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Swart BB, Reznikoff C, Steen K. Isolated Kratom Use Disorder Treated with Extended-Release Buprenorphine Taper. J Addict Med 2024:01271255-990000000-00314. [PMID: 38776432 DOI: 10.1097/adm.0000000000001328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT This case report highlights a 36-year-old male without history of psychiatric disease, chronic pain, or substance use disorder who developed severe substance use disorder per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria to kratom. He was successfully treated with sublingual buprenorphine after a 3-year period of intermittent withdrawal management and trials of oral and extended-release injectable naltrexone. After a period of abstinence from kratom, he was tapered from buprenorphine using 2 monthly injections of 100 mg extended-release buprenorphine. His case underscores some of the current uncertainties around kratom use disorder diagnosis and treatment.
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Affiliation(s)
- Benjamin B Swart
- From the Addiction Medicine Fellow, University of Minnesota, Minneapolis, MN (BBS); Associate Professor of Medicine, University of Minnesota, Internal Medicine and Addiction Medicine, Hennepin County Medical Center, Minneapolis, MN (CR); and Faculty Physician, Addictive Recovery Services, Veteran's Affairs Medical Center, Minneapolis, MN (KS)
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2
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Alghalith A, Nguyen H, Tennant R. The Complexities of Kratom: Insights on an Increasingly Frequent Clinical Encounter. Cureus 2024; 16:e59650. [PMID: 38832209 PMCID: PMC11146460 DOI: 10.7759/cureus.59650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2024] [Indexed: 06/05/2024] Open
Abstract
Mitragyna speciosa (kratom) is a tropical tree native to Southeast Asia with dose-dependent stimulant and opioid properties. Kratom has garnered attention due to its increasing popularity and potential for dependence, tolerance, and withdrawal. We report the case of a 72-year-old man admitted to the hospital for a deep vein thrombosis and obstructive uropathy who began experiencing kratom withdrawal. He experienced less cravings and improvement in withdrawal symptoms with buprenorphine-naloxone 8 mg/2 mg daily. Notably, our case highlights kratom's contributions to a medically complex presentation and potential kratom-drug interactions due to its posited inhibitory effect on cytochrome P450 enzymes and P-glycoprotein. Our case adds to the growing literature which describes buprenorphine-naloxone as an effective treatment for kratom dependence and withdrawal.
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Affiliation(s)
- Adam Alghalith
- Psychiatry, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Hoanglong Nguyen
- Internal Medicine, Olive View-University of California Los Angeles Medical Center, Los Angeles, USA
| | - Richard Tennant
- Internal Medicine, Olive View-University of California Los Angeles Medical Center, Los Angeles, USA
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3
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Smith KE, Feldman JD, Schriefer D, Weiss ST, Grundmann O, Dunn KE, Singh D, McCurdy CR, Butera G, Epstein DH. Diagnostic Ambiguities and Underuse of Clinical Assessment Tools: A Systematic Review of Case Reports on Kratom Addiction and Physical Dependence. CURRENT ADDICTION REPORTS 2023. [DOI: 10.1007/s40429-023-00474-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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4
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Mukhopadhyay S, Gupta S, Wilkerson JL, Sharma A, McMahon LR, McCurdy CR. Receptor Selectivity and Therapeutic Potential of Kratom in Substance Use Disorders. CURRENT ADDICTION REPORTS 2023. [DOI: 10.1007/s40429-023-00472-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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5
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Garmon EH, Olson K. Narrative Review of Kratom, an Emerging Psychoactive Substance With Perianesthetic Implications. Anesth Analg 2022; 135:1180-1188. [PMID: 35986675 DOI: 10.1213/ane.0000000000006177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Opioid overprescribing, with resultant overdose and death, has led to a national focus on alternative treatments for pain. With the decline in legal access to opioids, kratom has gained popularity as a legal, "natural," and easily accessible nonprescription analgesic for consumers wishing to self-medicate for pain, opioid use disorder, and other mental health conditions. While implications of kratom use in patients with chronic pain and/or opioid use disorder have been published, information on perianesthetic implications is lacking. Anesthesiologists should be informed about kratom, including the potential for unexpected physiologic derangements and adverse drug interactions resulting from complex pharmacologic activity, cytochrome P450 interactions, and common adulterations of the drug that may result in unpredictable clinical effects. This article explores the relevance of kratom to perioperative anesthetic care, including suggestions for anesthesiologists extrapolated from published information in nonoperative settings that may improve patient safety in individuals using kratom.
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Affiliation(s)
- Emily H Garmon
- From the Baylor Scott and White Temple Department of Anesthesiology, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Kandice Olson
- Mountain West Anesthesia, Provo, Utah.,Department of Anesthesiology, Utah Vallery Hospital, Provo, Utah
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6
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Leyrer-Jackson JM, Acuña AM, Olive MF. Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update. Expert Opin Pharmacother 2022; 23:1819-1830. [PMID: 36278879 PMCID: PMC9764962 DOI: 10.1080/14656566.2022.2140039] [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: 06/02/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States. AREAS COVERED In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal. EXPERT OPINION To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.
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Affiliation(s)
- Jonna M. Leyrer-Jackson
- Department of Medical Education, School of Medicine, Creighton University, Phoenix, AZ, 85012, USA
| | - Amanda M. Acuña
- Department of Psychology, Arizona State University, Tempe, AZ, 85257, USA
- Interdepartmental Graduate Program in Neuroscience, Arizona State University, Tempe, AZ, 85257, USA
| | - M. Foster Olive
- Department of Psychology, Arizona State University, Tempe, AZ, 85257, USA
- Interdepartmental Graduate Program in Neuroscience, Arizona State University, Tempe, AZ, 85257, USA
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Smith KE, Rogers JM, Strickland JC. Associations of Lifetime Nonmedical Opioid, Methamphetamine, and Kratom Use within a Nationally Representative US Sample. J Psychoactive Drugs 2022; 54:429-439. [PMID: 34842079 PMCID: PMC9148372 DOI: 10.1080/02791072.2021.2006374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/23/2021] [Accepted: 09/07/2021] [Indexed: 12/31/2022]
Abstract
Co-use of non-medical opioids (NMO) and methamphetamine is increasing. So too is the use of the psychoactive botanical "kratom," including among people with NMO and methamphetamine use histories. We assessed characteristics associated with respondent groups who reported lifetime methamphetamine and/or kratom use within a nationally representative US sample using 2019 National Survey on Drug Use and Health data from respondents reporting lifetime NMO use (diverted prescription opioids, heroin). Weighted prevalence estimates for demographic, mental health, and substance use outcomes were determined. Logistic regression examined associations between group membership and outcomes. Among this sample of respondents with lifetime NMO use, 67.6% (95% CI = 65.6-69.4%) reported only NMO use; 4.6% (3.9-5.4%) reported NMO+Kratom; 24.7% (22.7-26.7%) reported NMO+Methamphetamine; and 3.2% (2.5-3.9%) reported NMO+Methamphetamine+Kratom. Compared to those in the NMO-only group, the NMO+Kratom group was more likely to report past-year serious mental illness (SMI; OR = 2.27), suicidality (OR = 1.89), and past-month psychological distress (OR = 1.88). The NMO+Methamphetamine+Kratom group was more likely to report past-year SMI (OR = 2.65), past-month psychological distress (OR = 2.06), and unmet mental health needs (OR = 2.03); increased odds for drug injection, opioid withdrawal, and perceived treatment need also emerged. Risk factors were observed for all groups but were greatest among those reporting use of all three substances.
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Affiliation(s)
- Kirsten E. Smith
- National Institute on Drug Abuse Intramural Research Program, 251 Bayview Blvd. Baltimore, Maryland 21224, USA
| | - Jeffrey M. Rogers
- National Institute on Drug Abuse Intramural Research Program, 251 Bayview Blvd. Baltimore, Maryland 21224, USA
| | - Justin C. Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
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Stanciu C, Ahmed S, Gnanasegaram S, Gibson S, Penders T, Grundmann O, McCurdy C. Kratom as an opioid alternative: harm, or harm reduction? A systematic review of literature. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2022; 48:509-528. [PMID: 36001875 DOI: 10.1080/00952990.2022.2111685] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: Kratom (Mitragyna speciosa Korth.) products are increasingly endorsed for self-management of multiple ailments, including as opioid substitution. The FDA has expressed that there is no evidence to indicate that this botanical is safe or effective for any medical use.Objective: We systematically review the current state of the literature concerning the impact of kratom and its alkaloids in all paradigms that involve opioids.Methods: A keyword search of online literature databases identified 16 preclinical studies, 25 case reports, and 10 observational studies meeting our pre-selected criteria.Results: All rodent models support alkaloids' action on opioid receptors, translating in their ability to mitigate opioid withdrawal. Some studies found mitragynine (MG) to have less reinforcing properties than morphine, and possessing tolerance-sparing properties when coadministered with morphine. Two studies that assessed 7-hydroxymitragynine (7OHMG) found it to substitute for morphine with potential for tolerance and dependence. Aside from addiction development, case reports outline a variety of confounding toxicities. Ten surveys of users, some conducted with assistance from pro-kratom lobbying organizations, find a high self-reported efficacy as an opioid substitute, with minimal reported adverse effects.Conclusion: With no reported controlled human clinical trials, in the light of rising concerns surrounding kratom's liabilities, there is insufficient evidence to allow any conclusions to be drawn. Case reports and observational studies carry significant bias toward harm and efficacy, respectively. Existing animal studies are heterogeneous in methodology and ultimately findings, with concern for interspecies variability and human translatability. Further research should investigate the safety and efficacy of using kratom alkaloids as opioid substitutes.
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Affiliation(s)
- Cornel Stanciu
- New Hampshire Hospital, Psychiatry at Dartmouth's Geisel School of Medicine, Concord, NH, USA
| | - Saeed Ahmed
- Department of Psychiatry, Rutland Regional Medical Centre, Rutland, VT, USA
| | | | - Stephen Gibson
- Pharmacy Department, New Hampshire Hospital, Concord, NH, USA
| | - Thomas Penders
- Department of Addiction, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Christopher McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
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Grundmann O, Hendrickson RG, Greenberg MI. Kratom: History, pharmacology, current user trends, adverse health effects and potential benefits. Dis Mon 2022; 69:101442. [PMID: 35732553 DOI: 10.1016/j.disamonth.2022.101442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Kratom (Mitragyna speciosa Korth.) is a tree native to Southeast Asia with dose-dependent stimulant and opioid-like effects. Dried, powdered leaf material is among the kratom products most commonly consumed in the US and Europe, but other formulations also exist including enriched extracts, resins, tinctures, and edibles. Its prevalence in the US remains debated and the use pattern includes self-treatment of mood disorders, pain, and substance use disorders. Most of the adverse effects of kratom and its alkaloid mitragynine have been reported in the literature as case reports or part of surveys necessitating confirmation by clinical trials. Toxicities associated with kratom consumption have focused on hepatic, cardiac, and CNS effects with the potential to cause fatalities primarily as part of polydrug exposures. Kratom may also present with drug-drug interactions primarily through CYP 3A4 and 2D6 inhibition, although the clinical significance remains unknown to date. The variability in composition of commercially available kratom products complicates generalization of findings and requires further investigation by employing clinical trials. Healthcare professionals should remain cautious in counseling patients on the use of kratom in a therapeutic setting.
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Affiliation(s)
- Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, 1345 Center Drive, Room P3-20, Gainesville, FL 32611, United States.
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Smith KE, Dunn KE, Epstein DH, Feldman JD, Garcia-Romeu A, Grundmann O, Henningfield JE, McCurdy CR, Rogers JM, Schriefer D, Singh D, Weiss ST. Need for clarity and context in case reports on kratom use, assessment, and intervention. Subst Abus 2022; 43:1221-1224. [PMID: 35657649 DOI: 10.1080/08897077.2022.2074608] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This Letter to the Editor is a response to Broyan and colleagues who recently published a Case Report presenting data on 28 patients in the United States who identified kratom as their primary substance of use and who were subsequently induced on buprenorphine/naloxone for a reported diagnosis of kratom use disorder. We applaud the authors for helping to advance the science on kratom and recognize the difficulties in conducting kratom-related clinical assessment and research. However, a number of inconsistences and generalizations were identified in this Case Report, which also lacked some critical context. Importantly, such inconsistencies and generalizations can be observed throughout kratom-specific case reports. We feel this is now an important opportunity to highlight these issues that are present in the Broyan and colleagues Case report but emphasize that they are not unique to it. We do this with the hope that by acknowledging these issues it can help inform editors, clinicians, and researchers who may not be familiar with kratom and, as a result of this unfamiliarity, may inadvertently present findings in a manner that could confuse readers and even misinform clinical researchers and practitioners.
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Affiliation(s)
- Kirsten E Smith
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David H Epstein
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Jeffrey D Feldman
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Albert Garcia-Romeu
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Jack E Henningfield
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Pinney Associates, Inc, Bethesda, MD, USA
| | - Christopher R McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Jeffrey M Rogers
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA.,SDSU/UCSD Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - Destiny Schriefer
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA.,The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Darshan Singh
- Centre for Drug Research, Universiti Sains Malaysia, Penang, Malaysia
| | - Stephanie T Weiss
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
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Striley CW, Hoeflich CC, Viegas AT, Berkowitz LA, Matthews EG, Akin LP, Iheanyi-Okeahialam C, Mansoor U, McCurdy CR. Health Effects Associated With Kratom ( Mitragyna speciosa) and Polysubstance Use: A Narrative Review. Subst Abuse 2022; 16:11782218221095873. [PMID: 35645563 PMCID: PMC9130800 DOI: 10.1177/11782218221095873] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/01/2022] [Indexed: 11/15/2022]
Abstract
Background Kratom (Mitragyna speciosa) consumption and associated health effects have raised debates in the United States. Although most people using this herb do not experience adverse health effects associated with kratom use, medical providers should be knowledgeable of emerging substances and concurrent, sequential, or simultaneous use of other drugs which may impact healthcare recommendations and prescribing practices. Methods The objective of this narrative review was to elucidate selected health effects associated with using kratom-either alone or with other substances. Since scientifically controlled human subjects research on kratom use is still limited, relevant case reports were also described. Results Cardiovascular, gastrointestinal, neurological, and psychiatric effects associated with kratom use were especially notable, and in-utero exposure accompanied concern regarding a neonate's risk for developing neonatal abstinence syndrome. Our ability to identify and understand the role of this herb in kratom-associated fatalities is complicated since kratom is not routinely screened for in standard forensic toxicology. If a screening is performed, it is usually for the major alkaloid, mitragynine, as a surrogate for kratom use. In addition to lacking a standard practice of screening decedents for kratom alkaloids, the association between mortality and kratom use may be confounded by polysubstance use, adulteration of kratom products, and drug-herb interactions. Conclusions Increasing medical awareness of this herb is vital to ensuring prompt administration of best-practice medical advice or treatment for people seeking information related to kratom use or for patients experiencing an adverse health effect that may be associated with using or withdrawing from kratom. Knowledge gained from continued surveillance and study of kratom and its associated health effects may assist in guiding clinical decision-making and preventing development of adverse health effects among people using kratom.
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Affiliation(s)
- Catherine W Striley
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Carolin C Hoeflich
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Andrew T Viegas
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA.,College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Lindsey A Berkowitz
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA.,Department of Occupational Therapy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Emily G Matthews
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Leyla P Akin
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA.,Department of Anthropology, London School of Economics and Political Science, London, England, UK
| | - Chidinma Iheanyi-Okeahialam
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Urmeen Mansoor
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA.,College of Journalism and Communications, 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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12
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Broyan VR, Brar JK, Allgaier Student T, Allgaier JT. Long-term buprenorphine treatment for kratom use disorder: A case series. Subst Abus 2022; 43:763-766. [PMID: 35112990 DOI: 10.1080/08897077.2021.2010250] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Opioid agonist therapy with buprenorphine is an effective, evidence-based treatment for opioid use disorder. However, there has been increasing use of alternative substances which can still produce opioid-like effects. One of these substances is the herbal supplement kratom. The chemical composition of kratom, specifically mitragynine and 7-hydroxymitragynine, has partial mu-opioid receptor agonist and antagonist effects at the kappa- and delta-opioid receptors. Due to its addictive potential, accessibility, and legal status, there have been increasing cases of kratom use disorder (KUD). Thus, it is important to consider effective treatment options for this nontraditional substance. Methods: Twenty-eight patients self-identified kratom as their primary substance of use. Length of kratom use ranged between 1 month and 25 years, with an average daily kratom dose of 92 g/d. Nine patients were inducted on a buprenorphine/naloxone dose between 1 and 6 mg, 18 patients between 8 and 16 mg, and 1 patient at 20 mg. Three patients were stabilized on a dose at 4 mg, 23 patients between 8 and 16 mg, 1 patient at 18 mg, and 1 patient at 20 mg. Results: There was no correlation between stabilizing dose of buprenorphine/naloxone and past daily dose of kratom. As of March 2020, 20 of the 28 patients were still receiving outpatient buprenorphine/naloxone treatment. Six patients were lost to follow-up due to missed appointments, 1 tapered down to 0.25 mg of buprenorphine/naloxone and self-discharged, and 1 moved out of town. The rest have remained in treatment from 5 to 22 months, with an average duration of 11 months. Of the 28 patients, 68%, 82%, and 82% had negative test results for mitragynine at 4, 8, and 12 weeks of treatment, respectively. Conclusions: To our knowledge, this is the largest case series exploring long-term buprenorphine/naloxone treatment for KUD. Our findings suggest buprenorphine/naloxone can be used as an effective treatment option for KUD.
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Affiliation(s)
| | - Jessica K Brar
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
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Hiranita T, Obeng S, Sharma A, Wilkerson JL, McCurdy CR, McMahon LR. In vitro and in vivo pharmacology of kratom. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2021; 93:35-76. [PMID: 35341571 DOI: 10.1016/bs.apha.2021.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Kratom products have been historically and anecdotally used in south Asian countries for centuries to manage pain and opioid withdrawal. The use of kratom products has dramatically increased in the United States. More than 45 kratom alkaloids have been isolated, yet the overall pharmacology of the individual alkaloids is still not well characterized. The purpose of this chapter is to summarize in vitro and in vivo opioid activities of the primary kratom alkaloid mitragynine and its more potent metabolite 7-hydroxymitragynine. Following are experimental procedures described to characterize opioid receptor activity; receptor binding and functional assays, antinociceptive assays, operant conditioning assays, and respiratory plethysmography. The capacity of kratom alkaloids to confer tolerance and physical dependence as well as their pharmacokinetic properties are also summarized. The data reviewed here suggest that kratom products and mitragynine possess low efficacy agonist activity at the mu-opioid receptor in vivo. In addition, kratom products and mitragynine have been demonstrated to antagonize the effects of high efficacy mu-opioid agonists. The data further suggest that 7-hydroxymitragynine formed in vivo by metabolism of mitragynine may be minimally involved in the overall behavioral profile of mitragynine and kratom, whereas 7-hydroxymitragynine itself, at sufficiently high doses administered exogenously, shares many of the same abuse- and dependence-related behavioral effects associated with traditional opioid agonists. The apparent low efficacy of kratom products and mitragynine at mu-opioid receptors supports the development of these ligands as effective and potentially safe medications for opioid use disorder.
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Affiliation(s)
- Takato Hiranita
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Samuel Obeng
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States; Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States; Translational Drug Development Core, Clinical and Translational Sciences Institute, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Jenny L Wilkerson
- Department of Pharmacodynamics, 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; Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States; Translational Drug Development Core, Clinical and Translational Sciences Institute, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Lance R McMahon
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States.
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14
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Hassan R, Sreenivasan S, Müller CP, Hassan Z. Methadone, Buprenorphine, and Clonidine Attenuate Mitragynine Withdrawal in Rats. Front Pharmacol 2021; 12:708019. [PMID: 34322028 PMCID: PMC8311127 DOI: 10.3389/fphar.2021.708019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Kratom or Mitragyna speciosa Korth has been widely used to relieve the severity of opioid withdrawal in natural settings. However, several studies have reported that kratom may by itself cause dependence following chronic consumption. Yet, there is currently no formal treatment for kratom dependence. Mitragynine, is the major psychoactive alkaloid in kratom. Chronic mitragynine treatment can cause addiction-like symptoms in rodent models including withdrawal behaviour. In this study we assessed whether the prescription drugs, methadone, buprenorphine and clonidine, could mitigate mitragynine withdrawal effects. In order to assess treatment safety, we also evaluated hematological, biochemical and histopathological treatment effects. Methods: We induced mitragynine withdrawal behaviour in a chronic treatment paradigm in rats. Methadone (1.0 mg/kg), buprenorphine (0.8 mg/kg) and clonidine (0.1 mg/kg) were i.p. administered over four days during mitragynine withdrawal. These treatments were stopped and withdrawal sign assessment continued. Thereafter, toxicological profiles of the treatments were evaluated in the blood and in organs. Results: Chronic mitragynine treatment caused significant withdrawal behaviour lasting at least 5 days. Methadone, buprenorphine, as well as clonidine treatments significantly attenuated these withdrawal signs. No major effects on blood or organ toxicity were observed. Conclusion: These data suggest that the already available prescription medications methadone, buprenorphine, and clonidine are capable to alleviate mitragynine withdrawal signs rats. This may suggest them as treatment options also for problematic mitragynine/kratom use in humans.
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Affiliation(s)
- Rahimah Hassan
- Centre for Drug Research, Universiti Sains Malaysia, Minden, Malaysia
| | - Sasidharan Sreenivasan
- Institute for Research in Molecular Medicine, Universiti Sains Malaysia, Minden, Malaysia
| | - Christian P Müller
- Centre for Drug Research, Universiti Sains Malaysia, Minden, Malaysia.,Section of Addiction Medicine, Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Zurina Hassan
- Centre for Drug Research, Universiti Sains Malaysia, Minden, Malaysia.,Addiction Behaviour and Neuroplasticity Laboratory, National Neuroscience Institute, Singapore, Singapore
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15
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Jensen AN, Truong QN, Jameson M, Nadal CN. Kratom-induced transaminitis with subsequent precipitated opioid withdrawal following naltrexone. Ment Health Clin 2021; 11:220-224. [PMID: 34026398 PMCID: PMC8120986 DOI: 10.9740/mhc.2021.05.220] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Kratom is an herbal supplement that has gained popularity for recreational use within the United States. Kratom exerts opioid-like effects and, although not US FDA approved, is commonly used for self-treatment of pain, withdrawal management from opioids, and euphoria. Drug-related hepatic injury has been associated with kratom use. All of this raises concern for patient safety and monitoring. The potential for additive liver toxicity must be considered when kratom is used concurrently with hepatotoxic, over-the-counter, herbal, and prescription medications. This case report describes a case of kratom-induced liver inflammation complicated by opioid withdrawal that was precipitated by initiation of IM naltrexone. To our knowledge, there are no published case reports related to opioid withdrawal following naltrexone administration in patients using kratom (without other opioids). The purpose of this case report is to demonstrate potential complications that may arise with kratom use and considerations that should be taken prior to initiation of naltrexone in kratom users.
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Affiliation(s)
- Aimee N Jensen
- PGY-2 Pharmacy Administration and Leadership Resident, Bay Pines VA Healthcare System, Department of Veterans Affairs, Bay Pines, Florida.,PGY-1 Pharmacy Practice Resident, Bay Pines VA Healthcare System, Department of Veterans Affairs, Bay Pines, Florida.,Psychiatrist, Bay Pines VA Healthcare System, Department of Veterans Affairs, Bay Pines, Florida
| | - Quynh-Nhu Truong
- PGY-2 Pharmacy Administration and Leadership Resident, Bay Pines VA Healthcare System, Department of Veterans Affairs, Bay Pines, Florida
| | - Melanie Jameson
- PGY-1 Pharmacy Practice Resident, Bay Pines VA Healthcare System, Department of Veterans Affairs, Bay Pines, Florida
| | - Celeste N Nadal
- Psychiatrist, Bay Pines VA Healthcare System, Department of Veterans Affairs, Bay Pines, Florida
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16
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Lei J, Butz A, Valentino N. Management of kratom dependence with buprenorphine/naloxone in a veteran population. Subst Abus 2021; 42:497-502. [PMID: 33617752 DOI: 10.1080/08897077.2021.1878086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Kratom is a substance that when ingested produces an opioid-like effect. As kratom continues to gain popularity, increasing numbers of cases of addiction, dependence, and adverse events have been reported, as well as an increase in mortality associated with its use. George E. Wahlen Department of Veterans Affairs Medical Center has been using buprenorphine/naloxone for the treatment of kratom withdrawal and dependence in both primary care and specialty addiction treatment settings in the Veteran population. Cases: We present three cases that describe the use of buprenorphine/naloxone for kratom dependence. For each case, we describe the withdrawal symptoms from kratom, induction and long-term maintenance on buprenorphine/naloxone in kratom dependence, the impact of polysubstance use disorders in management of kratom dependence, and the use of urine drug screens for kratom alkaloids during treatment. Discussion: This case series demonstrates that patients with kratom dependence can effectively be treated with buprenorphine/naloxone. It appears that it is safe to induce buprenorphine/naloxone as early as eight hours after last kratom use and maintenance dosing for kratom use was similar to maintenance doses used in opioid use disorder. Prolonged and continued withdrawal symptoms were reported despite treatment with buprenorphine/naloxone and multiple daily doses of up to 24mg per day may be beneficial for prolonged withdrawal symptoms and for cooccurring pain. Polysubstance use with kratom dependence may require higher levels of care and higher doses of buprenorphine/naloxone. Urine drug screens may be best practice for monitoring kratom alkaloids concentrations and facilities that utilize buprenorphine/naloxone to treat kratom dependence should have testing available. Further research is needed on the impact and the treatment of kratom dependence.
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Affiliation(s)
- Jamie Lei
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Veterans Affairs New York Harbor Health Care System, New York City, New York, USA
| | - Amy Butz
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Natalie Valentino
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
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17
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Vento AE, de Persis S, De Filippis S, Schifano F, Napoletano F, Corkery JM, Kotzalidis GD. Case Report: Treatment of Kratom Use Disorder With a Classical Tricyclic Antidepressant. Front Psychiatry 2021; 12:640218. [PMID: 33868054 PMCID: PMC8044355 DOI: 10.3389/fpsyt.2021.640218] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/05/2021] [Indexed: 12/13/2022] Open
Abstract
Kratom or Mitragyna speciosa (Korth.) is an evergreen tree of the coffee family native to South-East Asia and Australasia. It is used by locals recreationally to induce stimulant and sedative effects and medically to soothe pain and opiate withdrawal. Its leaves are smoked, chewed, or infused, or ground to yield powders or extracts for use as liquids. It contains more than 40 alkaloids; among these, mitragynine and 7-hydroxymitragynine are endowed with variable mu, delta, and kappa opioid stimulating properties (with 7-hydroxymitragynine having a more balanced affinity), rhynchophylline, which is a non-competitive NMDA glutamate receptor antagonist, but is present in negligible quantities, and raubasine, which inhibits α1-adrenceptors preferentially over α2-adrenceptors, while the latter are bound by 7-hydroxymitragynine, while mitragynine counters 5-HT2A receptors. This complexity of neurochemical mechanisms may account for kratom's sedative-analgesic and stimulant effects. It is commonly held that kratom at low doses is stimulant and at higher doses sedative, but no cut-off has been possible to define. Long-term use of kratom may produce physical and psychological effects that are very similar to its withdrawal syndrome, that is, anxiety, irritability, mood, eating, and sleep disorders, other than physical symptoms resembling opiate withdrawal. Kratom's regulatory status varies across countries; in Italy, both mitragynine and the entire tree and its parts are included among regulated substances. We describe the case of a patient who developed anxiety and dysphoric mood and insomnia while using kratom, with these symptoms persisting after withdrawal. He did not respond to a variety of antidepressant combinations and tramadol for various months, and responded after 1 month of clomipramine. Well-being persisted after discontinuing tramadol.
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Affiliation(s)
- Alessandro E Vento
- ASL (Azienda Sanitaria Locale) Roma 2, Rome, Italy.,Addictions' Observatory (ODDPSS), Rome, Italy
| | | | - Sergio De Filippis
- Villa von Siebenthal Neuropsychiatric Clinic and Hospital, Genzano di Roma, Italy
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Flavia Napoletano
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - John M Corkery
- Psychopharmacology, Drug Misuse & Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Georgios D Kotzalidis
- Villa von Siebenthal Neuropsychiatric Clinic and Hospital, Genzano di Roma, Italy.,NESMOS Department (Neurosciences, Mental Health, and Sensory Organs), School of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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18
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Pharmacology of Herbal Sexual Enhancers: A Review of Psychiatric and Neurological Adverse Effects. Pharmaceuticals (Basel) 2020; 13:ph13100309. [PMID: 33066617 PMCID: PMC7602496 DOI: 10.3390/ph13100309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/13/2022] Open
Abstract
Sexual enhancers increase sexual potency, sexual pleasure, or libido. Substances increasing libido alter the concentrations of specific neurotransmitters or sex hormones in the central nervous system. Interestingly, the same pathways are involved in the mechanisms underlying many psychiatric and neurological disorders, and adverse reactions associated with the use of aphrodisiacs are strongly expected. However, sexual enhancers of plant origin have gained popularity over recent years, as natural substances are often regarded as a safer alternative to modern medications and are easily acquired without prescription. We reviewed the psychiatric and neurological adverse effects associated with the consumption of herbal aphrodisiacs Areca catechu L., Argemone Mexicana L., Citrus aurantium L., Eurycoma longifolia Jack., Lepidium meyenii Walp., Mitragyna speciosa Korth., Panax ginseng C. A. Mey, Panax quinquefolius L., Pausinystalia johimbe (K. Schum.) Pierre ex Beille, Piper methysticum G. Forst., Ptychopetalum olacoides Benth., Sceletium tortuosum (L.) N. E. Brown, Turnera diffusa Willd. ex. Schult., Voacanga africana Stapf ex Scott-Elliot, and Withania somnifera (L.) Dunal. A literature search was conducted on the PubMed, Scopus, and Web of Science databases with the aim of identifying all the relevant articles published on the issue up to June 2020. Most of the selected sexual enhancers appeared to be safe at therapeutic doses, although mild to severe adverse effects may occur in cases of overdosing or self-medication with unstandardized products. Drug interactions are more concerning, considering that herbal aphrodisiacs are likely used together with other plant extracts and/or pharmaceuticals. However, few data are available on the side effects of several plants included in this review, and more clinical studies with controlled administrations should be conducted to address this issue.
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19
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Treatment of Kratom Withdrawal and Dependence With Buprenorphine/Naloxone: A Case Series and Systematic Literature Review. J Addict Med 2020; 15:167-172. [DOI: 10.1097/adm.0000000000000721] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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20
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Reinert JP, Colunga K, Etuk A, Richardson V, Dunn RL. Management of overdoses of salvia, kratom, and psilocybin mushrooms: a literature review. Expert Rev Clin Pharmacol 2020; 13:847-856. [DOI: 10.1080/17512433.2020.1794811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Justin P. Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Kayla Colunga
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Alexandria Etuk
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | | | - Rebecca L. Dunn
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
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21
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Flores-Bocanegra L, Raja HA, Graf TN, Augustinović M, Wallace ED, Hematian S, Kellogg JJ, Todd DA, Cech NB, Oberlies NH. The Chemistry of Kratom [ Mitragyna speciosa]: Updated Characterization Data and Methods to Elucidate Indole and Oxindole Alkaloids. JOURNAL OF NATURAL PRODUCTS 2020; 83:2165-2177. [PMID: 32597657 PMCID: PMC7718854 DOI: 10.1021/acs.jnatprod.0c00257] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Two separate commercial products of kratom [Mitragyna speciosa (Korth.) Havil. Rubiaceae] were used to generate reference standards of its indole and oxindole alkaloids. While kratom has been studied for over a century, the characterization data in the literature for many of the alkaloids are either incomplete or inconsistent with modern standards. As such, full 1H and 13C NMR spectra, along with HRESIMS and ECD data, are reported for alkaloids 1-19. Of these, four new alkaloids (7, 11, 17, and 18) were characterized using 2D NMR data, and the absolute configurations of 7, 17, and 18 were established by comparison of experimental and calculated ECD spectra. The absolute configuration for the N(4)-oxide (11) was established by comparison of NMR and ECD spectra of its reduced product with those for compound 7. In total, 19 alkaloids were characterized, including the indole alkaloid mitragynine (1) and its diastereoisomers speciociliatine (2), speciogynine (3), and mitraciliatine (4); the indole alkaloid paynantheine (5) and its diastereoisomers isopaynantheine (6) and epiallo-isopaynantheine (7); the N(4)-oxides mitragynine-N(4)-oxide (8), speciociliatine-N(4)-oxide (9), isopaynantheine-N(4)-oxide (10), and epiallo-isopaynantheine-N(4)-oxide (11); the 9-hydroxylated oxindole alkaloids speciofoline (12), isorotundifoleine (13), and isospeciofoleine (14); and the 9-unsubstituted oxindoles corynoxine A (15), corynoxine B (16), 3-epirhynchophylline (17), 3-epicorynoxine B (18), and corynoxeine (19). With the ability to analyze the spectroscopic data of all of these compounds concomitantly, a decision tree was developed to differentiate these kratom alkaloids based on a few key chemical shifts in the 1H and/or 13C NMR spectra.
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Affiliation(s)
- Laura Flores-Bocanegra
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Huzefa A Raja
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Tyler N Graf
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Mario Augustinović
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - E Diane Wallace
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Shabnam Hematian
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Joshua J Kellogg
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Daniel A Todd
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Nadja B Cech
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
| | - Nicholas H Oberlies
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina 27402, United States
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22
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Bowe A, Kerr PL. A Complex Case of Kratom Dependence, Depression, and Chronic Pain in Opioid Use Disorder: Effects of Buprenorphine in Clinical Management. J Psychoactive Drugs 2020; 52:447-452. [PMID: 32546067 DOI: 10.1080/02791072.2020.1773586] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Mitragyna speciosa (Kratom) is a psychotropic tropical tree that is indigenous to Southeast Asia, Africa and New Guinea. Kratom has gained popularity in the United States in more recent years as an opioid agonist. Although Kratom is considered an opioid agonist with abuse potential, its use is not federally regulated. We report on a 47 year-old male presenting to our clinic for treatment of an opioid use disorder. This began with the use of prescription opioids from a doctor, and when this was no longer available this patient started using Kratom. He had used Kratom for one year to treat opioid withdrawal symptoms and chronic pain, resulting in worsening depression, anxiety and pain. He experienced tolerance and withdrawal symptoms related to Kratom. He was initiated on buprenorphine-naloxone at home with improved pain management. Four months after initiation, the patient's depression and anxiety symptoms resolved, and he was able to discontinue his antidepressant and anxiolytic medications. Kratom dependence and withdrawal appear similar to that of opioids, and may also lead to worsening depression and anxiety. Buprenorphine-naloxone may be a viable option to consider for treating opioid use disorder complicated by Kratom use, chronic pain, and depression.
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Affiliation(s)
- Adina Bowe
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine-Charleston Division , Charleston, West Virginia, USA
| | - Patrick L Kerr
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine-Charleston Division , Charleston, West Virginia, USA
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23
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Abstract
PURPOSE This article presents updated information on kratom (Mitragyna speciosa), a natural opioid with stimulant properties that is currently sold in the United States without a prescription. SUMMARY Kratom exerts opioid and alpha-2 agonistic effects, as well as anti-inflammatory and mild stimulant effects. Respiratory depression has not been commonly reported, but kratom does cause a host of adverse effects. While kratom may have a role in patients who are in chronic pain or dependent on opioid painkillers or heroin, this needs to be established in clinical trials. Kratom may have drug interactions as both a cytochrome P-450 system substrate and inhibitor. Kratom does not appear in normal drug screens and, especially when ingested with other substances of abuse, may not be recognized as an agent of harm. There are numerous cases of death in kratom users, but many involved polypharmaceutical ingestions. There are assessments where people have been unable to stop using kratom therapy and withdrawal signs/symptoms occurred in patients or their newborn babies after kratom cessation. Both banning and failure to ban kratom places people at risk; a middle-ground alternative, placing it behind the pharmacy counter, might be useful. CONCLUSION Kratom has a unique pharmacologic profile that might offer advantages over other opioids, but its high abuse liability, potential for drug interactions and adverse events, and inadequate research into the balance of benefits to harm are concerning. There is mounting information on the adverse events associated with kratom use and potential treatments that can be useful to clinicians.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, CT, and Department of Pharmacy, Hartford Hospital, Hartford, CT
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24
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Abstract
Kratom or Mitragna speciosa is a tropical tree that is indigenous to Southeast Asia, where it has been used for various medicinal reasons. In the West, it is used in the self-treatment of opioid withdrawal, pain, and a variety of mood and anxiety states. Two active ingredients in kratom are mitragynine and 7-hydroxymitragynine, which have affinity at the mu-opioid receptor among others. Kratom is easily available over the Internet and its use is increasing in the United States. It is currently listed by the Drug Enforcement Administration as a drug of concern. In 2017, the U.S. Food and Drug Administration started issuing a series of warnings about kratom, and by early 2018, it released a statement identifying 44 deaths related to kratom use. The Centers for Disease Control and Prevention has also reported 91 deaths directly linked to kratom use in 2019. Although its safety profile needs additional research for clarification, there have been reports of kratom-induced or kratom-related respiratory depression, hypothyroidism, secondary hypogonadism, hyperprolactinemia, psychosis, and seizures. We report a case of kratom-induced tonic-clonic seizures in a 27-year-old Caucasian male with a psychiatric history of anxiety, attention-deficit/hyperactivity disorder, benzodiazepine use disorder, and opioid use disorder. He was hospitalized after a witnessed tonic-clonic seizure. There was no significant metabolic abnormality on laboratory testing. Spinal cord and brain imaging were unremarkable, whereas his urine toxicology was positive for opioids only, which was likely a false-positive result due to cross-reactivity with his sleeping aids. He was evaluated by the Consultation-Liaison Psychiatry team for psychotic symptoms. On evaluation, the patient's psychosis had resolved, but he endorsed racing thoughts, significant anxiety, and insomnia. He admitted to drinking three to four 8-mL bottles of Kratom daily for one-and-a-half years to self-medicate his anxiety after losing his health insurance. In the hospital, he was treated with anxiolytics, counseled to abstain from Kratom use, and was referred for substance use disorder treatment. This case highlights the life-threatening complications of Kratom that is easily available online.
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Affiliation(s)
- Hasnain Afzal
- Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, USA
| | - Michael Esang
- Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, USA
| | - Sabreen Rahman
- Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, USA
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25
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Kucharik M, Gupta A, Averkiou P, Luck GR, Ross AS. Complicated postoperative course secondary to kratom withdrawal: a case report. J Surg Case Rep 2019; 2019:rjz309. [PMID: 31719971 PMCID: PMC6830039 DOI: 10.1093/jscr/rjz309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/17/2019] [Indexed: 12/16/2022] Open
Abstract
We herein report a case of a 55-year-old female with an unusual case of post-operative kratom withdrawal. The patient’s withdrawal symptoms subsequently contributed to complications and admission to the intensive care unit. Features of this case are discussed, alongside the management of kratom withdrawal and the implications of supplementation with unregulated herbal medications.
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Affiliation(s)
- Michael Kucharik
- Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL 33431, USA
| | - Anupam Gupta
- Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL 33431, USA.,Boca Raton Regional Hospital, 800 Meadows Rd, Boca Raton, FL 33486, USA
| | - Peter Averkiou
- Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL 33431, USA
| | - George R Luck
- Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL 33431, USA.,Boca Raton Regional Hospital, 800 Meadows Rd, Boca Raton, FL 33486, USA
| | - Andrew S Ross
- Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL 33431, USA.,Boca Raton Regional Hospital, 800 Meadows Rd, Boca Raton, FL 33486, USA
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26
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Schmuhl KK, Gardner SM, Cottrill CB, Bonny AE. Home induction and outpatient treatment of kratom use disorder with buprenorphine-naloxone: A case report in a young adult. Subst Abus 2019; 41:311-314. [PMID: 31644379 DOI: 10.1080/08897077.2019.1671945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The use of the natural product, kratom, has increased significantly in recent years. The active compounds in kratom have been shown to produce both opioid and stimulant-like effects. While kratom is marketed as a safe, non-addictive method to treat pain and opioid withdrawal, there have been reports demonstrating that kratom is physiologically addictive and linked to overdose deaths. A limited number of case-reports are available describing treatment of kratom use disorder in middle-aged adults, generally in the context of chronic pain and in inpatient settings. Our case is unique in that we describe outpatient treatment of kratom use disorder in a young adult with comorbid attention deficit hyperactivity disorder (ADHD) and in the absence of chronic pain. Case: A 20-year-old college student with ADHD presented to an office-based opioid agonist treatment clinic (OBOT) for treatment of kratom use disorder. He was unable to attend inpatient or residential substance use treatment due to work and school obligations. Additionally, he had stopped taking his prescribed stimulant due to cardiac side effects. The OBOT team successfully initiated buprenorphine-naloxone (BUP/NAL) sublingual films via home induction to treat his kratom use disorder. The patient is being monitored monthly with plans to slowly taper his BUP/NAL dose as tolerated. Discussion: We present a case of a young adult male with kratom use disorder, complicated by a diagnosis of ADHD, successfully treated with BUP/NAL via home induction. The patient is currently kratom-free, reports improved mood and sleep patterns since initiating BUP/NAL, and is able to once again tolerate his ADHD stimulant medication. Healthcare providers should be aware of the use of kratom and consider utilizing BUP/NAL to treat dependence to this botanical drug.
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Affiliation(s)
- Kelsey K Schmuhl
- The College of Pharmacy, The Ohio State University, Columbus, Ohio, USA.,Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Spencer M Gardner
- The College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Casey B Cottrill
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,The College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Andrea E Bonny
- The College of Medicine, The Ohio State University, Columbus, Ohio, USA
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27
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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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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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Agapoff JR, Kilaru U. Outpatient buprenorphine induction and maintenance treatment for kratom dependence: A case study. JOURNAL OF SUBSTANCE USE 2019. [DOI: 10.1080/14659891.2019.1638459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- James R. Agapoff
- Spark M. Matsunaga VA Medical Center, Honolulu, Hawai‘i, USA
- Department of Psychiatry, University of Hawai‘i at Mānoa, Honolulu, Hawai‘i, USA
| | - Usha Kilaru
- Department of Psychiatry, University of Hawai‘i at Mānoa, Honolulu, Hawai‘i, USA
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