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Smith KE, Epstein DH, Weiss ST. Controversies in Assessment, Diagnosis, and Treatment of Kratom Use Disorder. Curr Psychiatry Rep 2024; 26:487-496. [PMID: 39134892 PMCID: PMC11344726 DOI: 10.1007/s11920-024-01524-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2024] [Indexed: 08/25/2024]
Abstract
PURPOSE OF REVIEW We apply the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria for substance use disorders (SUDs) to the herbal product kratom. Similarities and differences between kratom use disorder (KUD) and other SUDs are explored, along with assessment, diagnostic, and therapeutic recommendations for KUD. RECENT FINDINGS Literature reports of "kratom addiction" or KUD rarely specify the criteria by which patients were diagnosed. Individuals meeting DSM-5 KUD criteria typically do so via tolerance and withdrawal, using more than intended, and craving, not functional or psychosocial disruption, which occur rarely. Most clinicians who use medication to treat patients with isolated KUD select buprenorphine formulations, although there are no controlled studies showing that buprenorphine is safe or efficacious in this patient population. Diagnosis and treatment decisions for KUD should be systematic. We propose an algorithm that takes into consideration whether KUD occurs with comorbid opioid use disorder.
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Affiliation(s)
- Kirsten E Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David H Epstein
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, 251 Bayview Blvd., Baltimore, MD, 21224, USA
| | - Stephanie T Weiss
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, 251 Bayview Blvd., Baltimore, MD, 21224, USA.
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Rhee J, Shin I, Kim J, Lee J, Cho B, Kim J, Park M, Kim E. LC-MS-MS method for mitragynine and 7-hydroxymitragynine in hair and its application in authentic hair samples of suspected kratom abusers. J Anal Toxicol 2024; 48:429-438. [PMID: 38780234 DOI: 10.1093/jat/bkae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/11/2024] [Accepted: 05/21/2024] [Indexed: 05/25/2024] Open
Abstract
Kratom is a natural psychoactive product known primarily in Southeast Asia, including Thailand, Malaysia, etc. It is also known as krathom, kakuam, ithang, thom (Thailand), biak-biak, ketum (Malaysia) and mambog (Philippines) and is sometimes used as an opium substitute. It is stimulant at doses of 1-5 g, analgesic at doses of 5-15 g and euphoric and sedative at doses of >15 g. Mitragynine is the most abundant indole compound in kratom (Mitragyna speciosa) and is metabolized in humans to 7-hydroxymitragynine, the more active metabolite. Adverse effects include seizures, nausea, vomiting, diarrhea, tachycardia, restlessness, tremors, hallucinations and death. There are few studies on the analytical method for the detection of mitragynine and 7-hydroxymitragynine in hair. Therefore, this study proposes a liquid chromatography-tandem mass spectrometry (LC-MS-MS) method for the analysis of kratom in hair. Hair samples were first weighed to ∼10 mg and washed with methanol. Then the washed hair samples were cut into pieces and incubated in methanol with stirring and heating (16 h/38℃). Extracts were then analyzed by LC-MS-MS. This method was validated by determining the limit of detection (LOD), limit of quantification, linearity, intra- and inter-day accuracy and precision, recovery and matrix effects. The intra- and inter-day precision (CV%) and accuracy (bias%) were within ±20%, which was considered acceptable. Using this newly developed LC-MS-MS method, the simultaneous detection of mitragynine and 7-hydroxymitragynine in six authentic hair samples was achieved to provide the direct evidence of kratom use in the past. Mitragynine concentrations ranged from 16.0 to 2,067 pg/mg (mean 905.3 pg/mg), and 7-hydroxymitragynine concentrations ranged from 0.34 to 15 pg/mg (mean 7.4 pg/mg) in six authentic hair samples from kratom abusers. This may be due to the higher sensitivity of the LOD in this study, with values of 0.05 pg/mg for mitragynine and 0.2 pg/mg for 7-hydroxymitragynine in hair.
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Affiliation(s)
- Jongsook Rhee
- Toxicology & Narcotics Division, National Forensic Service Seoul Institute, 139 Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Ilchung Shin
- Toxicology & Narcotics Division, National Forensic Service Seoul Institute, 139 Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Jihyun Kim
- Toxicology & Narcotics Division, National Forensic Service Seoul Institute, 139 Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Juseun Lee
- Forensic Science Department, National Forensic Service, 10 Ipchun-ro, Wonju-si, Gangwon-do 26460, Republic of Korea
| | - Byungsuk Cho
- Forensic Science Department, National Forensic Service, 10 Ipchun-ro, Wonju-si, Gangwon-do 26460, Republic of Korea
| | - Junghyun Kim
- Toxicology & Narcotics Division, National Forensic Service Seoul Institute, 139 Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Meejung Park
- Toxicology & Narcotics Division, National Forensic Service Seoul Institute, 139 Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Eunmi Kim
- Forensic Science Department, National Forensic Service, 10 Ipchun-ro, Wonju-si, Gangwon-do 26460, Republic of Korea
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Sureram S, Chutiwitoonchai N, Pooprasert T, Sangsopha W, Limjiasahapong S, Jariyasopit N, Sirivatanauksorn Y, Khoomrung S, Mahidol C, Ruchirawat S, Kittakoop P. Discovery of procyanidin condensed tannins of (-)-epicatechin from Kratom, Mitragyna speciosa, as virucidal agents against SARS-CoV-2. Int J Biol Macromol 2024; 273:133059. [PMID: 38866269 DOI: 10.1016/j.ijbiomac.2024.133059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 06/14/2024]
Abstract
Kratom, Mitragyna speciosa, is one of the most popular herbs in the West and Southeast Asia. A number of previous works have focused on bioactive alkaloids in this plant; however, non-alkaloids have never been investigated for their biological activities. Antiviral and virucidal assays of a methanol leaf extract of Kratom, M. speciosa, revealed that a crude extract displayed virucidal activity against the SARS-CoV-2. Activity-guided isolation of a methanol leaf extract of Kratom led to the identification of B-type procyanidin condensed tannins of (-)-epicatechin as virucidal compounds against SARS-CoV-2. The fraction containing condensed tannins exhibited virucidal activity with an EC50 value of 8.38 μg/mL and a selectivity index (SI) value >23.86. LC-MS/MS analysis and MALDI-TOF MS identified the structure of the virucidal compounds in Kratom as B-type procyanidin condensed tannins, while gel permeation chromatograph (GPC) revealed weight average molecular weight of 238,946 Da for high molecular-weight condensed tannins. In addition to alkaloids, (-)-epicatechin was found as a major component in the leaves of M. speciosa, but it did not have virucidal activity. Macromolecules of (-)-epicatechin, i.e., procyanidin condensed tannins, showed potent virucidal activity against SARS-CoV-2, suggesting that the high molecular weights of these polyphenols are important for virucidal activity.
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Affiliation(s)
- Sanya Sureram
- Chulabhorn Research Institute, Kamphaeng Phet 6 Road, Laksi, Bangkok 10210, Thailand University, Thailand
| | - Nopporn Chutiwitoonchai
- Virology and Cell Technology Research Team, National Center for Genetic Engineering and Biotechnology (BIOTEC), National Science and Technology Development Agency (NSTDA), 113 Thailand Science Park, Phahonyothin Rd., Pathumthani 12120, Thailand.
| | - Tam Pooprasert
- Chulabhorn Research Institute, Kamphaeng Phet 6 Road, Laksi, Bangkok 10210, Thailand University, Thailand
| | - Watchara Sangsopha
- Chulabhorn Research Institute, Kamphaeng Phet 6 Road, Laksi, Bangkok 10210, Thailand University, Thailand
| | - Suphitcha Limjiasahapong
- Siriraj Metabolomics and Phenomics Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Narumol Jariyasopit
- Siriraj Metabolomics and Phenomics Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Center of Research Excellent in Metabolomics and Systems Biology (SiCORE-MSB), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yongyut Sirivatanauksorn
- Siriraj Metabolomics and Phenomics Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Center of Research Excellent in Metabolomics and Systems Biology (SiCORE-MSB), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sakda Khoomrung
- Siriraj Metabolomics and Phenomics Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Center of Research Excellent in Metabolomics and Systems Biology (SiCORE-MSB), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chulabhorn Mahidol
- Chulabhorn Research Institute, Kamphaeng Phet 6 Road, Laksi, Bangkok 10210, Thailand University, Thailand; Chulabhorn Graduate Institute, Program in Chemical Sciences, Kamphaeng Phet, 6 Road, Laksi, Bangkok 10210, Thailand
| | - Somsak Ruchirawat
- Chulabhorn Research Institute, Kamphaeng Phet 6 Road, Laksi, Bangkok 10210, Thailand University, Thailand; Chulabhorn Graduate Institute, Program in Chemical Sciences, Kamphaeng Phet, 6 Road, Laksi, Bangkok 10210, Thailand; Center of Excellence on Environmental Health and Toxicology (EHT), OPS, Ministry of Higher Education, Science, Research and Innovation, Bangkok 10400, Thailand
| | - Prasat Kittakoop
- Chulabhorn Research Institute, Kamphaeng Phet 6 Road, Laksi, Bangkok 10210, Thailand University, Thailand; Chulabhorn Graduate Institute, Program in Chemical Sciences, Kamphaeng Phet, 6 Road, Laksi, Bangkok 10210, Thailand; Center of Excellence on Environmental Health and Toxicology (EHT), OPS, Ministry of Higher Education, Science, Research and Innovation, Bangkok 10400, Thailand.
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Smith KE, Rogers JM, Sharma A, McCurdy CR, Weiss ST, Dunn KE, Feldman JD, Kuntz MA, Mukhopadhyay S, Raju KSR, Taylor RC, Epstein DH. Responses to a "Typical" Morning Dose of Kratom in People Who Use Kratom Regularly: A Direct-Observation Study. J Addict Med 2024; 18:144-152. [PMID: 38174871 PMCID: PMC10939942 DOI: 10.1097/adm.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Use of kratom has outpaced systematic study of its effects, with most studies reliant on retrospective self-report. METHODS We aimed to assess acute effects following kratom use in adults who use regularly, and quantify alkaloids in the products, urine, and plasma. Between July and November 2022, 10 adults came to our clinic and orally self-administered their typical kratom dose; blinding procedures were not used. Physiological measures included blood pressure, respiratory rate, heart rate, pulse oximetry, temperature, and pupil diameter. Subjective outcomes included Subjective Opioid Withdrawal Scale, Addiction Research Center Inventory, and Drug Effects Questionnaire. Psychomotor performance was also assessed. RESULTS Participants were 6 men and 4 women, mean age 41.2 years. Nine were non-Hispanic White; 1 was biracial. They had used kratom for 6.6 years (SD, 3.8 years) on average (2.0-14.1). Sessions were 190.89 minutes on average (SD, 15.10 minutes). Mean session dose was 5.16 g (median, 4.38 g; range, 1.1-10.9 g) leaf powder. Relative to baseline, physiological changes were minor. However, pupil diameter decreased (right, b = -0.70, P < 0.01; left, b = -0.73, P < 0.01) 40-80 minutes postdose and remained below baseline >160 minutes. Subjective Opioid Withdrawal Scale pre-dosing was mild (5.5 ± 3.3) and decreased postdose (b = [-4.0, -2.9], P < 0.01). Drug Effects Questionnaire "feeling effects" increased to 40/100 (SD, 30.5) within 40 minutes and remained above baseline 80 to 120 minutes (b = 19.0, P = 0.04), peaking at 72.7/100; 6 participants rated euphoria as mild on the Addiction Research Center Inventory Morphine-Benzedrine-scale. Psychomotor performance did not reliably improve or deteriorate postdosing. CONCLUSIONS Among regular consumers, we found few clinically significant differences pre- and post-kratom dosing. Alkaloidal contents in products were within expected ranges.
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Affiliation(s)
- Kirsten E. Smith
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey M. Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Stephanie T. Weiss
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey D. Feldman
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Michelle A. Kuntz
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Sushobhan Mukhopadhyay
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Kanumuri Siva Rama Raju
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Richard C. Taylor
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - David H. Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
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McCurdy CR, Sharma A, Smith KE, Veltri CA, Weiss ST, White CM, Grundmann O. An update on the clinical pharmacology of kratom: uses, abuse potential, and future considerations. Expert Rev Clin Pharmacol 2024; 17:131-142. [PMID: 38217374 PMCID: PMC10846393 DOI: 10.1080/17512433.2024.2305798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/11/2024] [Indexed: 01/15/2024]
Abstract
INTRODUCTION Kratom (Mitragyna speciosa) has generated substantial clinical and scientific interest as a complex natural product. Its predominant alkaloid mitragynine and several stereoisomers have been studied for activity in opioid, adrenergic, and serotonin receptors. While awaiting clinical trial results, the pre-clinical evidence suggests a range of potential therapeutic applications for kratom with careful consideration of potential adverse effects. AREAS COVERED The focus of this review is on the pharmacology, pharmacokinetics, and potential drug-drug interactions of kratom and its individual alkaloids. A discussion on the clinical pharmacology and toxicology of kratom is followed by a summary of user surveys and the evolving concepts of tolerance, dependence, and withdrawal associated with kratom use disorder. EXPERT OPINION With the increasing use of kratom in clinical practice, clinicians should be aware of the potential benefits and adverse effects associated with kratom. While many patients may benefit from kratom use with few or no reported adverse effects, escalating dose and increased use frequency raise the risk for toxic events in the setting of polysubstance use or development of a use disorder.
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Affiliation(s)
- Christopher R McCurdy
- College of Pharmacy, Department of Pharmaceutics, University of Florida, FL, 32610, U.S.A
- College of Pharmacy, Department of Medicinal Chemistry, University of Florida, FL, 32610, U.S.A
| | - Abhisheak Sharma
- College of Pharmacy, Department of Pharmaceutics, University of Florida, FL, 32610, U.S.A
| | - Kirsten E. Smith
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, MD, 21205, U.S.A
| | - Charles A. Veltri
- Midwestern University, College of Pharmacy, Department of Pharmaceutical Sciences, Glendale, AZ, 85308, U.S.A
| | - Stephanie T. Weiss
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, U.S.A
| | - Charles M. White
- University of Connecticut School of Pharmacy, Storrs, CT, and Department of Pharmacy, Hartford Hospital, Hartford, CT, U.S.A
| | - Oliver Grundmann
- College of Pharmacy, Department of Medicinal Chemistry, University of Florida, FL, 32610, U.S.A
- Midwestern University, College of Pharmacy, Department of Pharmaceutical Sciences, Glendale, AZ, 85308, U.S.A
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