Fatal Mitragynine-Associated Toxicity in Canada: A Case Report and Review of the Literature

Beneficial and adverse health effects of kratom (Mitragyna speciosa): A critical review of the literature

Used in Southeast Asia for generations, kratom gained popularity in the United States and elsewhere over the past several decades. Derived from Mitragyna speciosa, kratom preparations including leaves, teas, powders, capsules, and extracts may yield stimulant, analgesic, and opioid-like effects that occur dose-dependently based on concentrations of kratom's key alkaloids, mitragynine and 7-hydroxymitragynine. Such effects are responsible for kratom's potential as a reduced-harm alternative to opiates and as a withdrawal treatment. But these properties are also associated with tolerance development and addictive potential. Given mitragynine and 7-hydroxymitragynine activity on cytochrome P450 isoforms and opioid receptors, adverse effects among polysubstance users are a concern. Current literature on the toxicology of kratom is reviewed, including product alkaloid concentrations, in vitro and in vivo data, epidemiological evidence, and human case data. The potential harms and benefits of kratom products are discussed within an exposure assessment framework, and recommendations for industry are presented. Current evidence indicates that kratom may have therapeutic potential in some persons and that products present few risks with typical, non-polysubstance use. However, few studies identified alkaloid doses at which adverse effects were expected in humans or animals. Such research is needed to inform future assessments of kratom's risks and benefits.

An insight review on the neuropharmacological effects, mechanisms of action, pharmacokinetics and toxicity of mitragynine

Mitragynine is one of the main psychoactive alkaloids in Mitragyna speciosa Korth. (kratom). It has opium-like effects by acting on μ-, δ-, and κ-opioid receptors in the brain. The compound also interacts with other receptors, such as adrenergic and serotonergic receptors and neuronal Ca2+ channels in the central nervous system to have its neuropharmacological effects. Mitragynine has the potential to treat diseases related to neurodegeneration such as Alzheimer's disease and Parkinson's disease, as its modulation on the opioid receptors has been reported extensively. This review aimed to provide an up-to-date and critical overview on the neuropharmacological effects, mechanisms of action, pharmacokinetics and safety of mitragynine as a prospective psychotropic agent. Its multiple neuropharmacological effects on the brain include antinociceptive, anti-inflammatory, antidepressant, sedative, stimulant, cognitive, and anxiolytic activities. The potential of mitragynine to manage opioid withdrawal symptoms related to opioid dependence, its pharmacokinetics and toxic effects were also discussed. The interaction of mitragynine with various receptors in the brain produce diverse neuropharmacological effects, which have beneficial properties in neurological disorders. However, further studies need to be carried out on mitragynine to uncover its complex mechanisms of action, pharmacokinetics, pharmacodynamic profiles, addictive potential, and safe dosage to prevent harmful side effects.

Cardiovascular health in kratom users; a narrative review

BACKGROUND

Kratom, also known as Mitragyna speciosa, is a plant that originates in Southeast Asia and possesses unique pharmacological characteristics. It is commonly consumed in the form of tea made by boiling the leaves or using the leaves to create the powder. According to its pain-relieving effects, the prevalence of kratom use around the world has increased, which has various implications for healthcare providers. Mitragynine is a well-known active compound in kratom.

OBJECTIVE

This review aims to provide a comprehensive perspective on the cardiovascular effects of mitragynine and its potential cardiotoxicity through the literature.

METHOD

Authors searched PubMed, Scopus, and Google Scholar databases using appropriate search strategies for each database. After the screening, all relevant studies were included.

RESULTS

Although kratom may have the potential for therapeutic benefits, it has been associated with multi-organ damage and cardiac toxicity in some cases. According to the available data, tachycardia and hypertension are the most common adverse effects. Other possible cardiovascular effects include atherosclerosis, ventricular arrhythmia, cardiomyopathy, dose-dependent prolonged QTc interval, myocarditis, cardiomegaly, and cardiopulmonary arrest.

CONCLUSION

While prior research has indicated the possible negative effects of mitragynine overdose on the cardiovascular system, there are no definitive conclusions, and additional investigations are needed.

Postmortem Mitragynine Distribution in a Single Drug Fatality Case

A 32-year-old Caucasian male was found unconscious at his sober-living home and pronounced dead after transportation to the emergency room. The decedent had a documented history of substance-use disorder and past suicide attempts, but according to his family, he was sober for the past year. Significant autopsy findings were cardiomegaly, hepatomegaly, congested lungs, cerebral edema, and obesity. The toxicology examination of blood and tissues using liquid chromatography tandem mass spectrometry detected only mitragynine in the central blood (7.5 mg/L), peripheral blood (3.3 mg/L), liver (42.2 mg/kg), and gastric contents (33.1 mg). The qualitative identification of 7-hydroxymitragynine was performed only on the central blood. The pathologist ruled the cause of death acute mitragynine intoxication combined with cardiomegaly with left ventricular hypertrophy, with severe hepatomegaly and obesity listed as other significant conditions. The mode, or manner, of death was determined to be an accidental overdose. To the authors' knowledge, this is the first reported case where mitragynine was the only drug detected. This case study will contribute to the understanding of mitragynine-only death investigation and provide valuable toxicology information for medical examiners and pathologists.

Kratom exposures managed by the British Columbia poison centre, 2012-2019: a descriptive analysis

BACKGROUND

Kratom, a plant indigenous to Southeast Asia, which has been used both recreationally and in the treatment of pain and opioid dependence, has received little scrutiny in the United States and almost none in Canada. We analyzed calls to the British Columbia poison centre to describe caller-declared exposures to kratom and the acute health effects of these exposures.

METHODS

For this descriptive analysis, we accessed electronic records, including transcriptions and extracted variables, of calls specifying kratom exposure managed by the BC Drug and Poison Information Centre (DPIC) from 2012 to 2019. We describe changes in case numbers, reasons for exposure, concurrent drug exposures and clinical outcomes over the study period.

RESULTS

We identified 32 cases during the study period. In 23 cases (72%), the DPIC was consulted by a health care worker. Case numbers increased from 0 in 2012 to 9 in 2019. Numbers were highest for males in their 20s (n = 17, 53%). A total of 27 cases (84%) involved ingestion, with online distributors and local stores named as sources of procurement. A concurrent drug exposure was identified in 13 (41%) cases. There were no deaths; in 1 case, the exposed individual was intubated to manage agitation following kratom withdrawal.

INTERPRETATION

We observed a steady increase in kratom-related poison centre calls from 2012 to 2019, especially in young adult males. Rising call numbers may reflect increasing availability of kratom and may be a consequence of BC's opioid crisis, with kratom used by some to lessen symptoms of opioid withdrawal.

Understanding Kratom Use: A Guide for Healthcare Providers

Kratom (Mitragyna speciosa Korth., Rubiaceae) is a plant native to Southeast Asia, where it has been used for centuries as a mild stimulant and as medicine for various ailments. More recently, as kratom has gained popularity in the West, United States federal agencies have raised concerns over its safety leading to criminalization in some states and cities. Some of these safety concerns have echoed across media and broad-based health websites and, in the absence of clinical trials to test kratom’s efficacy and safety, considerable confusion has arisen among healthcare providers. There is, however, a growing literature of peer-reviewed science that can inform healthcare providers so that they are better equipped to discuss kratom use with consumers and people considering kratom use within the context of their overall health and safety, while recognizing that neither kratom nor any of its constituent substances or metabolites have been approved as safe and effective for any disease. An especially important gap in safety-related science is the use of kratom in combination with physiologically active substances and medicines. With these caveats in mind we provide a comprehensive overview of the available science on kratom that has the potential to i clarity for healthcare providers and patients. We conclude by making recommendations for best practices in working with people who use kratom.

Two Single Drug Fatal Intoxications By Mitragynine

Mitragyna speciosa, a species of plant that is native to Thailand, Malaysia and Southeast Asia, contains two major psychoactive alkaloids: mitragynine and 7-hydroxymitragynine. Pharmacologically, the alkaloids exhibit biphasic effects - at low dose, stimulant effects are realized, while high doses exhibit sedative effects. For years, the plant has been used recreationally and medicinally for these effects, but its use has been implicated in and associated with intoxications and deaths. In this case report we describe two cases whereby decedents presented with single substance fatal intoxications by mitragynine in the absence of other postmortem toxicological findings. The cases entail young male decedents in outdoor settings (e.g. driving a vehicle and bicycle). Postmortem blood concentrations were 2,325 ng/mL and 3,809 ng/mL. The medical examiner (ME) certified cause of death (COD) as acute mitragynine intoxication in both cases. The toxicology results presented become useful when considering mitragynine to be the offending agent in lethal single drug intoxications; further, the information included is pertinent to medical examiners, forensic pathologists, forensic toxicologists, and emergency department personnel in evaluating possible poisoning and lethality by mitragynine.

Kratom Ingestion and Emergency Care: Summary and a Case Report

Kratom ingestion for its psychotropic effect or to self-treat opioid withdrawal symptoms has increased over the last 10 years in the United States. Although mild adverse effects have been observed in users, reports of respiratory failure and shock after kratom consumption remain rare. In this case, a 35-year-old man initially presented to the emergency department with profound circulatory shock, metabolic acidosis, hypoxia, and symptoms of autonomic nervous system dysfunction. The patient required vasopressor support, multiregimen sedation and rapid sequence intubation, mechanical ventilation, and emergent hemodialysis. Within 72 hours, the patient's condition stabilized, and he was extubated. The patient reported regular consumption of large quantities of kratom as well as injection of heroin and cocaine. In this report, a rare clinical presentation after kratom ingestion is described.

Kratom-Associated Fatalities in Northern Nevada-What Mitragynine Level Is Fatal?

ABSTRACT

Mitragyna speciosa, commonly known as the kratom tree, has been utilized in Southeast Asia for centuries for its opioid-like effects. Kratom has been available in the United States for the past decade and has grown increasingly popular despite a lack of clinical research to determine its safety. With its widespread use, there have been an increasing number of fatalities. This study aims to establish a potential lethal range for mitragynine, the active compound in kratom, by investigating the toxicology reports of 35 deaths in Northern Nevada between 2015 and 2020. Mitragynine concentrations ranged from 8.7 to 1800 ng/mL (n = 27) in cases with drug toxicity as the cause of death; in 1 case, the sole intoxicant was mitragynine with a blood concentration of 950 ng/mL. In cases with nonmitragynine causes of death, the concentration was 110 to 980 ng/mL (n = 8). There was no statistically significant difference in blood concentrations between cases where mitragynine was not listed as a cause of death (mean, 315 ± 297.2 ng/mL) and cases in which mitragynine contributed to death (mean, 269.4 ± 382.5 ng/mL; P < 0.201). A literature review is also presented.

The Causes of Death and Pathological Findings of Kratom Users: A 5-Year Retrospective Analysis

ABSTRACT

Kratom is a psychoactive substance in Thailand. The major psychoactive chemical component of Kratom is mitragynine. This study aims to elucidate the characteristics and pathologies of autopsied cases where mitragynine was present and quantify the amounts of mitragynine. The autopsy reports in which the blood samples were positive for mitragynine were selected in Ramathibodi Hospital between January 2015 and December 2019. Data from autopsy reports comprised sex, age, circumstances of death, pathological findings, other substances, causes of death, and mitragynine concentrations. Mitragynine was quantitatively analyzed using liquid chromatography-mass spectrometry/mass spectrometry. Twenty-four cases from 2160 autopsy cases were found to be positive for mitragynine. The most commonly observed pathological findings were pulmonary edema (7 cases) and coronary atherosclerosis (6 cases). Antihistamine (8 cases), ethanol (4 cases), and amphetamine (4 cases) were commonly found. The mitragynine concentrations were 0.0035 to 3.6 mg/L (median 0.069). One interesting case involved a 43-year-old man whose pathological findings showed chronic asthma with a high concentration of mitragynine in the blood (3.6 mg/L), although no other substances were detected. In conclusion, the use of mitragynine may be a direct or indirect cause of death, whereas the lethal concentration has yet to be clearly determined.

Case Report: Treatment of Kratom Use Disorder With a Classical Tricyclic Antidepressant

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-HT_2A 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.

Kratom Adulterated with Phenylethylamine and Associated Intracerebral Hemorrhage: Linking Toxicologists and Public Health Officials to Identify Dangerous Adulterants

INTRODUCTION

Kratom is derived from the plant Mitragyna speciosa which is indigenous to Southeast Asia. Active compounds, mitragynine and 7-hydroxymitragynine, cause mild stimulant and opioid agonist effects. Although reported to have potential benefits in the treatment of opioid use disorder, efficacy remains uncertain while adverse health effects have been reported. A compounding concern is the presence of adulterants given that this is an unregulated product.

CASE DETAILS

A 54-year-old fitness instructor who used an online purchased kratom product regularly for one year developed stimulatory effects and suffered a large hemorrhagic stroke with a close temporal relationship to ingestion of a different kratom product from the one he regularly used. A collaborative investigation by medical toxicologists, a regional poison center, the state public health laboratory, and public health officials determined that his new kratom product was adulterated with phenylethylamine (PEA).

DISCUSSION

We report a case of PEA adulterated kratom purchased and used with resultant adverse effects. PEA is structurally similar to amphetamine and is known to produce sympathomimetic effects. It is possible the stimulatory effect of PEA resulted in a marked and transient increase in blood pressure resulting in hemorrhagic stroke.

CONCLUSION

Medical toxicologists should form working relationships with laboratories and public health officials to aid in early identification of adulterated products that carry risk to the general population.

Characteristics of deaths associated with kratom use

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.

The Trouble With Kratom: Analytical and Interpretative Issues Involving Mitragynine

Mitragynine is the primary active alkaloid in the leaves of the tropical tree Mitragyna speciosa, and goes by the popular names “Kratom”, biak-biak and maeng da. Mitragynine is increasingly seen in forensic toxicology casework including driving under the influence of drugs and medicolegal death investigation cases. The toxicity of mitragynine continues to be debated in the scientific community as advocates highlight its long history of use in Southeast Asia and testimonials to its benefits by present-day users, while opponents point to an increasing number of adverse events tied to mitragynine use in Western societies. Quantitative reports of mitragynine in biological specimens from forensic investigations in the literature are sparse and may be influenced by poor analyte stability and inadequate resolution of mitragynine from its diastereomers, which could lead to falsely elevated concentrations and subsequently render those reported concentrations inappropriate for comparison to a reference range. Over the course of 27 months, 1,001 blood specimens submitted to our laboratory tested positive for mitragynine using a sensitive and specific quantitative LC-MS/MS method; concentrations ranged from 5.6–29,000 ng/mL, with mean and median concentrations of 410 ± 1,124 and 130 ng/mL, respectively. Mitragynine presents an analytical challenge that requires a method that appropriately separates and identifies mitragynine itself from its isomers and other related natural products. We describe a validated analytical method and present a short series of case reports that provide examples of apparent adverse events, and the associated range of mitragynine concentrations. This type of analytical specificity is required to appropriately interpret mitragynine concentrations detected in biological specimens from forensic casework and assess its potential toxicity.