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Kratom from Head to Toe—Case Reviews of Adverse Events and Toxicities. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00194-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Purpose of Review
This review describes case reports for patients with kratom-associated adverse events in order to assist clinicians with patient management. A stepwise approach is proposed for assessing active kratom users as well as considerations for the management of toxicities or withdrawal.
Recent Findings
Multiple in vitro and in vivo studies illustrate the pharmacologic and toxicologic effects of kratom extract. No randomized controlled trials in humans exist that assess the safety and efficacy of the substance. Cross-sectional surveys from active users and reports from poison control centers have shown acute and chronic physiological and psychological adverse events.
Summary
Reports of adverse effects associated with kratom use have demonstrated hypothyroidism, hypogonadism, hepatitis, acute respiratory distress syndrome, posterior reversible encephalopathy syndrome, seizure, and coma. Overdose toxidrome leads to respiratory failure, cardiac arrest, and fatalities. Adult and neonatal withdrawal symptoms have also occurred. Clinicians should be aware of the risks and benefits of kratom use.
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252
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Peckham EJ, Cooper K, Roberts ER, Agrawal A, Brabyn S, Tew G. Homeopathy for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2019; 9:CD009710. [PMID: 31483486 PMCID: PMC6724562 DOI: 10.1002/14651858.cd009710.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a common, chronic disorder that leads to decreased health-related quality of life and work productivity. A previous version of this review was not able to draw firm conclusions about the effectiveness of homeopathic treatment for IBS and recommended that further high quality RCTs were conducted to explore the clinical and cost effectiveness of homeopathic treatment for IBS. Two types of homeopathic treatment were evaluated in this systematic review: 1. Clinical homeopathy where a specific remedy is prescribed for a specific condition; 2. Individualised homeopathic treatment, where a homeopathic remedy based on a person's individual symptoms is prescribed after a detailed consultation. OBJECTIVES To assess the effectiveness and safety of homeopathic treatment for IBS. SEARCH METHODS For this update we searched MEDLINE, CENTRAL, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), the Cochrane IBD Group Specialised Register and trials registers from inception to 31 August 2018. SELECTION CRITERIA Randomised controlled trials (RCTs), cohort and case-control studies that compared homeopathic treatment with placebo, other control treatments, or usual care, in adults with IBS were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data. The primary outcome was global improvement in IBS as measured by an IBS symptom severity score. Secondary outcomes included quality of life, abdominal pain, stool frequency, stool consistency, and adverse events. The overall certainty of the evidence supporting the primary and secondary outcomes was assessed using the GRADE criteria. We used the Cochrane risk of bias tool to assess risk of bias. We calculated the mean difference (MD) and 95% confidence interval (CI) for continuous outcomes and the risk ratio (RR) and 95% CI for dichotomous outcomes. MAIN RESULTS Four RCTs (307 participants) were included. Two studies compared clinical homeopathy (homeopathic remedy, asafoetida or asafoetida plus nux vomica) to placebo for IBS with constipation (IBS-C). One study compared individualised homeopathic treatment (consultation plus remedy) to usual care for the treatment of IBS in female patients. One study was a three armed RCT comparing individualised homeopathic treatment to supportive listening or usual care. The risk of bias in three studies (the two studies assessing clinical homeopathy and the study comparing individualised homeopathic treatment to usual care) was unclear on most criteria and high for selective reporting in one of the clinical homeopathy studies. The three armed study comparing individualised homeopathic treatment to usual care and supportive listening was at low risk of bias in four of the domains and high risk of bias in two (performance bias and detection bias).A meta-analysis of the studies assessing clinical homeopathy, (171 participants with IBS-C) was conducted. At short-term follow-up of two weeks, global improvement in symptoms was experienced by 73% (46/63) of asafoetida participants compared to 45% (30/66) of placebo participants (RR 1.61, 95% CI 1.18 to 2.18; 2 studies, very low certainty evidence). In the other clinical homeopathy study at two weeks, 68% (13/19) of those in the asafoetida plus nux vomica arm and 52% (12/23) of those in the placebo arm experienced a global improvement in symptoms (RR 1.31, 95% CI 0.80 to 2.15; very low certainty evidence). In the study comparing individualised homeopathic treatment to usual care (N = 20), the mean global improvement score (feeling unwell) at 12 weeks was 1.44 + 4.55 (n = 9) in the individualised homeopathic treatment arm compared to 1.41 + 1.97 (n=11) in the usual care arm (MD 0.03; 95% CI -3.16 to 3.22; very low certainty evidence).In the study comparing individualised homeopathic treatment to usual care, the mean IBS symptom severity score at 6 months was 210.44 + 112.4 (n = 16) in the individualised homeopathic treatment arm compared to 237.3 + 110.22 (n = 60) in the usual care arm (MD -26.86, 95% CI -88.59 to 34.87; low certainty evidence). The mean quality of life score (EQ-5D) at 6 months in homeopathy participants was 69.07 (SD 17.35) compared to 63.41 (SD 23.31) in usual care participants (MD 5.66, 95% CI -4.69 to 16.01; low certainty evidence).For In the study comparing individualised homeopathic treatment to supportive listening, the mean IBS symptom severity score at 6 months was 210.44 + 112.4 (n = 16) in the individualised homeopathic treatment arm compared to 262 + 120.72 (n = 18) in the supportive listening arm (MD -51.56, 95% CI -129.94 to 26.82; very low certainty evidence). The mean quality of life score at 6 months in homeopathy participants was 69.07 (SD 17.35) compared to 63.09 (SD 24.38) in supportive listening participants (MD 5.98, 95% CI -8.13 to 20.09; very low certainty evidence).None of the included studies reported on abdominal pain, stool frequency, stool consistency, or adverse events. AUTHORS' CONCLUSIONS The results for the outcomes assessed in this review are uncertain. Thus no firm conclusions regarding the effectiveness and safety of homeopathy for the treatment of IBS can be drawn. Further high quality, adequately powered RCTs are required to assess the efficacy and safety of clinical and individualised homeopathy for IBS compared to placebo or usual care.
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Affiliation(s)
- Emily J Peckham
- University of YorkDepartment of Health SciencesHeslingtonYork‐ None ‐UKY010 5DD
| | - Katy Cooper
- University of SheffieldSchool of Health and Related Research (ScHARR)Regent Court30 Regent StreetSheffieldUKS1 4DA
| | - E Rachel Roberts
- Homeopathy Research Institute39 Great Windmill StreetLondonWalesUKW1D 7LX
| | - Anurag Agrawal
- Doncaster Royal InfirmaryDepartment of Gastroenterology and MedicineArmthorpe RoadDoncasterUKDN2 5LT
| | - Sally Brabyn
- University of YorkDepartment of Health SciencesHeslingtonYork‐ None ‐UKY010 5DD
| | - Garry Tew
- Northumbria UniversityDepartment of Sport, Exercise and RehabilitationNewcastle Upon TyneUK
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253
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Coe MA, Pillitteri JL, Sembower MA, Gerlach KK, Henningfield JE. Kratom as a substitute for opioids: Results from an online survey. Drug Alcohol Depend 2019; 202:24-32. [PMID: 31284119 DOI: 10.1016/j.drugalcdep.2019.05.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Kratom is a South Eastern Asian tree whose leaves are used to make tea-like brews or swallowed in powdered form for various health and well-being reasons including to relieve pain and opioid withdrawal. It is important to learn more about the potential public health impact of kratom in the context of the opioid epidemic. METHODS An anonymous online survey of kratom users (2867 current users and 157 former users) was conducted in September 2017 through the American Kratom Association and associated social media sites. RESULTS Kratom was used primarily to relieve pain (endorsed by 48% of respondents), for anxiety, PTSD, or depression (22%), to increase energy or focus (10%) and to help cut down on opioid use and/or relieve withdrawal (10%). Over 90% of respondents who used it in place of opioids indicated that it was helpful to relieve pain, reduce opioid use, and relieve withdrawal. The reported incidence of bad adverse reactions was 13%, and reactions were overwhelmingly mild and self-managed. CONCLUSIONS Respondents reported using kratom for conditions which often require use of opioids, including pain and reduction of opioid use. The high self-reported efficacy and low incidence of adverse reactions associated with kratom use suggest that it may provide a potential alternative to opioids for some persons even though it has not been evaluated in multi-center clinical trials or approved for any therapeutic purpose. Further study of kratom, including systematic characterization of its safety and efficacy for various conditions is warranted.
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Affiliation(s)
- Marion A Coe
- Research, Health Policy and Abuse Liability, Pinney Associates, Inc., 4800 Montgomery Lane, Suite 400, Bethesda, MD, 20814, USA.
| | - Janine L Pillitteri
- Pinney Associates, Inc., 201 North Craig Street, Suite 320, Pittsburgh, PA 15213, USA.
| | - Mark A Sembower
- Pinney Associates, Inc., 201 North Craig Street, Suite 320, Pittsburgh, PA 15213, USA.
| | - Karen K Gerlach
- Pinney Associates, Inc., 201 North Craig Street, Suite 320, Pittsburgh, PA 15213, USA.
| | - Jack E Henningfield
- Research, Health Policy and Abuse Liability, Pinney Associates, Inc., 4800 Montgomery Lane, Suite 400, Bethesda, MD, 20814, USA; Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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254
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Nicewonder JA, Buros AF, Veltri CA, Grundmann O. Distinct kratom user populations across the United States: A regional analysis based on an online survey. Hum Psychopharmacol 2019; 34:e2709. [PMID: 31347212 DOI: 10.1002/hup.2709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Kratom preparations have raised concerns of public health and safety in the United States. This paper analyzed the patterns and predictors of kratom use by four U.S. regions according to the U.S. Census. METHOD An anonymous cross-sectional online survey yielded 8,049 valid responses. The data were categorised by regions (Northeast, South, Midwest, and West) and analyzed for the following predictors: age, gender, marital status, ethnicity, employment status, insurance coverage, education, and household income. RESULTS After adjusting for state population, the survey response rates were highest from Oregon, Idaho, and Florida. Kratom use was significantly lower for both prescription drug dependency and acute or chronic pain in the Northeast region than the rest of the country. Multiple logistic regression models found that gender, employment, and education were significant on the regional level. Higher education was associated with lower kratom use for an illicit drug dependency (p = .002) independent of region whereas men were less likely to use kratom for acute or chronic pain in the Northeast (p < .001) but more likely in the Midwest (p = .041). CONCLUSIONS The regional pattern of kratom use differed from opioid use data in both demographics and trend direction warranting further investigation.
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Affiliation(s)
- Jessica A Nicewonder
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, Arizona, United States
| | - Amy F Buros
- Office of Research and Sponsored Programs, Midwestern University, Glendale, Arizona, United States
| | - Charles A Veltri
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, Arizona, United States
| | - Oliver Grundmann
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, Arizona, United States.,Department of Medicinal Chemistry, College of Pharmacy, University of Gainesville, Florida, United States
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255
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Corkery JM, Streete P, Claridge H, Goodair C, Papanti D, Orsolini L, Schifano F, Sikka K, Körber S, Hendricks A. Characteristics of deaths associated with kratom use. J Psychopharmacol 2019; 33:1102-1123. [PMID: 31429622 DOI: 10.1177/0269881119862530] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Kratom (Mitragyna speciosa Korth) use has increased in Western countries, with a rising number of associated deaths. There is growing debate about the involvement of kratom in these events. AIMS This study details the characteristics of such fatalities and provides a 'state-of-the-art' review. METHODS UK cases were identified from mortality registers by searching with the terms 'kratom', 'mitragynine', etc. Databases and online media were searched using these terms and 'death', 'fatal*', 'overdose', 'poisoning', etc. to identify additional cases; details were obtained from relevant officials. Case characteristics were extracted into an Excel spreadsheet, and analysed employing descriptive statistics and thematic analysis. RESULTS Typical case characteristics (n = 156): male (80%), mean age 32.3 years, White (100%), drug abuse history (95%); reasons for use included self-medication, recreation, relaxation, bodybuilding, and avoiding positive drug tests. Mitragynine alone was identified/implicated in 23% of cases. Poly substance use was common (87%), typically controlled/recreational drugs, therapeutic drugs, and alcohol. Death cause(s) included toxic effects of kratom ± other substances; underlying health issues. CONCLUSIONS These findings add substantially to the knowledge base on kratom-associated deaths; these need systematic, accurate recording. Kratom's safety profile remains only partially understood; toxic and fatal levels require quantification.
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Affiliation(s)
- John M Corkery
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield, UK
| | | | - Hugh Claridge
- National Programme on Substance Abuse Deaths, Population Health Research Institute, St George's, University of London, London, UK
| | - Christine Goodair
- National Programme on Substance Abuse Deaths, Population Health Research Institute, St George's, University of London, London, UK
| | - Duccio Papanti
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield, UK
| | - Laura Orsolini
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield, UK
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield, UK
| | - Kanav Sikka
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield, UK
| | - Sophie Körber
- Department of Pharmaceutical Science, University of Basel, Basel, Switzerland
| | - Amy Hendricks
- Retired Forensic Pathology Technician, Santa Clara County, CA, USA
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256
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Hemby SE, McIntosh S, Leon F, Cutler SJ, McCurdy CR. Abuse liability and therapeutic potential of the Mitragyna speciosa (kratom) alkaloids mitragynine and 7-hydroxymitragynine. Addict Biol 2019; 24:874-885. [PMID: 29949228 DOI: 10.1111/adb.12639] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/20/2018] [Accepted: 05/10/2018] [Indexed: 12/17/2022]
Abstract
Kratom, derived from the plant Mitragyna speciosa, is receiving increased attention as an alternative to traditional opiates and as a replacement therapy for opiate dependence. Mitragynine (MG) and 7-hydroxymitragynine (7-HMG) are major psychoactive constituents of kratom. While MG and 7-HMG share behavioral and analgesic properties with morphine, their reinforcing effects have not been examined to date. 7-HMG, but not MG, substituted for morphine self-administration in a dose-dependent manner in the rat self-administration paradigm. Following the substitution procedure, re-assessment of morphine self-administration revealed a significant increase following 7-HMG and a significant decrease following MG substitution. In a separate cohort, 7-HMG, but not MG, engendered and maintained intravenous self-administration in a dose-dependent manner. The effects of pretreatment with nalxonaxine (NLXZ), a μ1 opiate receptor antagonist, and naltrindole (NTI), a δ opiate receptor antagonist, on 7-HMG and morphine self-administration were also examined. Both NLXZ and NTI reduced 7-HMG self-administration, whereas only NLXZ decreased morphine intake. The present results are the first to demonstrate that 7-HMG is readily self-administered, and the reinforcing effects of 7-HMG are mediated in part by μ and δ opiate receptors. In addition, prior exposure to 7-HMG increased subsequent morphine intake whereas prior exposure to MG decreased morphine intake. The present findings indicate that MG does not have abuse potential and reduces morphine intake, desired characteristics of candidate pharmacotherapies for opiate addiction and withdrawal, whereas 7-HMG should be considered a kratom constituent with high abuse potential that may also increase the intake of other opiates.
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Affiliation(s)
- Scott E. Hemby
- Department of Basic Pharmaceutical Sciences, Fred Wilson School of Pharmacy; High Point University; High Point NC USA
| | - Scot McIntosh
- Department of Basic Pharmaceutical Sciences, Fred Wilson School of Pharmacy; High Point University; High Point NC USA
| | - Francisco Leon
- Department of Medicinal Chemistry, College of Pharmacy; University of Florida; Gainesville FL USA
| | | | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy; University of Florida; Gainesville FL USA
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257
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Carter T, Goldenberg JZ, Steel A. An examination of naturopathic treatment of non-specific gastrointestinal complaints: comparative analysis of two cases. Integr Med Res 2019; 8:209-215. [PMID: 31467841 PMCID: PMC6712490 DOI: 10.1016/j.imr.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 02/07/2023] Open
Abstract
Background Functional gastrointestinal disorders (FGID) affect more than one-third of the general population and contribute a considerable burden on the health and wellbeing of the community and the economy. This study aims to examine the treatment approaches and outcomes of naturopathic management of individuals presenting with a non-specific FGID. Methods We report a comparison of two clinical case studies of patients being treated by a naturopath for a functional gastrointestinal disorder. The care was provided by two different student practitioners under the supervision of an industry qualified mentor within a multidisciplinary academic clinic at the Endeavour College of Natural Health. A student practitioner and student observer conduct consultations under the supervision of an industry qualified mentor. The outcomes of care were measured by the Gastrointestinal Symptom Rating Scale. Results Clinical notations partially correlate to Jane's outcomes measured by gastrointestinal rating scale scores, which remain stable. Significant changes in Rona's gastrointestinal rating scale scores equate to only generalizable minimal clinical notations. Conclusions The holistic and individualised approach core to naturopathic medicine practice is also informed by traditional methods, research evidence and the pragmatic needs of the patient. The emphasis within naturopathic treatment approaches on dietary changes and lifestyle prescription alongside other ingestive therapies such as herbal and nutritional medicine underscores the need for clinical research designs which support evaluation of complex interventions in real-world settings.
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Affiliation(s)
- Tristan Carter
- Endeavour College of Natural Health, Brisbane, Queensland, Australia
| | - Joshua Z Goldenberg
- National University of Natural Medicine, Portland, Oregon, United States.,Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, Sydney, Australia
| | - Amie Steel
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, Sydney, Australia
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258
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Aldyab M, Ells PF, Bui R, Chapman TD, Lee H. Kratom-Induced Cholestatic Liver Injury Mimicking Anti-Mitochondrial Antibody-Negative Primary Biliary Cholangitis: A Case Report and Review of Literature. Gastroenterology Res 2019; 12:211-215. [PMID: 31523332 PMCID: PMC6731044 DOI: 10.14740/gr1204] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 07/31/2019] [Indexed: 12/11/2022] Open
Abstract
Kratom is an herbal supplement used to relieve chronic pain or opioid withdrawal symptoms. Recent news articles covering adverse effects associated with kratom use have brought attention to its organ toxicities. Reports of kratom-induced hepatic toxicity are limited and only three case reports of kratom-induced liver injury with histopathologic examination of the liver biopsies are available. A 40-year-old female presented with symptoms of mixed cholestatic and hepatocellular liver injury without clear etiology. The laboratory and imaging workup suggested possibilities of autoimmune hepatitis, autoimmune hepatitis-primary biliary cholangitis (PBC) overlap syndrome, or drug-induced liver injury. Autoantibodies including anti-mitochondrial antibody (AMA) were negative. Liver biopsy showed granulomatous hepatitis with prominent duct injury, suggestive of AMA-negative PBC. She subsequently was referred to a hepatologist and a history of recent kratom use was finally revealed. Kratom was discontinued and the symptoms improved. Kratom-induced hepatic toxicity may manifest with variable biochemical and clinical abnormalities. Histologically, it may mimic AMA-negative PBC. Our case highlights the importance of thorough history taking, interdisciplinary approach and communication for optimal patient care.
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Affiliation(s)
- Mahmoud Aldyab
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, NY 12208, USA
| | - Peter F Ells
- Gastroenterology, Albany Medical College, Albany, NY 12208, USA
| | - Rosa Bui
- Gastroenterology, Albany Medical College, Albany, NY 12208, USA
| | | | - Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, NY 12208, USA
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259
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Cowan AF, Elkins KM. Detection and Identification of Kratom (Mitragyna speciosa) and Marijuana (Cannabis sativa) by a Real-Time Polymerase Chain Reaction High-Resolution Melt Duplex Assay . J Forensic Sci 2019; 65:52-60. [PMID: 31433500 DOI: 10.1111/1556-4029.14167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/12/2019] [Accepted: 07/29/2019] [Indexed: 02/05/2023]
Abstract
Mitragyna speciosa (MS), a plant commonly known as kratom, is a widely used "legal high" opiate alternative for pain relief. DNA extracted from MS and 26 additional plant species was amplified by PCR using primers targeting the strictosidine beta-D-glucosidase (SGD) and secologanin synthase 2 (SLS2) genes and detected by high-resolution melt curves using three intercalating dyes. Amplicon sizes were confirmed using agarose gel electrophoresis. The observed melt temperatures for SGD and SLS2 were 77.08 ± 0.38°C and 77.61 ± 0.46°C, respectively, using SYBR® Green I; 80.18 ± 0.27°C and 80.59 ± 0.08°C, respectively, using Radiant™ Green; and 82.19 ± 0.04°C and 82.62 ± 0.13°C, respectively, using the LCGreen® PLUS dye. The SLS2 primers demonstrated higher specificity and identified MS DNA at 0.05 ng/μL. In a duplex reaction, SLS2 and tetrahydrocannabinoic acid synthase gene primers detected and differentiated MS and Cannabis sativa (CS) by melt peaks at 82.63 ± 0.35°C and 85.58 ± 0.23°C, respectively, using LCGreen® PLUS.
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Affiliation(s)
- Ashley F Cowan
- Chemistry Department, Forensic Science Program, Towson University, 8000 York Rd, Towson, MD, 21252
| | - Kelly M Elkins
- Chemistry Department, Forensic Science Program, Towson University, 8000 York Rd, Towson, MD, 21252
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260
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Abdullah HMA, Haq I, Lamfers R. Cardiac arrest in a young healthy male patient secondary to kratom ingestion: is this 'legal high' substance more dangerous than initially thought ? BMJ Case Rep 2019; 12:e229778. [PMID: 31326902 PMCID: PMC6663180 DOI: 10.1136/bcr-2019-229778] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 12/17/2022] Open
Abstract
Kratom is a psychoactive herb that has stimulant properties at low doses and has opioid-like properties at higher doses. It has been used for centuries in southeast Asia as a stimulant but has gained increasing popularity as a substitute for opioids in western countries as it is easily available. As most cases of kratom use involve other drugs too, the Food and Drug Administration (FDA) has stopped short of restricting kratom due to difficulty in assessing the adverse effects of kratom alone. We present the case of a young healthy 35-year-old man who suffered a cardiac arrest due to kratom use with no other coingestants. He was subsequently intubated and found to have systolic dysfunction and small brain infarcts. Fortunately, he made a successful recovery and was discharged after a stay at thebehavioural health centre. Our case highlights the potential adverse effects of kratom and the need to regulate its use.
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Affiliation(s)
| | - Iqra Haq
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Randall Lamfers
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
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261
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Veltri C, Grundmann O. Current perspectives on the impact of Kratom use. Subst Abuse Rehabil 2019; 10:23-31. [PMID: 31308789 PMCID: PMC6612999 DOI: 10.2147/sar.s164261] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/07/2019] [Indexed: 12/15/2022] Open
Abstract
The leaves from the tree Mitragyna speciosa, commonly known as Kratom, in the coffee plant family (Rubiaceae) are commonly used in their native habitat of Southeast Asia as a stimulant to sustain energy during hard day labor and as an opioid-like analgesic and sedative. Traditional and modern uses overlap based on the effects of the leaf extract which has also gained popularity in the United States and Europe in the last two decades. Kratom has and is being used for the mitigation of opioid withdrawal symptoms and as a harm reduction agent with a minority of users subsequently developing a dependence on the extract. The respective demographic use patterns of Kratom differ between Southeast Asia and the Western world. While pure Kratom is primarily used by day laborers and misused in conjunction with cough medicine by youth in Southeast Asia, a majority of users in the United States is middle-aged, has at least middle income, private health insurance, and completed some college. Deaths attributed to the use of Kratom have been reported in Europe and the United States but not in Southeast Asia. Although Kratom was detected as the alkaloid mitragynine in the blood of the decedents, causality could not be established in almost all cases because of poly-drug exposures. It is notable that Kratom can cause herb–drug interactions, especially with other central nervous system -active substances. Given the mostly unregulated market for Kratom products in Western countries, consumers may be exposed to adulterated or contaminated products, especially if purchased through websites or the darknet. A number of countries have scheduled Kratom because of its stimulant- and opioid-like effects and the established interaction of the alkaloid mitragynine with opioid receptors.
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Affiliation(s)
- Charles Veltri
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, AZ 85308, USA
| | - Oliver Grundmann
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, AZ 85308, USA.,Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
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262
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Kruegel A, Uprety R, Grinnell SG, Langreck C, Pekarskaya EA, Le Rouzic V, Ansonoff M, Gassaway MM, Pintar JE, Pasternak GW, Javitch JA, Majumdar S, Sames D. 7-Hydroxymitragynine Is an Active Metabolite of Mitragynine and a Key Mediator of Its Analgesic Effects. ACS CENTRAL SCIENCE 2019; 5:992-1001. [PMID: 31263758 PMCID: PMC6598159 DOI: 10.1021/acscentsci.9b00141] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Indexed: 05/17/2023]
Abstract
Mitragyna speciosa, more commonly known as kratom, is a plant native to Southeast Asia, the leaves of which have been used traditionally as a stimulant, analgesic, and treatment for opioid addiction. Recently, growing use of the plant in the United States and concerns that kratom represents an uncontrolled drug with potential abuse liability, have highlighted the need for more careful study of its pharmacological activity. The major active alkaloid found in kratom, mitragynine, has been reported to have opioid agonist and analgesic activity in vitro and in animal models, consistent with the purported effects of kratom leaf in humans. However, preliminary research has provided some evidence that mitragynine and related compounds may act as atypical opioid agonists, inducing therapeutic effects such as analgesia, while limiting the negative side effects typical of classical opioids. Here we report evidence that an active metabolite plays an important role in mediating the analgesic effects of mitragynine. We find that mitragynine is converted in vitro in both mouse and human liver preparations to the much more potent mu-opioid receptor agonist 7-hydroxymitragynine and that this conversion is mediated by cytochrome P450 3A isoforms. Further, we show that 7-hydroxymitragynine is formed from mitragynine in mice and that brain concentrations of this metabolite are sufficient to explain most or all of the opioid-receptor-mediated analgesic activity of mitragynine. At the same time, mitragynine is found in the brains of mice at very high concentrations relative to its opioid receptor binding affinity, suggesting that it does not directly activate opioid receptors. The results presented here provide a metabolism-dependent mechanism for the analgesic effects of mitragynine and clarify the importance of route of administration for determining the activity of this compound. Further, they raise important questions about the interpretation of existing data on mitragynine and highlight critical areas for further research in animals and humans.
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Affiliation(s)
- Andrew
C. Kruegel
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
| | - Rajendra Uprety
- Department
of Neurology and Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
| | - Steven G. Grinnell
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
| | - Cory Langreck
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
| | - Elizabeth A. Pekarskaya
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
| | - Valerie Le Rouzic
- Department
of Neurology and Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
| | - Michael Ansonoff
- Department
of Neuroscience and Cell Biology, Rutgers
Robert Wood Johnson Medical School, Piscataway, New Jersey 08854, United States
| | - Madalee M. Gassaway
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
| | - John E. Pintar
- Department
of Neuroscience and Cell Biology, Rutgers
Robert Wood Johnson Medical School, Piscataway, New Jersey 08854, United States
| | - Gavril W. Pasternak
- Department
of Neurology and Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
| | - Jonathan A. Javitch
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
- Division
of Molecular Therapeutics, New York State
Psychiatric Institute, New York, New York 10032, United States
| | - Susruta Majumdar
- Department
of Neurology and Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
- Center
for Clinical Pharmacology, St. Louis College
of Pharmacy and Washington University School of Medicine, St. Louis, Missouri 63110, United States
| | - Dalibor Sames
- Department
of Chemistry, Department of Psychiatry, Department of Pharmacology, Department of Neuroscience, Columbia University, New York, New York 10027, United States
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263
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Spetea M, Schmidhammer H. Unveiling 7-Hydroxymitragynine as the Key Active Metabolite of Mitragynine and the Promise for Creating Novel Pain Relievers. ACS CENTRAL SCIENCE 2019; 5:936-938. [PMID: 31263752 PMCID: PMC6598155 DOI: 10.1021/acscentsci.9b00462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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264
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Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom Use and Toxicities in the United States. Pharmacotherapy 2019; 39:775-777. [PMID: 31099038 DOI: 10.1002/phar.2280] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Kratom is an herbal supplement containing alkaloids with opioid properties. This review was conducted to determine toxicities associated with kratom use in the United States in order to provide insight into its safety as a dietary supplement. METHODS We conducted a retrospective review of kratom exposures reported to the National Poison Data System to determine the toxicities associated with kratom use. We also reviewed records from a county medical examiner's office in New York State to identify kratom-associated fatalities. RESULTS A total of 2312 kratom exposures were reported, with 935 cases involving kratom as the only substance. Kratom most commonly caused agitation (18.6%), tachycardia (16.9%), drowsiness (13.6%), vomiting (11.2%), and confusion (8.1%). Serious effects of seizure (6.1%), withdrawal (6.1%), hallucinations (4.8%), respiratory depression (2.8%), coma (2.3%), and cardiac or respiratory arrest (0.6%) were also reported. Kratom was listed as a cause or contributing factor in the death of four decedents identified by the county medical examiner's office. CONCLUSIONS Kratom use is increasing and is associated with significant toxicities. Our findings suggest kratom is not reasonably expected to be safe and poses a public health threat due to its availability as an herbal supplement.
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Affiliation(s)
- William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York.,Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Robert Stoppacher
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York
| | - Kyle Suen
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Jeanna M Marraffa
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York.,Upstate New York Poison Center, Syracuse, New York
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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265
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Vermaire DJ, Skaer D, Tippets W. Kratom and General Anesthesia: A Case Report and Review of the Literature. A A Pract 2019; 12:103-105. [PMID: 30052532 DOI: 10.1213/xaa.0000000000000857] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Kratom is a botanical substance derived from the Mitragyna speciosa plant, which grows naturally in Southeast Asia. Its active compounds include alkaloids with psychoactive and opioid properties. Low doses act as a stimulant, while higher doses cause analgesia and euphoria. As a drug of abuse, there are reports of seizure, acute psychosis, and death. Both the US Food and Drug Administration and the Drug Enforcement Agency warn against the use of kratom. Here is the first reported case of an anesthetic in a patient using kratom for chronic pain.
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266
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Goh CF, Ong ET. Flipped classroom as an effective approach in enhancing student learning of a pharmacy course with a historically low student pass rate. CURRENTS IN PHARMACY TEACHING & LEARNING 2019; 11:621-629. [PMID: 31213319 DOI: 10.1016/j.cptl.2019.02.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/16/2019] [Accepted: 02/18/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND PURPOSE The flipped classroom has not been fully exploited to improve tertiary education in Malaysia. A transformation in pharmacy education using flipped classrooms will be pivotal to resolve poor academic performance in certain courses. This study aimed to investigate the effectiveness of the flipped classroom in improving student learning and academic performance in a course with a historically low pass rate. EDUCATIONAL ACTIVITY AND SETTING A quasi-experimental pre- and posttest control group design was employed. The experimental group experienced the flipped classroom for selected topics while the control group learned in a traditional classroom. Analysis of covariance was utilized to compare the performance on the final exam using the grade point of a pre-requisite course as the covariate. Students' perceptions of their experience in the flipped classroom were gauged through a web-based survey. FINDINGS Student performance on the final exam was significantly higher in the flipped classroom group. The lowest-scoring students benefitted the most in terms of academic performance. More than two-thirds of students responded positively to the use of the flipped classroom and felt more confident while participating in classes and tests. SUMMARY The flipped classroom is academically beneficial in a challenging course with a historically low pass rate; it was also effective in stimulating learning interest. The current study identified that for the flipped classroom to be successful, the role of educators, the feasibility of the approach, and the acceptance of students were important.
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Affiliation(s)
- Choon Fu Goh
- Discipline of Pharmaceutical Technology, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia.
| | - Eng Tek Ong
- Department of Educational Studies, Sultan Idris Education University, Proton City Campus, Tanjung Malim 35900, Perak, Malaysia.
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267
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Ya K, Tangamornsuksan W, Scholfield CN, Methaneethorn J, Lohitnavy M. Pharmacokinetics of mitragynine, a major analgesic alkaloid in kratom (Mitragyna speciosa): A systematic review. Asian J Psychiatr 2019; 43:73-82. [PMID: 31100603 DOI: 10.1016/j.ajp.2019.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/05/2019] [Accepted: 05/08/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Kratom (Mitragyna speciosa) is a tropical tree found in southern Thailand and northern states of the Malay Peninsula. Kratom is commercially available and used as an alternative to treat opioid withdrawal. Mitragynine is the major indole alkaloid found in kratom leaves. This review aimed to summarize available pharmacokinetic information about mitragynine. METHODS PubMed, Scopus, and Web of Science were systematically searched from their inceptions to June 2018. All types of pharmacokinetic studies of mitragynine were included for further systematic review. RESULTS Seventeen articles were reviewed. Mitragynine is a lipophilic weak base passively transported across the intestinal wall and blood brain barrier. 85-95% is bound to plasma protein and extensively metabolized by phase I and particularly phase II enzymes. Actions on CYP enzymes are unlikely to impact drug metabolism at concentrations likely to exist in kratom-consuming humans. In rats and humans, mitragynine is rapidly absorbed after orally administration (Tmax˜1.5 h, Cmax˜0.3-1.8 μM). Vd was 37-90 L/kg; t1/2 was 3-9 hr; mostly excreted as metabolites in urine. Bioavailability was estimated as 21%. It also rapidly penetrated and redistributed in brain. A quality assessment tool tailored for pharmacokinetic studies was also created which rated some studies of lower value. CONCLUSION Rudimentary pharmacokinetics of mitragynine was described in this systematic review. However, the discovered studies provided scant information on the role of metabolism and redistribution into tissues nor the rate of excretion.
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Affiliation(s)
- Kimheang Ya
- Center of Excellence for Environmental Health & Toxicology, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; Pharmacokinetic Research Unit, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Wimonchat Tangamornsuksan
- Faculty of Medicine and Public Health, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - C Norman Scholfield
- Center of Excellence for Environmental Health & Toxicology, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Janthima Methaneethorn
- Center of Excellence for Environmental Health & Toxicology, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; Pharmacokinetic Research Unit, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Manupat Lohitnavy
- Center of Excellence for Environmental Health & Toxicology, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; Pharmacokinetic Research Unit, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.
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268
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Matson M, Schenk N. Fatality of 33-Year-Old Man Involving Kratom Toxicity. J Forensic Sci 2019; 64:1933-1935. [PMID: 31121058 DOI: 10.1111/1556-4029.14082] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/22/2019] [Accepted: 04/29/2019] [Indexed: 11/29/2022]
Abstract
Kratom is an herbal product commonly used for its effects which are similar to opioids and stimulants. Few studies demonstrate the dangers and lethality of Kratom, and most fatalities from Kratom involve other abused substances. In the current case report, a 33-year-old white man with a known history of opioid abuse and mental illnesses was found unresponsive in his basement with no obvious signs of trauma. After resuscitative efforts, he was pronounced dead and taken for autopsy evaluation. Blood from the inferior vena cava was analyzed for common abused substances. The laboratory toxicology work-up revealed positive findings of caffeine, cotinine, and naloxone with low levels of Δ-9 tetrahydrocannabinol. However, a marked level of mitragynine at 1.9 mg/L was observed, the highest reported to date. Given the facts and evidence, the medical examiner certified the cause of death as "mitragynine toxicity" and the manner of death was classified as an "accident."
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Affiliation(s)
- Marcus Matson
- Kirksville College of Osteopathic Medicine, A.T. Still University, 800 West Jefferson Street, Kirksville, MO
| | - Noel Schenk
- Davis Behavioral Health, 934 South Main Street, #6, Layton, UT
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269
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Prozialeck WC, Avery BA, Boyer EW, Grundmann O, Henningfield JE, Kruegel AC, McMahon LR, McCurdy CR, Swogger MT, Veltri CA, Singh D. Kratom policy: The challenge of balancing therapeutic potential with public safety. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 70:70-77. [PMID: 31103778 PMCID: PMC7881941 DOI: 10.1016/j.drugpo.2019.05.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/01/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
Kratom (Mitragyna speciosa) is a tree-like plant indigenous to Southeast Asia. Its leaves, and the teas brewed from them have long been used by people in that region to stave off fatigue and to manage pain and opioid withdrawal. Evidence suggests kratom is being increasingly used by people in the United States and Europe for the self-management of opioid withdrawal and treatment of pain. Recent studies have confirmed that kratom and its chemical constituents have potentially useful pharmacological actions. However, there have also been increasing numbers of reports of adverse effects resulting from use of kratom products. In August 2016, the US Drug Enforcement Administration announced plans to classify kratom and its mitragynine constituents as Schedule I Controlled Substances, a move that triggered a massive response from pro-kratom advocates. The debate regarding the risks, and benefits and safety of kratom continues to intensify. Kratom proponents tout kratom as a safer and less addictive alternative to opioids for the management of pain and opioid addiction. The anti-kratom faction argues that kratom, itself, is a dangerous and addictive drug that ought to be banned. Given the widespread use of kratom and the extensive media attention it is receiving, it is important for physicians, scientists and policy makers to be knowledgeable about the subject. The purpose of this commentary is to update readers about recent developments and controversies in this rapidly evolving area. All of the authors are engaged in various aspects of kratom research and it is our intention to provide a fair and balanced overview that can form the basis for informed decisions on kratom policy. Our conclusions from these analyses are: (a) User reports and results of preclinical studies in animals strongly suggest that kratom and its main constituent alkaloid, mitragynine may have useful activity in alleviating pain and managing symptoms of opioid withdrawal, even though well-controlled clinical trials have yet to be done. (b) Even though kratom lacks many of the toxicities of classic opioids, there are legitimate concerns about the safety and lack of quality control of purported "kratom" products that are being sold in the US. (c) The issues regarding the safety and efficacy of kratom and its mitragynine constituent can only be resolved by additional research. Classification of the Mitragyna alkaloids as Schedule I controlled substances would substantially impede this important research on kratom.
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Affiliation(s)
- Walter C Prozialeck
- Department of Pharmacology, Midwestern University, 555 31st Street, Downers Grove, IL 60515, USA.
| | - Bonnie A Avery
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Edward W Boyer
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA.
| | - Jack E Henningfield
- Research, Health Policy and Abuse, Liability, Pinney Associates And Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 4800 Montgomery Lane, Suite 400, Bethesda, MD 20814, USA.
| | - Andrew C Kruegel
- Department of Chemistry, Columbia University, 3000 Broadway, New York, NY 10027, USA.
| | - Lance R McMahon
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA.
| | - Christopher R McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA.
| | - Marc T Swogger
- Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Blvd., Rochester, NY 14682, USA.
| | - Charles A Veltri
- Department of Pharmaceutical Sciences, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ 85308, USA.
| | - Darshan Singh
- Centre for Drug Research, Universiti Sains Malaysia, Minden, Malaysia.
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270
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Sharma A, Kamble SH, León F, Chear NJY, King TI, Berthold EC, Ramanathan S, McCurdy CR, Avery BA. Simultaneous quantification of ten key Kratom alkaloids in Mitragyna speciosa leaf extracts and commercial products by ultra-performance liquid chromatography-tandem mass spectrometry. Drug Test Anal 2019; 11:1162-1171. [PMID: 30997725 DOI: 10.1002/dta.2604] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 12/21/2022]
Abstract
Kratom (Mitragyna speciosa) is a psychoactive plant popular in the United States for the self-treatment of pain and opioid addiction. For standardization and quality control of raw and commercial kratom products, an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed and validated for the quantification of ten key alkaloids, namely: corynantheidine, corynoxine, corynoxine B, 7-hydroxymitragynine, isocorynantheidine, mitragynine, mitraphylline, paynantheine, speciociliatine, and speciogynine. Chromatographic separation of diastereomers, or alkaloids sharing same ion transitions, was achieved on an Acquity BEH C18 column with a gradient elution using a mobile phase containing acetonitrile and aqueous ammonium acetate buffer (10mM, pH 3.5). The developed method was linear over a concentration range of 1-200 ng/mL for each alkaloid. The total analysis time per sample was 22.5 minutes. The analytical method was validated for accuracy, precision, robustness, and stability. After successful validation, the method was applied for the quantification of kratom alkaloids in alkaloid-rich fractions, ethanolic extracts, lyophilized teas, and commercial products. Mitragynine (0.7%-38.7% w/w), paynantheine (0.3%-12.8% w/w), speciociliatine (0.4%-12.3% w/w), and speciogynine (0.1%-5.3% w/w) were the major alkaloids in the analyzed kratom products/extracts. Minor kratom alkaloids (corynantheidine, corynoxine, corynoxine B, 7-hydroxymitragynine, isocorynantheidine) were also quantified (0.01%-2.8% w/w) in the analyzed products; however mitraphylline was below the lower limit of quantification in all analyses.
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Affiliation(s)
- Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Shyam H Kamble
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Francisco León
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Nelson J-Y Chear
- Centre for Drug Research, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia
| | - Tamara I King
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Erin C Berthold
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Surash Ramanathan
- Centre for Drug Research, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia
| | - Christopher R McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Bonnie A Avery
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
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271
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Dietary Supplement Use in Gastrointestinal Symptom Management and Effect on Hopelessness Levels in Patients With Irritable Bowel Syndrome. Holist Nurs Pract 2019; 33:155-162. [DOI: 10.1097/hnp.0000000000000324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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272
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Smith KE, Bunting AM, Walker R, Hall MT, Grundmann O, Castillo O. Non-Prescribed Buprenorphine Use Mediates the Relationship between Heroin Use and Kratom Use among a Sample of Polysubstance Users. J Psychoactive Drugs 2019; 51:311-322. [PMID: 30961450 PMCID: PMC10083077 DOI: 10.1080/02791072.2019.1597224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In Asia, Mitragyna speciosa (e.g., "kratom") has been used to mitigate alcohol and drug dependence. Some preliminary findings suggest kratom's potential use as an informal harm-reduction method in the United States, such as an opioid substitute or as a means of lessening opioid withdrawal symptoms. To determine correlates of past-year kratom use among a sample of polysubstance users enrolled in residential recovery programs in Kentucky, an anonymous survey was completed by clients in April 2017. Logistic regression was used to identify significant associations with past-year kratom use. Of the final sample (N = 478), 10.4% reported past-year kratom use. Past-year heroin use, but not past-year prescription opioid (e.g., oxycodone, hydrocodone) use, was significantly associated with kratom use, such that individuals who reported past-year heroin use were 2.5 times more likely to also report past-year kratom use. Non-prescribed buprenorphine (i.e., Suboxone) use partially mediated the relationship between past-year heroin and kratom use by explaining 36% of the association between the two drugs. Though amphetamines were highly preferred, past-year use was negatively correlated with past-year kratom use. Rates of past-year kratom use were lower than rates of alcohol and illicit drug use. Kratom was not preferred over heroin or prescription opioids.
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Affiliation(s)
- Kirsten E. Smith
- Kent School of Social Work, University of Louisville, Louisville, KY, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | | | - Robert Walker
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA
| | - Martin T. Hall
- Kent School of Social Work, University of Louisville, Louisville, KY, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Olivia Castillo
- University of Miami School of Law, University of Miami, Coral Gables, FL, USA
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273
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Chomchai S, Phuditshinnapatra J, Mekavuthikul P, Chomchai C. Effects of unconventional recreational drug use in pregnancy. Semin Fetal Neonatal Med 2019; 24:142-148. [PMID: 30744980 DOI: 10.1016/j.siny.2019.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Recreational drug toxicity is a rapidly evolving aspect in clinical practice. The prevalence of recreational drug abuse in the past decade has achieved an epidemic scale due to invention of new agents and ease of accessibility to the abused drugs. "Unconventional recreational drugs" is the term that includes new psychoactive drugs and medications diverted for recreational goals. Misuse of unconventional recreational drugs during pregnancy can affect both the pregnant woman and the fetus. However, the problems are usually unrecognized and overlooked by healthcare professionals. In this articles, obstetric complications, teratogenicity and neonatal abstinence syndrome from exposure during pregnancy to synthetic cannabinoids, synthetic cathinones, tramadol, kratom, olanzapine, quetiapine, ketamine and ketamine are reviewed. The main purpose is to create awareness about maternal, fetal and neonatal effects of these unconventional recreational drugs, so healthcare professionals will have improved vigilance for these under-recognized issues.
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Affiliation(s)
- Summon Chomchai
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Chulathida Chomchai
- Mahidol University International College, Mahidol University, Nakhon Pathom, Thailand.
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274
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Ehrlich AT, Kieffer BL, Darcq E. Current strategies toward safer mu opioid receptor drugs for pain management. Expert Opin Ther Targets 2019; 23:315-326. [PMID: 30802415 DOI: 10.1080/14728222.2019.1586882] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Pain relief remains a major public health challenge. The most efficient available painkillers are opioids targeting the mu opioid receptor (MOR). MORs are expressed in the areas of the brain [including pain and respiratory centers] that are important for processing reward and aversion. Thus, MOR activation efficiently alleviates severe pain, but the concomitant reward and respiratory depressant effects pose a threat; patients taking opioids potentially develop opioid addiction and high risk for overdose. Areas covered: Ongoing efforts to generate safer opioid analgesics are reviewed here. The design of biased compounds that trigger MOR induced G protein over β-arrestin signaling, peripheral opioids, drugs targeting MORs in heteromers and drugs enhancing endogenous opioid activity are discussed. Expert opinion: There is evidence that throttling MOR signaling may lead to an era of opioids that are truly efficient painkillers with lower side effects and risk of overdose. However, few of the drugs derived from the advanced approaches outlined here, are getting approval by regulatory committees for use in clinical settings. Thus, there is an urgent need to (i) better clarify mechanisms underlying the hazardous physiological effects of MOR activation, and (ii) fully validate the safety of these new MOR-based therapies.
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Affiliation(s)
- Aliza T Ehrlich
- a Department of Psychiatry , McGill University, Douglas Hospital Research Center , Montréal , QC , Canada
| | - Brigitte L Kieffer
- a Department of Psychiatry , McGill University, Douglas Hospital Research Center , Montréal , QC , Canada
| | - Emmanuel Darcq
- a Department of Psychiatry , McGill University, Douglas Hospital Research Center , Montréal , QC , Canada
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275
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Pires C, Cavaco A. Scoping Pharmacy Students' Learning Outcomes: Where Do We Stand? PHARMACY 2019; 7:pharmacy7010023. [PMID: 30818854 PMCID: PMC6473488 DOI: 10.3390/pharmacy7010023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 02/17/2019] [Accepted: 02/22/2019] [Indexed: 01/09/2023] Open
Abstract
Background: The professional abilities of graduate pharmacists have been associated with pharmacy undergraduates’ educational settings and features. This study aimed to perform a scoping review on how students’ learning outcomes are achieved, including learning assessment strategies, focusing on current pharmacy practice education. Methods: Relevant keywords, e.g., “pharmacy practice”, “(students or undergraduates)” and “outcomes” were browsed in Public/Publisher MEDLINE, Scientific Electronic Library Online, Directory of Open Access Journals, and other relevant databases for recently published sources (2018 and 2017). Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria were followed to assure the scoping quality. All types of students’ learning outcomes were addressed for indexed publications in English, Portuguese or Spanish. Reviews, descriptive studies and commentaries were excluded. Study data are presented in tables comprising objectives, methods, number of participants and main research findings. Results: Overall, 100 studies were identified and 22 were selected. The selected studies were distributed into seven main topics: real practices (n = 9); active-learning strategies (n = 5); comparisons between different teaching pedagogies (n = 3); pharmacy curriculum (n = 2); and other evaluations (n = 3). Conclusions: Studies on pharmacy students’ learning outcomes are limited. Pharmacy undergraduates’ performance was dependent on the learning strategies and extension of syllabus implementation.
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Affiliation(s)
- Carla Pires
- CBIOS-Universidade Lusófona Research Center for Biosciences and Health Technologies, Campo Grande, 376, 1749-024 Lisboa, Portugal.
| | - Afonso Cavaco
- iMed.ULisboa & Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Av. Prof Gama Pinto, 1649-003 Lisboa, Portugal.
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276
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Fu R, Chen M, Chen Y, Mao G, Liu S. Expression and clinical significance of 5-HT and 5-HT 3R in the intestinal mucosa of patient with diarrhea-type irritable bowel syndrome. Exp Ther Med 2019; 17:3077-3082. [PMID: 30936979 PMCID: PMC6434247 DOI: 10.3892/etm.2019.7297] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/18/2019] [Indexed: 12/13/2022] Open
Abstract
Expression levels and clinical significance of 5-HT and 5-HT3R in the intestinal mucosa tissue of patients with diarrhea-type irritable bowel syndrome (D-IBS) were investigated. A retrospective analysis was performed on 46 tissue specimens (observation group) of the intestinal mucosa of patients with D-IBS, who were diagnosed in the Tongde Hospital of Zhejiang Province and received colonoscopy from March 2016 to December 2017, and 18 tissue specimens (control group) of the intestinal mucosa of healthy subjects who received physical examinations. The expression levels of 5-HT and 5-HT3R in the intestinal mucosa tissue of patients in the observation and control group were detected by ELISA, and the relationship between 5-HT, 5-HT3R and the clinicopathological parameters of patients with D-IBS was analyzed. Pearson's correlation analysis was used to analyze the correlation of 5-HT and 5-HT3R in the intestinal mucosa tissue of patients with D-IBS. The expression levels of 5-HT and 5-HT3R in the intestinal mucosa tissue of patients in the observation group were significantly higher than those of the patients in the control group (344.86±67.52 ng/ml and 13.04±8.34 pg/ml) (P<0.001). There was a positive correlation between the expression level of 5-HT and the expression level of 5-HT3R in the intestinal mucosa tissue of patients with D-IBS (r=0.725, P<0.001). The expression levels of 5-HT and 5-HT3R in the intestinal mucosa tissue of patients with D-IBS were both significantly higher than those of the healthy subjects. The expression levels of 5-HT and 5-HT3R in patients with D-IBS were correlated with age, sex and the history of gastrointestinal infection. 5-HT and 5-HT3R may be involved in the pathogenesis of D-IBS, and potentially used for clinical treatment.
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Affiliation(s)
- Rui Fu
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
| | - Mingxian Chen
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
| | - Yu Chen
- Laboratory Animal Center, Zhejiang Province Academy of Traditional Chinese Medicine, Hangzhou, Zhejiang 310012, P.R. China
| | - Guoqun Mao
- Department of Radiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
| | - Saiyue Liu
- Department of Adverse Drug Reaction Monitoring, Zhejiang Province Center of Adverse Drug Reaction Monitoring, Hangzhou, Zhejiang 310012, P.R. China
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277
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Post S, Spiller HA, Chounthirath T, Smith GA. Kratom exposures reported to United States poison control centers: 2011-2017. Clin Toxicol (Phila) 2019; 57:847-854. [PMID: 30786220 DOI: 10.1080/15563650.2019.1569236] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Context: Kratom, or Mitragyna speciosa, is a plant indigenous to Southeast Asia that has gained national attention in the United States for its increased use in the self-management of opioid withdrawal and pain, as well as for concerns about its safety. Methods: This study analyzes exposures to kratom reported to poison control centers (PCCs) in the United States during 2011-2017 from the National Poison Data System (NPDS). Discussion: From 2011 through 2017, 1807 kratom exposures were reported to United States PCCs. Almost two-thirds (65.0%) of these exposures occurred during 2016-2017. Most exposures occurred among adults ≥20 years (88.9%), males (70.8%), at a residence (86.1%), and were intentional (74.3%). Among first-ranked kratom exposures, 31.8% resulted in admission to a health care facility (HCF) and 51.9% in a serious medical outcome. Multiple-substance exposures were associated with greater odds of admission to a HCF (OR: 2.80; 95% CI: 2.21-3.55) and a serious medical outcome (OR: 2.25; 95% CI: 1.77-2.85) compared with single-substance exposures. There were 11 deaths associated with kratom exposure, including two that occurred after exposure to kratom only. Among kratom-only exposures, 86.1% resulted in one or more clinical effects. The most common clinical effects were agitation/irritability (22.9%) and tachycardia (21.4%). There were seven neonatal exposures, including five experiencing withdrawal. Conclusions: Kratom is associated with a variety of serious medical outcomes, especially when used with other substances. More research is needed to define the human response to kratom. Increased regulation of kratom products would help guarantee product quality and safety. Individuals who choose to use kratom should be educated about its potential risks, including the dangers of using it in combination with other substances.
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Affiliation(s)
- Sara Post
- a Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital , Columbus , OH , USA.,b Northeast Ohio Medical University , Rootstown , OH , USA
| | - Henry A Spiller
- c Central Ohio Poison Center , Columbus , OH , USA.,d Department of Pediatrics, College of Medicine, The Ohio State University , Columbus , OH , USA
| | - Thitphalak Chounthirath
- a Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital , Columbus , OH , USA
| | - Gary A Smith
- a Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital , Columbus , OH , USA.,d Department of Pediatrics, College of Medicine, The Ohio State University , Columbus , OH , USA.,e Child Injury Prevention Alliance , Columbus , OH , USA
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278
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Use of Complementary and Alternative Medicine by Patients with Irritable Bowel Syndrome According to the Roma IV Criteria: A Single-Center Italian Survey. ACTA ACUST UNITED AC 2019; 55:medicina55020046. [PMID: 30781771 PMCID: PMC6409648 DOI: 10.3390/medicina55020046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 12/12/2022]
Abstract
Aim: This study was conducted to evaluate the impact of complementary and alternative medicine (CAM) in patients with irritable bowel syndrome (IBS) as assessed by the Rome IV criteria. Methods: Consecutive patients referring for IBS were re-evaluated according to the Rome IV criteria. Demographic features and characteristics potentially associated with the use of CAM were collected. A validated, self-administered, survey questionnaire dealing with CAM and patients’ level of knowledge, motivation, perception, and information seeking-behavior toward the use of CAM was analyzed. Multivariate logistic regression analysis was performed in order to identify predictors of CAM use among participants. Results: Among 156 patients claiming IBS, 137 (88%) met the Rome IV criteria, and 62 of them (45%) were CAM users. Biologically based therapy was the most chosen CAM (78%). Significant risk factors (adjusted odds ratio, 95% confidence interval) for the use of CAM were female gender (7.22, 2.31–22.51), a higher BMI (1.16, 1.02–1.33), and a good knowledge of CAM (4.46, 1.73–11.45), while having children was a protective factor (0.25, 0.07–0.95). Only 19% of patients used CAM due to medical advice and over half (51%) thought it was a “more natural” approach. Although a minority of patients (16%) had full satisfaction from CAM, 81% of users would repeat the CAM experience for their IBS symptoms. Conclusions: The widespread use of CAM in IBS, the patients’ belief in its safety, and their willingness to re-use it suggest that knowledge of health-care providers and patient education should be improved.
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279
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Xu PW, Yu JS, Chen C, Cao ZY, Zhou F, Zhou J. Catalytic Enantioselective Construction of Spiro Quaternary Carbon Stereocenters. ACS Catal 2019. [DOI: 10.1021/acscatal.8b03694] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Peng-Wei Xu
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, East China Normal University, Shanghai 200062, P. R. China
| | - Jin-Sheng Yu
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, East China Normal University, Shanghai 200062, P. R. China
| | - Chen Chen
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, East China Normal University, Shanghai 200062, P. R. China
| | - Zhong-Yan Cao
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, East China Normal University, Shanghai 200062, P. R. China
| | - Feng Zhou
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, East China Normal University, Shanghai 200062, P. R. China
| | - Jian Zhou
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, East China Normal University, Shanghai 200062, P. R. China
- Shanghai Key Laboratory of Green Chemistry and Chemical Process, East China Normal University, Shanghai 200062, P. R. China
- State Key Laboratory of Organometallic Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai 200032, P. R. China
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280
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Wu IXY, Wong CHL, Ho RST, Cheung WKW, Ford AC, Wu JCY, Mak ADP, Cramer H, Chung VCH. Acupuncture and related therapies for treating irritable bowel syndrome: overview of systematic reviews and network meta-analysis. Therap Adv Gastroenterol 2019; 12:1756284818820438. [PMID: 30719074 PMCID: PMC6348567 DOI: 10.1177/1756284818820438] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/19/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND An overview of systematic reviews (SRs) and a network meta-analysis (NMA) were conducted to evaluate the comparative effectiveness of acupuncture and related therapies used either alone, or as an add-on to other irritable bowel syndrome (IBS) treatments. METHODS A total of eight international and Chinese databases were searched for SRs of randomized controlled trials (RCTs). The methodological quality of SRs was appraised using the AMSTAR instrument. From the included SRs, data from RCTs were extracted for the random-effect pairwise meta-analyses. An NMA was used to evaluate the comparative effectiveness of different treatment options. The risk of bias among included RCTs was assessed using the Cochrane risk of bias tool. RESULTS From 15 SRs of mediocre quality, 27 eligible RCTs (n = 2141) were included but none performed proper blinding. Results from pairwise meta-analysis showed that both needle acupuncture and electroacupuncture were superior in improving global IBS symptoms when compared with pinaverium bromide. NMA results showed needle acupuncture plus Geshanxiaoyao formula had the highest probability of being the best option for improving global IBS symptoms among 14 included treatment options, but a slight inconsistency exists. CONCLUSION The risk of bias and NMA inconsistency among included trials limited the trustworthiness of the conclusion. Patients who did not respond well to first-line conventional therapies or antidepressants may consider acupuncture as an alternative. Future trials should investigate the potential of (1) acupuncture as an add-on to antidepressants and (2) the combined effect of Chinese herbs and acupuncture, which is the norm of routine Chinese medicine practice.
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Affiliation(s)
- Irene X. Y. Wu
- Xiangya School of Public Health, Central South University, Changsha Hunan, China
| | - Charlene H. L. Wong
- Department of Medicine and Therapeutics, Chung Chi College, The Chinese University of Hong Kong, Rm LG02, Li Wai Chun Building, Shatin, Hong Kong; Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Robin S. T. Ho
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - William K. W. Cheung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Alexander C. Ford
- Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Justin C. Y. Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
- Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Arthur D. P. Mak
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
| | - Holger Cramer
- Department of Internal and Integrative Medicine, University of Duisburg-Essen, Duisburg, Germany
- Australian Research Centre in Complementary and Integrative Medicine, University Technology Sydney, Sydney, Australia
| | - Vincent C. H. Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
- School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong
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281
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Lovrecic B, Lovrecic M, Gabrovec B, Carli M, Pacini M, Maremmani AGI, Maremmani I. Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020177. [PMID: 30634521 PMCID: PMC6352208 DOI: 10.3390/ijerph16020177] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 01/28/2023]
Abstract
Background: In the last decade there has been a progressive increase in the use of new psychoactive substances (NPSs) that are not yet under international control. In particular, novel synthetic opioids (NSOs) have reappeared on the recreational drug market in the last few years. As a result, the use of NSOs has increased rapidly. This poses an emerging and demanding challenge to public health. Aim: To raise awareness among clinicians and other professionals about NPSs, especially NSOs, to summarize current knowledge about pharmacological properties, forms of NSO on the market, pattern of use, effects and consequences of use. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms. Results: Some NPSs are already controlled, while others can be legally sold directly on the drug market (mainly via internet, less so by drug dealers) or be used as precursors for the synthesis of other designer drugs that mimic the psychoactive effects of controlled substances. Potential side-effects of NSOs include miosis, sedation, respiratory depression, hypothermia, inhibition of gastrointestinal propulsion, death (from opioid overdose). Conclusions: The severity of the opioid crisis has intensified with the introduction of highly potent NSOs on the drug market. As long as addicts are dying from overdose or similar causes, there is something more constructive to do than waiting for addicts to overdose on heroin at a place located near a remedy, as if to say, within reach of naloxone.
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Affiliation(s)
| | - Mercedes Lovrecic
- National Institute of Public Health, 1000 Ljubljana, Slovenia.
- Centre for Psychiatry and Addiction Medicine, Izola Health Centre, 6310 Izola, Slovenia.
| | - Branko Gabrovec
- National Institute of Public Health, 1000 Ljubljana, Slovenia.
| | - Marco Carli
- Department of Translational Research and New Technologies, University of Pisa, 56100 Pisa, Italy.
| | - Matteo Pacini
- G. De Lisio Institute of Behavioral Sciences, 56100 Pisa, Italy.
| | - Angelo G I Maremmani
- Department of Psychiatry, North-Western Tuscany Region NHS Local Health Unit, Versilia Zone, 55049 Viareggio, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
| | - Icro Maremmani
- G. De Lisio Institute of Behavioral Sciences, 56100 Pisa, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
- Vincent P. Dole Dual Disorder Unit, Santa Chiara University Hospital, University of Pisa, 56100 Pisa, Italy.
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282
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Palasamudram Shekar S, Rojas EE, D'Angelo CC, Gillenwater SR, Martinez Galvis NP. Legally Lethal Kratom: A Herbal Supplement with Overdose Potential. J Psychoactive Drugs 2019; 51:28-30. [PMID: 30620247 DOI: 10.1080/02791072.2018.1562591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This case report describes an overdose on kratom, and elicits the potential dangers of overdose on the regulated dietary supplement. A young male presented to the emergency department intubated after being found unresponsive. He was found by his family to be unarousable and agonal breathing with minimal response to naloxone administered by Emergency Medical Services (EMS). Urine toxicology and blood alcohol content were negative. Physical exam was significant for tachycardia, hypotension, and pinpoint pupils with sluggish reactivity to light. Laboratory studies were significant for elevated liver enzymes, blood urea nitrogen, creatinine, lipase, amylase, troponins, and lactic acid. Family members revealed that the patient consumed kratom, which he obtained through an e-commerce business, and had consumed over 500 grams the previous day. Urine sample for kratom on day 3 tested positive with levels of more than 500 ng/dL. The patient received supportive care and, by day 10, pupillary reflexes returned to normal and he was extubated by day 14. Most of the medications/drugs labelled under herbal supplements by the U.S. Food and Drug Administration (FDA) are not regulated and can be purchased over the counter. The safety and side-effect profile of kratom is not well-studied, especially in an overdose scenario.
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Affiliation(s)
- S Palasamudram Shekar
- a Pulmonary and Critical Care Medicine , Cleveland Clinic Florida , Weston , FL , USA
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283
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Kamble SH, Sharma A, King TI, León F, McCurdy CR, Avery BA. Metabolite profiling and identification of enzymes responsible for the metabolism of mitragynine, the major alkaloid of Mitragyna speciosa (kratom). Xenobiotica 2019; 49:1279-1288. [PMID: 30547698 DOI: 10.1080/00498254.2018.1552819] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
1. Mitragynine is the major indole-based alkaloid of Mitragyna speciosa (kratom). Decoctions (teas) of the plant leaves have been used traditionally for cough, diarrhoea, pain, hypertension and for the treatment of opioid addiction. In the West, kratom has become increasingly utilized for mood elevation, pain treatment and as a means of self-treating opioid addiction. 2. Metabolic pathways of mitragynine were identified in human liver microsomes (HLM) and S9 fractions. A total of thirteen metabolites were identified, four oxidative metabolites and a metabolite formed by demethylation at the 9-methoxy group were the major metabolites of mitragynine. 3. The cytochrome P450 enzymes involved in the metabolism of mitragynine were identified using selective chemical inhibitors of HLM and recombinant cytochrome P450. The metabolism of mitragynine was predominantly carried out through the CYP3A4 with minor contributions by CYP2D6 and CYP2C9. The formation of five oxidative metabolites (Met2, Met4, Met6, Met8 and Met11) was catalyzed by the CYP3A4. 4. In summary, mitragynine was extensively metabolized in HLM primarily to O-demethylated and mono-oxidative metabolites. The CYP3A4 enzyme plays a predominant role in the metabolic clearance of mitragynine and also in the formation of 7-hydroxymitragynine (Met2), a known active minor alkaloid identified in the leaf material.
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Affiliation(s)
- Shyam H Kamble
- a Department of Pharmaceutics, University of Florida , Gainesville , FL , USA
| | - Abhisheak Sharma
- a Department of Pharmaceutics, University of Florida , Gainesville , FL , USA
| | - Tamara I King
- a Department of Pharmaceutics, University of Florida , Gainesville , FL , USA
| | - Francisco León
- b Department of Medicinal Chemistry, University of Florida , Gainesville , FL , USA
| | | | - Bonnie A Avery
- a Department of Pharmaceutics, University of Florida , Gainesville , FL , USA
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284
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Gershman K, Timm K, Frank M, Lampi L, Melamed J, Gerona R, Monte AA. Deaths in Colorado Attributed to Kratom. N Engl J Med 2019; 380:97-98. [PMID: 30601742 PMCID: PMC6688840 DOI: 10.1056/nejmc1811055] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ken Gershman
- Colorado Department of Public Health and Environment, Denver, CO
| | - Krista Timm
- Denver Office of the Medical Examiner, Denver, CO
| | | | | | | | - Roy Gerona
- University of California, San Francisco, San Francisco, CA
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285
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Singh D, Narayanan S, Grundmann O, Dzulkapli EB, Vicknasingam B. Effects of Kratom ( Mitragyna Speciosa Korth.) Use in Regular Users. Subst Use Misuse 2019; 54:2284-2289. [PMID: 31347441 DOI: 10.1080/10826084.2019.1645178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Mitragyna speciosa (Korth.) or kratom is an indigenous medicinal plant of Southeast Asia. Kratom is widely reported to have dose-dependent effects based on available literature, but to our knowledge, this has not been established conclusively. Objective: This study sought to evaluate if kratom use produces dose-dependent effects, with a stimulant effect at low doses and a sedative effect at high doses, in a sample of regular kratom users. Methods: A total of 63 regular kratom users participated in this cross-sectional study. The Brief-Biphasic Alcohol Effects Scale (B-BAES) was used to determine subjects self-report kratom use experiences. Results: Almost all in the sample were male (98%, n = 62/63), and the majority of subjects were Malays (94%, n = 59/63). The mean age of the subjects in the sample was 43.8 years (SD = 12.1). Seventy-five percent (n = 47/63) have >5 years kratom use history, and 65% (n = 41/63) consumed >3 glasses of kratom daily. Results from first test showed no significant difference in the stimulant (t61 =0.371, p < .331) and sedative effects (t61 =502, p < .759) between those who consumed >3 glasses a day or less than this amount, regardless of duration of use. In the second test, no significant differences in the mean scores were found among those who consumed >3 glasses daily or less than this amount among short-term or long-term uses. Conclusions: Daily kratom use produced both stimulant and sedative effects but they were not statistically significantly associated with the dose consumed, both among short-term and long-term users in our sample.
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Affiliation(s)
- Darshan Singh
- Centre for Drug Research, Universiti Sains Malaysia, Minden, Penang, Malaysia
| | - Suresh Narayanan
- School of Social Sciences, Universiti Sains Malaysia, Minden, Penang, Malaysia
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Eshal Bin Dzulkapli
- Centre for Drug Research, Universiti Sains Malaysia, Minden, Penang, Malaysia
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286
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Abstract
Drug use and the associated overdose deaths have been a serious public health threat in the United States and the world. While traditional drugs of abuse such as cocaine remain popular, recreational use of newer synthetic drugs has continued to increase, but the prevalence of use is likely underestimated. In this review, epidemiology, chemistry, pharmacophysiology, clinical effects, laboratory detection, and clinical treatment are discussed for newly emerging drugs of abuse in the following classes: (1) opioids (e.g., fentanyl, fentanyl analogues, and mitragynine), (2) cannabinoids [THC and its analogues, alkylindole (e.g., JWH-018, JWH-073), cyclohexylphenol (e.g., CP-47,497), and indazole carboxamide (e.g., FUB-AMB, ADB-FUBINACA)], (3) stimulants and hallucinogens [β-keto amphetamines (e.g., methcathinone, methylone), pyrrolidinophenones (e.g., α-PVP, MDPV), and dimethoxyphenethylamine ("2C" and "NBOMe")], (4) dissociative agents (e.g., 3-MeO-PCP, methoxetamine, 2-oxo-PCE), and (5) sedative-hypnotics (e.g., gabapentin, baclofen, clonazolam, etizolam). It is critically important to coordinate hospital, medical examiner, and law enforcement personnel with laboratory services to respond to these emerging threats.
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Affiliation(s)
- Kenichi Tamama
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Clinical Laboratories, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA. .,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Clinical Laboratory, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
| | - Michael J Lynch
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Pittsburgh Poison Center, Pittsburgh, PA, USA.
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287
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Toce MS, Chai PR, Burns MM, Boyer EW. Pharmacologic Treatment of Opioid Use Disorder: a Review of Pharmacotherapy, Adjuncts, and Toxicity. J Med Toxicol 2018; 14:306-322. [PMID: 30377951 PMCID: PMC6242798 DOI: 10.1007/s13181-018-0685-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 12/27/2022] Open
Abstract
Opioid use disorder continues to be a significant source of morbidity and mortality in the USA and the world. Pharmacologic treatment with methadone and buprenorphine has been shown to be effective at retaining people in treatment programs, decreasing illicit opioid use, decreasing rates of hepatitis B, and reducing all cause and overdose mortality. Unfortunately, barriers exist in accessing these lifesaving medications: users wishing to start buprenorphine therapy require a waivered provider to prescribe the medication, while some states have no methadone clinics. As such, users looking to wean themselves from opioids or treat their opioid dependence will turn to alternative agents. These agents include using prescription medications, like clonidine or gabapentin, off-label, or over the counter drugs, like loperamide, in supratherapeutic doses. This review provides information on the pharmacology and the toxic effects of pharmacologic agents that are used to treat opioid use disorder. The xenobiotics reviewed in depth include buprenorphine, clonidine, kratom, loperamide, and methadone, with additional information provided on lofexidine, akuamma seeds, kava, and gabapentin.
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Affiliation(s)
- Michael S Toce
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Peter R Chai
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Edward W Boyer
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
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288
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Hughes RL. Fatal combination of mitragynine and quetiapine - a case report with discussion of a potential herb-drug interaction. Forensic Sci Med Pathol 2018; 15:110-113. [PMID: 30498933 DOI: 10.1007/s12024-018-0049-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2018] [Indexed: 12/17/2022]
Abstract
Kratom is a plant with dose-dependent mixed stimulant and opioid properties whose pharmacologic characteristics and social impact continue to be described. The main active isolate of kratom is mitragynine, an indole-containing alkaloid with opioid-like effects. Kratom toxicity and kratom-associated fatalities have been described, including those in association with additional drugs. In this paper we describe the case of a 27-year-old man who was found deceased with a toxic blood concentration of quetiapine in conjunction with the qualitative presence of mitragynine. Investigative and autopsy findings suggested perimortem hyperthermia and seizure-like activity. Kratom toxicity and kratom-associated fatalities are being increasingly reported. Experiments with kratom extracts have shown inhibitory effects upon hepatic CYP enzymes, leading to previous speculation of the potential for clinically significant interactions between kratom and a wide array of medications. Herein is described a fatal case of quetiapine toxicity complicated by mitragynine use. The potential ability of mitragynine to alter the pharmacokinetics of a prescription medication via inhibition of its hepatic metabolism is discussed.
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Affiliation(s)
- Rhome L Hughes
- University of North Dakota School of Medicine and Health Sciences, 1301 N. Columbia Rd (Room W430), Grand Forks, ND, 58203, USA.
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289
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Grace S, Barnes L, Reilly W, Vlass A, de Permentier P. An integrative review of dietetic and naturopathic approaches to functional bowel disorders. Complement Ther Med 2018; 41:67-80. [PMID: 30477867 DOI: 10.1016/j.ctim.2018.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Naturopathy and dietetics have evolved as two separate but parallel professions that use diet to promote optimal health and manage many illnesses and diseases. Given the increasing recognition of the influence of diet on health outcomes, there is increasing demand for the services of both professions. The aim of this research was to investigate similarities and differences between naturopathic and dietetic approaches to functional bowel disorders (FBDs). DESIGN For this integrative review AMED, CINAHL, the Cochrane Database of Systematic Reviews, EMBASE, Medline and PubMed databases were searched for articles that focused on dietetic or naturopathic diagnosis and treatment of food intolerance expressing as a FBD in adults. (Registration: PROSPERO 2016 CRD42016049469). RESULTS Of the 55 papers in the final review, 10 discussed complementary medicine approaches to FBDs. Both dietitians and naturopaths used similar holistic approaches to diagnosis and treatment, adjusted diets as a primary treatment approach, and individualised treatment for their patients. The professions differed in their use of vitamin, mineral and herbal supplements and in their willingness to recommend other treatments like osteopathy and acupuncture. CONCLUSIONS There is much overlap between dietetic and naturopathic approaches to assessment and treatment of FBDs. Further publications that describe naturopathic treatments for FBDs are needed to confirm these results and to provide opportunities for increased recognition and scrutiny of any distinctively naturopathic approaches. Without doing so, naturopathic practices are likely to remain marginalised and poorly understood. Moreover, the opportunity to fully contribute to the management of lifestyle-related diseases will be missed.
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Affiliation(s)
- Sandra Grace
- School of Health and Human Sciences, Southern Cross University, PO Box 157, Lismore, NSW 2480, Australia.
| | - Larisa Barnes
- The University Centre of Rural Health, The University of Sydney, 61 Uralba St, Lismore, NSW 2480, Australia.
| | - Wayne Reilly
- Wellness Care Australia Pty Ltd, Coorparoo, Queensland 4151, Australia.
| | - Ann Vlass
- Helping Nature Heal, Balwyn North, Victoria 3104, Australia.
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290
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Grundmann O, Yoon SL, Mason S, Smith K. Gastrointestinal symptom improvement from fiber, STW 5, peppermint oil, and probiotics use-Results from an online survey. Complement Ther Med 2018; 41:225-230. [PMID: 30477844 DOI: 10.1016/j.ctim.2018.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Several common supplements are used by a significant number of patients affected by gastrointestinal (GI) disorders to improve symptoms and quality of life. We investigated the impact of GI symptom improvement with the use of fiber, STW 5, probiotics, and peppermint oil in relation to overall GI pain and quality of life via an online survey. DESIGN We used a cross-sectional, descriptive, correlation design. A Qualtrics online survey was utilized to collect data from January to June 2013 through various websites. Areas evaluated included participant demographics, use of supplements, and gastrointestinal symptom severity. RESULTS The rate of supplement use among patients with GI disorders was high (90% in past year) and consultation with healthcare providers was reported by 80%. Participants who completed the survey (n = 68) reported a strong correlation between GI symptom severity and overall quality of life (r2 = 0.8682, p < 0.001). The use of fiber improved GI symptom severity while both STW 5 and probiotics were linked to specific improvements. CONCLUSIONS Persons with chronic GI disorders often choose the complementary use of common supplements to mitigate GI symptoms and consult with their healthcare providers frequently. The use of STW 5 and probiotics specifically is linked to overall reduction in GI symptoms and improvement of quality of life.
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Affiliation(s)
- Oliver Grundmann
- College of Pharmacy, Department of Medicinal Chemistry, University of Florida, FL, 32610, USA; College of Nursing, Department of Biobehavioral Nursing Science, University of Florida, FL, 32610, USA.
| | - Saunjoo L Yoon
- College of Nursing, Department of Biobehavioral Nursing Science, University of Florida, FL, 32610, USA
| | - Sydney Mason
- College of Nursing, Department of Biobehavioral Nursing Science, University of Florida, FL, 32610, USA
| | - Keore Smith
- College of Nursing, Department of Biobehavioral Nursing Science, University of Florida, FL, 32610, USA
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291
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Bailey RL. Current regulatory guidelines and resources to support research of dietary supplements in the United States. Crit Rev Food Sci Nutr 2018; 60:298-309. [PMID: 30421981 PMCID: PMC6513729 DOI: 10.1080/10408398.2018.1524364] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 12/31/2022]
Abstract
The U.S. Dietary Supplement Health and Education Act (DSHEA) established the regulatory framework for dietary supplements as foods through the Food and Drug Administration (FDA). DSHEA outlined the legal definition, labeling requirements, and process for adverse event reporting for dietary supplements. FDA also issued formal guidance on current Good Manufacturing Practice to ensure that processes for preparation, packaging, labeling, and storage of supplements and ingredients are documented and meet specifications to ensure purity, composition, and strength. However, efficacy of dietary supplements is not required under U.S. law. Despite regulations to improve the marketplace, many challenges remain; as a result, the quality and safety of products available can be highly variable, especially for botanical and herbal products. The ability of regulators to successfully carry out their mission is hampered by the sheer number of products and manufacturing facilities and a lack of analytical methods for all ingredients and products in the marketplace, this is especially difficult for herbal and botanical dietary supplements. Safety issues continue to exist such as adulteration and contamination, especially with specific product types (i.e. body building, sexual enhancement). Thus, a need remains for continued efforts and improved techniques to assess the quality of dietary supplements, especially with regard to purity, bioavailability, and safety. This review will highlight the existing American regulatory framework for dietary supplements and will describe the remaining regulatory barriers to ensuring that safe and high-quality dietary supplements are offered in the marketplace.
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Affiliation(s)
- Regan L Bailey
- Department of Nutrition Science, Purdue University, , West Lafayette, Indiana 47907, USA
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292
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A review on the abuse of three NPS (synthetic cannabinoids, kratom, poppers) among youths in Asia. Forensic Sci Int 2018; 292:45-49. [DOI: 10.1016/j.forsciint.2018.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 09/06/2018] [Accepted: 09/10/2018] [Indexed: 01/24/2023]
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293
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Peng Y, You H, Chen X, Chen Y, Yang Y, Huang J, Xu N, Liu J. Effect of electroacupuncture at homotopic and heterotopic acupoints on abdominal pain in patients with irritable bowel syndrome: study protocol for a randomized controlled trial. Trials 2018; 19:559. [PMID: 30326940 PMCID: PMC6192074 DOI: 10.1186/s13063-018-2948-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 09/27/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acupuncture has been widely applied in the clinic to treat irritable bowel syndrome (IBS), but the underlying mechanism remains unknown. Diffuse noxious inhibitory control (DNIC) is deficient in patients with IBS, which attenuates the systemic analgesic effect elicited by noxious stimulation that is remote from pain areas. Therefore, the aim of this study is to investigate the analgesic effect of electroacupuncture (EA) at homotopic or heterotopic acupoints on abdominal pain in patients with IBS. METHODS/DESIGN This study is a randomized, single-blinded, controlled, four-arm parallel trial. A total of 144 patients will be randomly assigned to four groups: a homotopic noxious stimulation group (group A), a homotopic innocuous stimulation group (group B), a heterotopic noxious stimulation group (group C), and a heterotopic innocuous stimulation group (group D). Each patient will receive 14 sessions of treatment, twice per week for 7 weeks. The primary outcome will be pain intensity measured with the visual analog scale. The secondary outcomes will include the IBS Symptom Severity Scale, IBS Quality of Life questionnaire, pain threshold (PT), and the Symptom Checklist-90 for psychological distress. The PT will be measured before and after every treatment. All other outcomes will be evaluated before the 1st treatment, after 7th and 14th treatment, and 3 months later during follow-up. DISCUSSION The aim of this study is to assess the analgesic effect of EA at homotopic (abdomen) acupoints and heterotopic (lower limb) acupoints on abdominal pain in patients with IBS, as well as the difference in analgesic effects between noxious and innocuous stimulation. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-IPR-15006879 . Registered on 5 August 2015.
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Affiliation(s)
- Yanhui Peng
- The Secondary Medical College, Guangzhou University of Traditional Chinese Medicine, 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Hui You
- Guangzhou University of Traditional Chinese Medicine, 12 Jichang Road, Guangzhou, 510006, People's Republic of China
| | - Xiaoman Chen
- Guangzhou University of Traditional Chinese Medicine, 12 Jichang Road, Guangzhou, 510006, People's Republic of China
| | - Yanbing Chen
- Guangzhou University of Traditional Chinese Medicine, 12 Jichang Road, Guangzhou, 510006, People's Republic of China
| | - Yiling Yang
- Guangzhou University of Traditional Chinese Medicine, 12 Jichang Road, Guangzhou, 510006, People's Republic of China
| | - Jianpeng Huang
- The Secondary Medical College, Guangzhou University of Traditional Chinese Medicine, 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Nenggui Xu
- Guangzhou University of Traditional Chinese Medicine, 12 Jichang Road, Guangzhou, 510006, People's Republic of China
| | - Jianhua Liu
- The Secondary Medical College, Guangzhou University of Traditional Chinese Medicine, 111 Dade Road, Guangzhou, 510120, People's Republic of China.
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294
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Ekar T, Kreft S. Common risks of adulterated and mislabeled herbal preparations. Food Chem Toxicol 2018; 123:288-297. [PMID: 30339960 DOI: 10.1016/j.fct.2018.10.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 12/13/2022]
Abstract
Due to the growing trend of returning to nature and the fear of adverse reactions from conventional medicines, people are increasingly resorting to the use of herbal preparations. Because of long-term use and natural origin these preparations give a sense of security. But herbal formulations also possess undesirable effects and, among other dangers, present a risk connected with deliberate addition of synthetic compounds, deliberate or unintentional replacement of the plant species or simply a risk of mislabeling. While the replacement of the plant species occurs in a very different groups of herbal products, reports of added illicit synthetic substances often include groups of herbal weight-loss preparations, sexual enhancers, preparations for treatment of rheumatic and inflammatory diseases, antidiabetic and blood pressure lowering preparations. In the world of Internet ordering, these are the dangers that everyone should be aware of. In this article, we reviewed the safety issues related to adulterated or mislabeled herbal products.
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Affiliation(s)
- Tjaša Ekar
- Public Institution Gorenjske Lekarne, Kranj, Slovenia
| | - Samo Kreft
- University of Ljubljana, Faculty of Pharmacy, Ljubljana, Slovenia.
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295
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Duangjai A, Goh BH, Lee LH, Saokaew S. Relaxant effects of Azadirachta indica A. Juss var. siamensis Valeton flower extract on isolated rat ileum contractions and the mechanisms of action. J Tradit Complement Med 2018; 8:515-520. [PMID: 30302332 PMCID: PMC6174269 DOI: 10.1016/j.jtcme.2018.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/11/2017] [Accepted: 01/02/2018] [Indexed: 02/07/2023] Open
Abstract
Azadirachta indica A. Juss var. siamensis Valeton or commonly known as Siamese neem is one of the most well-known plant in traditional Ayurvedic medicine. The aim of the present study was to investigate the relaxant effects of A. indica on isolated rat ileum contractions and its potential underlying mechanisms involved. The isometric contractions of ileum segments were investigated in organ baths for spontaneous activity and response to aqueous extract of Siamese neem flower (SNF). The spasmolytic action of the extract was also assessed on contraction induced by acetylcholine and high potassium. Our findings indicate that cumulative concentrations of SNF aqueous extract induced relaxant effect on spontaneous rat ileum contractions. The extract has also suppressed the cumulative concentration response curve for acetylcholine and pottasium ions-induced contraction. The presence and absence of propranol (antagonist of β-adrenergic receptor) and l-Name (antagonist of nitric oxide synthase) in SNF aqeous extract co-treatment demonstrated no significant different in term of contraction activity when compared to SNF extract treatment alone. The treatment of SNF extract caused a significant inhibition in tissue contraction stimulated by accumulation of calcium ions. Our results showed the relaxant effect of SNF aqueous extract on the isolated rat ileum. In short, the SNF aqueous extract exhibited an inhibitory effect on the spontaneous ileum contactions particularly on the contraction stimulated by acetylcholine and high potassium. The observed effect might acted through the modulation of calcium channels. This findings provide a pharmacological basis for the traditional use of SNF for the treatment of gastrointestinal spasms.
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Affiliation(s)
- Acharaporn Duangjai
- Division of Physiology, School of Medical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Bey-Hing Goh
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
| | - Learn-Han Lee
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor Darul Ehsan, Malaysia.,Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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296
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Hunt MG, Wong C, Aajmain S, Dawodu I. Fecal incontinence in people with self-reported irritable bowel syndrome: Prevalence and quality of life. J Psychosom Res 2018; 113:45-51. [PMID: 30190047 DOI: 10.1016/j.jpsychores.2018.07.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome (IBS) is a common functional gastrointestinal (GI) disorder characterized by recurrent abdominal pain and altered bowel habits. IBS is a risk factor for fecal incontinence (FI), the unintentional passage of solid or liquid stool. FI can substantially interfere with health related quality of life (HRQL), leading to heightened anxiety and avoidance behavior. Nevertheless, relatively little research has been conducted on the prevalence of FI in IBS patients. This study evaluated the prevalence of FI in people with self-reported IBS and the relationship between FI and HRQL. 703 people who reported a diagnosis of IBS completed questionnaires on IBS symptom severity, FI symptom severity, HRQL, fear of food, anxiety about visceral sensations, and GI specific catastrophizing. Overall, 60% of people with IBS reported experiencing at least one lifetime episode of FI. In a subsample of 360 people who met strict Rome IV criteria and reported no other GI related co-morbidities, 62% reported experiencing at least one lifetime episode. While people who experienced FI more frequently had worse HRQL statistically, the differences in HRQL between people who had experienced FI and those who had not were not clinically significant. Rather than frequency of FI or physical symptom severity, quality of life was mostly determined by psychological variables, such as fear of food, anxiety, and catastrophizing. This study suggests that FI is quite prevalent in IBS patients, but that the best way to improve HRQL for IBS patients with FI may be to focus on reducing anxiety, catastrophizing and avoidance.
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297
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Yue K, Kopajtic TA, Katz JL. Abuse liability of mitragynine assessed with a self-administration procedure in rats. Psychopharmacology (Berl) 2018; 235:2823-2829. [PMID: 30039246 DOI: 10.1007/s00213-018-4974-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/12/2018] [Indexed: 11/26/2022]
Abstract
RATIONALE Substantial use of the plant kratom for psychoactive effects has driven interest in its abuse liability. Several place conditioning studies suggest abuse liability of the active ingredient mitragynine, though studies of its self-administration have not been published. METHODS Binding of mitragynine to rat brain mu, kappa, and delta opioid receptors was compared to that for heroin and morphine. Self-administration of mitragynine, heroin, methamphetamine, or saline was assessed during single-session substitutions in rats trained to self-administer methamphetamine (0.022 mg/kg/injection, i.v.) during 1-h daily sessions. RESULTS Mitragynine had > 2- or ~ 16-fold greater affinity for the mu opioid receptor than, respectively, for kappa or delta opioid receptors. Its affinity for the mu receptor was ~ 200-fold less than that for morphine. In rats trained to self-administer methamphetamine, saline substitutions significantly decreased the number of responses, whereas different doses of methamphetamine (0.002-0.068 mg/kg/injection) or heroin (0.001-0.03 mg/kg/injection) maintained self-administration with maximal responding at 0.022 or 0.01 mg/kg/injection, respectively. In contrast, no dose of mitragynine maintained response rates greater than those obtained with saline. Presession mitragynine treatment (0.1 to 3.0 mg/kg) decreased response rates maintained by heroin but had little effect on responding maintained by methamphetamine across the same range of doses. CONCLUSIONS These results suggest a limited abuse liability of mitragynine and potential for mitragynine treatment to specifically reduce opioid abuse. With the current prevalence of opioid abuse and misuse, it appears currently that mitragynine is deserving of more extensive exploration for its development or that of an analog as a medical treatment for opioid abuse.
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Affiliation(s)
- Kai Yue
- Wuhan Institute of Biomedical Science, Jianghan University, No. 8 Sanjiaohu Street, Wuhan, China
| | - Theresa A Kopajtic
- Psychobiology Section, Molecular Neuropsychiatry Research Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, 251 Bayview Blvd., Baltimore, MD, 21224, USA
| | - Jonathan L Katz
- Psychobiology Section, Molecular Neuropsychiatry Research Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, 251 Bayview Blvd., Baltimore, MD, 21224, USA.
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298
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Lacy BE. Review article: an analysis of safety profiles of treatments for diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 2018; 48:817-830. [PMID: 30194692 PMCID: PMC6667996 DOI: 10.1111/apt.14948] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/27/2018] [Accepted: 07/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is multifactorial in nature, and a wide range of therapies is available to manage symptoms of this common disorder. AIM To provide an overview of the safety of interventions that may be used to manage patients with diarrhoea-predominant IBS (IBS-D). METHODS Medline and Embase database searches (through 02 May 2018) to identify clinical studies that evaluated treatment safety and/or efficacy in adults with IBS-D. RESULTS IBS-D treatments include dietary modification, probiotics, serotonin receptor antagonists, opioid receptor agonists and antagonists, nonsystemic antibiotics, bile acid sequestrants, antidepressants, and complementary and alternative therapies. These treatments vary in administration frequency (eg, daily; short-course therapy) and target various pathophysiologic factors. Safety profiles vary considerably by treatment among IBS-D therapies. The number needed to harm (defined as the number of patients treated to encounter an adverse event) was lowest (worse) for antidepressants (8.5) and highest (best) for probiotics (35), and the number needed to harm (defined as the number of patients who discontinued due to an adverse event) was lowest for tricyclic antidepressants (9) and highest for rifaximin (8971). Notable safety concerns with IBS-D treatments include pancreatitis with eluxadoline, ischaemic colitis and serious complications of constipation with alosetron, and cardiac adverse events with loperamide and tricyclic antidepressants. Treatment decisions need to account for medication risks and adverse events for each patient. CONCLUSIONS Multiple treatment options are now available for patients with IBS-D. However, the safety profiles of these agents vary widely by number needed to harm value. Providers should consider both safety and efficacy of a specific intervention when determining how best to manage patients' IBS-D symptoms.
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Affiliation(s)
- Brian E. Lacy
- Section of GastroenterologyMayo ClinicJacksonvilleFlorida
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299
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Nguyen L. Complementary and Alternative Medicine for the Management of Irritable Bowel Syndrome. Gastroenterol Hepatol (N Y) 2018; 14:536-538. [PMID: 30364316 PMCID: PMC6194653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Linda Nguyen
- Clinical Associate Professor Clinic Director, Digestive Health Center Director, Neurogastroenterology & Motility Stanford University Stanford, California
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300
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Vitta S, Sayuk GS. Editorial: Tong-Xie-Yao-Fang (TXYF) for irritable bowel syndrome with diarrhoea (IBS-D)-ancient medicine meets modern study. Aliment Pharmacol Ther 2018; 48:485-486. [PMID: 30588695 DOI: 10.1111/apt.14902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S Vitta
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - G S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.,Gastroenterology Section, St. Louis Veterans Affairs Medical Center, St. Louis, MO, USA
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