processed plant extract. The invention of the hypodermic needle also helped the popularity of morphine, which is injectable whereas opium was eaten, smoked, or when dissolved in alcohol (laudanum) used as a drink or tincture.

However, I don't know if Bayer ended up making acetylcodeine, but acetylcodeine is a major contaminant in poorly made black-market heroin. Acetylcodeine is less good than codeine or morphine and was just as toxic as morphine. Small amounts mixed with morphine makes the preparation much more toxic (causes convulsions at much lower doses than pure morphine or pure heroin; the contamination by acetylcodeine is a significant etiology behind overdose deaths, the other being heroin of higher-than-expected purity and heroin cut with other drugs).

Heroin is diacetylmorphine, morphine with two acetyl additions, turned out to be more than twice as effective than morphine for analgesia and about ten times better as an antitussive. It was heavily marketed as a safer and less addictive substance than morphine.

The bigwigs at Bayer were so excited by heroin (named after the German word heroisch: "heroic, strong") that they almost gave up on aspirin thinking that they had a blockbuster and didn't need aspirin (economically).
posted by porpoise at 2:26 PM on February 2, 2016 [12 favorites]

Hydrocodone works _really well_.


I recently used it after gum surgery and it was fab. I felt nothing but mild discomfort.
posted by thelonius at 2:37 PM on February 2, 2016 [1 favorite]

NYT: Some deaths in the United States have resulted from kratom’s being laced with the prescription pain reliever hydrocodone or morphine.

I don't buy this for a minute. No drug dealer laces inexpensive drugs with more expensive ones.
posted by porn in the woods at 2:46 PM on February 2, 2016 [17 favorites]

I don't believe in prohibition. Legalize all drugs - or at least decriminalize them - and treat addiction as a health issue calling for rehab, not a criminal issue calling for arrests and prisons. The original Prohibition didn't do anyone except organized crime any good, and I don't see how modern day prohibition does any good now.
posted by Rosie M. Banks at 2:49 PM on February 2, 2016 [5 favorites]

I take kratom occasionally, and it gives me a mild, pleasant buzz, not unlike a glass or two of wine but without the motor impairment. It's not even in the same ballpark as cannabis, so I'm surprised to see it being compared to heroin. But then, I've found that any dose over a teaspoonful risks triggering a debilitating headache, so I couldn't take an ounce a day even if I tried. Maybe other people are immune to that particular side effect. In any case, if "it's addictive" is a reason for banning things, let's start by banning coffee and gasoline.
posted by zeri at 3:10 PM on February 2, 2016 [4 favorites]

The FDA has the authority to prohibit sales of any supplement it designates as a public health risk, and does so with some regularity (e.g., playing whack-a-mole with sketchy body-building supplements). Otherwise supplements are completely outside of their authority. Rigorous testing of all supplements for safety would be ideal but is totally unfeasible.

If the rules for prescription drugs were applied to supplements then every formulation would have to be tested individually in clinical trials, or at least proven bioequivalent to a previously-approved formulation. That's every individual product from every individual manufacturer. It would cost hundreds of billions (if not trillions) of dollars and take decades even with a massively-expanded FDA. GMP rules for prescription drugs are also much more strict, so even after approval, manufacturing costs would be greatly increased. Then you can look forward to $400/bottle melatonin. Not to mention a total clusterfuck of patent wars.

There is surely a middle path, but it would require an entirely new regulatory framework. That is extremely unlikely to happen. Congress has been at war with the FDA over dietary supplements for well over 50 years now. The FDA periodically tries to expand its authority in this area and each time congress responds with new legislation to block it. This was going on long before anti-government zealots filled congress and long before supplements became a multibillion dollar industry. The probability of it happening in the present political climate is somewhere between zero and a number which closely approximates zero.

So a supplement can either be totally unsafe for consumption or the regulatory equivalent of ¯\_(ツ)_/¯.
posted by dephlogisticated at 3:47 PM on February 2, 2016 [2 favorites]

I discovered kratom many, many years ago--long before it became fashionable. I am an addict now in recovery. Withdrawals from kratom are just as bad as any traditional opiate. As I like to say to my also-in-recovery friends who are curious about kratom: All the downside of regular opiates with virtually zero upside. This is by no means a dangerous substance by itself, but as an addict it always brought me back to my drug of choice, and therefore I had to come to see it as what it is: just another drug I can't touch.
posted by eggman at 4:03 PM on February 2, 2016 [8 favorites]

I have lupus, and thought about trying kratom to replace my occasional use of hydrocodone, but was told by a chemist friend in London that the liver metabolism issues in conjunction with the lupus drugs I've recently been given would probably make it fatal, and I should just learn to live with American doctors treating me like a junkie because I take 10mg of hydrocodone a few times a week.

I've decided I'm just going to move to a state with a rational marijuana policy.
posted by SecretAgentSockpuppet at 5:10 PM on February 2, 2016 [3 favorites]

As long as the medical profession as a whole, and especially the all too aptly named 'pain clinics', persist in their absolute refusal to treat patients suffering from chronic pain conditions as anything other than wheedling junkies, there will be a market for -- and indeed a crying need for -- things like kratom.

Yes, this is what I was getting at. Heroin and meth users take their shit because they have some kind of hole in their life they need to fill with drugs. Oxy and vicodin users take their shit because they hurt. It's important to make the distinction, because you address those two root causes very differently.
posted by tobascodagama at 6:30 PM on February 2, 2016 [2 favorites]

Heroin and meth users take their shit because they have some kind of hole in their life they need to fill with drugs. Oxy and vicodin users take their shit because they hurt.

How do you figure that exactly? Meth is not an opioid but the rest of those I assure you people take for any of the above reasons, and more. And a lot of people who start with pills eventually end up switching to heroin because it's far less expensive.
posted by atoxyl at 7:26 PM on February 2, 2016 [2 favorites]

Heroin and meth users take their shit because they have some kind of hole in their life they need to fill with drugs. Oxy and vicodin users take their shit because they hurt.

You might find the book Dreamland informative or some other resources on perscription drug abuse.

It's far more complicated than saying good people take certain opiates and bad people take others.
posted by Candleman at 9:11 PM on February 2, 2016 [3 favorites]

Thanks so much for posting my article!!!

What I find weird is that people get fixated on the abuse potential and the physical dependence while missing a key point: kratom has been taken for hundreds of years without causing an overdose problem.

With a market full of heroin and prescription opioids, a substitute that is extremely hard to OD on is not something you should pull from the shelves, even though it would obviously be better to have clinical trials done first to see if there are other long term issues.

As for people in recovery, give me a break: if you are into 12-step abstinence and you are messing around with teas and powders that are clearly intended (no matter what the label says) to give you a high and/or opioid-like pain relief, you have *already* relapsed. Why would you take kratom if you are in recovery? Take some responsibility and don't blame this for "leading you back"— once you decide to mess around with chemical consciousness-alteration of any sort, from the 12 step perspective, as any sponsor will tell you, you have already slipped.

And I say this as a former heroin and cocaine addict myself. It is really not fair for people like us to deny other people pain relief and harm reduction because we want to pretend we're not relapsing.
posted by Maias at 6:03 AM on February 3, 2016 [12 favorites]

A friend uses kratom to help them through overnight shifts in a hospital. They shared some with me after a night of drinking to help with hangover. Powdered kratom isn't water soluble and tastes disgusting and sticks in your teeth. It also gave me a really mellow high and energetic feeling, similar to smoking pot, but much more clear headed.

It seems like if kratom has the potential to supplement or even replace opioid pain killers, that's a good thing. If some one is going to be addicted to opioids, not overdosing is a good thing. Some one, somewhere is going to be addicted to something whether that's kratom, or heroin, internet, food, etc.
posted by BooneTheCowboyToy at 6:24 AM on February 3, 2016 [2 favorites]

It's far more complicated than saying good people take certain opiates and bad people take others.

Good people don't ever have emotional voids they can't fill? I'm not making a value judgment at all, I'm just pointing out that different drugs are attractive to different people for different reasons. One of the major reasons people get addicted to opiates -- particularly prescription opiates -- is that they have chronic pain that can't be managed any other way. Given that fact, it seems immoral not to study alternative painkillers. It's not rocket science.
posted by tobascodagama at 6:44 AM on February 3, 2016

Tried it a few times. I too found that it gave me a pleasant, mild high and woke me up more effectively and for a longer period of time than eg coffee or Red Bull. Ran out months ago and never replaced it because meh, but then again I made a point of consuming it no more than once every couple of weeks.
posted by 1adam12 at 7:40 AM on February 3, 2016

> Well, no shit. What company is going to spend the $1billion USD to get it to market, just to let any asshole sell it?

That's an indictment of capitalism if ever I heard one. People are hurting. Not "ow I got a boo-boo" but debilitating, life-destroying pain, all day, and everyday, but some schmuck like Martin Shkreli can't make a buck to buy a second yacht with, so sucks for the millions that have chronic pain?

Not that this would ever work, but the FDA could grant a company that takes this gamble exclusive use of a substance for, oh, I don't know, 14 years, later extendible to 20 years by an act of Congress.

The narrative of how drugs get onto pharmacy shelves is slowly changing from one of a genius scientist slaving away until they excitedly yells Eureka! to a narrative that centers on business entangled with the FDA and their regulation and oversight. In that business focused narrative, it seems desirable for patent law to be changed to include a ceiling dollar amount that can be made off a patent.

Barring any constitutional changes to patent law, any doctor-scientist-lawyers want to launch a Kickstarter instead?

> There is surely a middle path, but it would require an entirely new regulatory framework. That is extremely unlikely to happen. Congress has been at war with the FDA over dietary supplements for well over 50 years now.

You're right, but I'm hopeful that culture changes will force a workable middle ground of which there are a few specific factors involved that I'd like to point out.

Increased access to doctors thanks to Obamacare, along with access to a doctor via videophone over the Internet. You should be telling your doctor things they should know, like drinking kratom extract tea to alleviate pain.

The stigma of buying illegal drugs off the internet will fade with time, like how finding a date off the Internet is just "how it's done" now. Cheaper at-home testing that previously required a lab to perform is also important for removing that stigma. Being able to prove "kratom extract" bought off the internet isn't just crushed up oxy goes a long way towards legitimizing its use.

Heart rate monitors are slowly becoming commonplace. Ostensibly for measuring heart rate while exercising, but they do just as well to measure heart rate while high and using that to decide when to take the next dose. This helps a user monitor their intake, including graphs that can be referenced later.

Culturally, I think those add up and are multiplied by the Internet so that there's information, beyond anecdotes on Bluelight and Erowid, so as to be able to suggest certain substances are actually fairly safe, even if the FDA won't (and shouldn't) say something officially.

Hopefully the reverse would also be true, and the FDA would step in when it looks like something is dangerous, and do further studies, banning it if warranted, like they managed to do with ephedra, despite industry lobbying.
posted by fragmede at 10:20 AM on February 3, 2016

Good people don't ever have emotional voids they can't fill? I'm not making a value judgment at all, I'm just pointing out that different drugs are attractive to different people for different reasons. One of the major reasons people get addicted to opiates -- particularly prescription opiates -- is that they have chronic pain that can't be managed any other way. Given that fact, it seems immoral not to study alternative painkillers. It's not rocket science.

I realized you didn't mean to make a value judgement it's just misleading to classify heroin users apart from other opioid users.
posted by atoxyl at 11:39 AM on February 3, 2016

I have been curious about kratom. It's been banned in my home state because of serious nanny stating by republicans that swear they hate the nanny state. I have chronic pain that is at times severe. I take a fairly mild opiate and it only works some of the time. I've definitely built up a tolerance. The thing is, have such a weird metabolism that opiates and opiods are really rough on me. I've had this confirmed through genetic testing; I'm not making it up, my body really does have trouble metabolizing a number of medications.

I don't want to go on a stronger opiate and my doctor doesn't want me to either (which I am okay with. The "new" analgesics with miserable results. Paradoxical results in some cases. (Ever want a doctor to not believe you? Tell them that their pain killer made the pain worse. Shesh, that was a long fight and I still get the side eye.)

I don't want to say pot doesn't help, but it doesn't help for long enough and I hate feeling high. I have to smoke enough to be high all the time to have any relief (it provides extremely short lived relief.) and yes, I do realize there are many interesting strains that might be better for pain- but I'm not in a state where that is possible to explore, and street weed is just whatever someone can get.

I haven't a clue of kratom would help. But I'd like the option to try. Anything that might restore some function would be a good thing in my book. And if it doesn't, then I'd know. I'd like to at least have the option to find out.
posted by [insert clever name here] at 11:05 AM on February 4, 2016 [1 favorite]

Another Vice piece from Szalavitz: Why Isn't America Doing the One Thing That Would Reduce Heroin Deaths Right Now?
posted by homunculus at 6:23 PM on February 11, 2016