Kratom Is an Opioid, Doctor Argues

— Severe kratom addiction can resemble heroin or fentanyl addiction, expert says

Kratom is often described as a botanical substance with opioid-like effects, but Andrew Kolodny, MD, argues that framing downplays what clinicians are increasingly seeing in practice.

In a recent guest editorial in the Journal of Clinical Psychopharmacologyopens in a new tab or window, Kolodny, of Brandeis University's Opioid Policy Research Collaborative in Waltham, Massachusetts, and Christopher P. Holstege, MD, of the University of Virginia School of Medicine in Charlottesville, argued that kratom should be classified as an opioid rather than merely an opioid-like substance.

In this installment of "Off the 'Page," MedPage Today's video series exploring thought-provoking perspectives in medicine, Kolodny discusses what he is seeing in patients, how kratom addiction is being treated, and why he believes the language clinicians use to describe the substance matters.

The following is a transcript of this video:

For the patients who've been consuming substantial amounts of mitragynine or the semisynthetic kratom opioidsopens in a new tab or window, those patients clinically look no different from patients who I've treated who've been addicted to oxycodone or heroin or fentanyl.

A little over a year ago, I went back to clinical practice after taking a break to focus on research and teaching. And when I went back to clinical practice, I was surprised to see that just about every patient I'd come across who had become newly opioid addicted, became addicted taking kratom. And some had transitioned from kratom leaf products to more potent semisynthetic kratom products, but almost everyone who had newly become addicted was [with] kratom.

And so I began calling colleagues who do addiction work in other parts of the country and learned that they're really seeing the same thing, this sharp increase in addiction involving kratom. I went to the medical literature to learn more about kratom and was surprised to see that it was routinely characterized as a botanical substance with stimulant-like effects in low doses and opioid-like effects at higher doses. And of course, the implication there, if you're saying it's like an opioid is that it's not an opioid, that it mimics the effects of an opioid, which isn't at all true.

Routinely, these patients are being treated with buprenorphine. I'd like to think that there are many people addicted to kratom products who can recover without using buprenorphine. And I think that may be true for people with a shorter duration of being addicted to kratom or maybe using lower doses of kratom. But the withdrawal that these patients were experiencing when they tried to come off of kratom was so severe and the impact on their lives from their addiction to kratom was so substantial, the negative impact, that these patients really looked no different.

It really does feel like history is repeating itself. The opioid crisis began with this multifaceted campaign by opioid manufacturers, in particular Purdue Pharma, with this message that opioids rarely cause addiction and we could use them long term and that's the compassionate way to treat just about any complaint of pain. And of course, we know that that campaign had an impact -- prescribing took off and it led to an epidemic of opioid addiction.

We're seeing the kratom industry really use many of the same tactics. Although, with a little bit of a difference, the kratom industry isn't saying that kratom is a safer opioid. They're actually promoting kratom as a non-opioid. They're saying it's a non-opioid, that it's non-addictive, that it's a safe alternative.

I mentioned that when you read about kratom in the medical literature, when you hear doctors, experts, even well-intended experts who have no ties to the kratom industry at all, when you hear them describe kratom, they just sort of routinely almost out of reflex describe it as having stimulant-like effects in low doses and opioid-like effects in high doses, as if it's not an opioid and has these unique properties.

In reality, opioids have a stimulating effect often in a lower dose that's not at all unique to kratom. So, I think that surprises many people. We think of opioids as being sedating, but actually lower doses of opioids do have a stimulating effect that isn't unique to kratom. And again, it is not an opioid-like drug, it's an opioid.