Opioid-like herb has yet to be researched extensively

Host Amber Smith: =Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A growing fraction of the overdose deaths in America involve an herbal substance that people may use for pain and anxiety. It's called kratom. And to learn more about it, I'm talking with Dr. Willie Eggleston, a toxicologist from the Upstate New York Poison Center.

Welcome back to "The Informed Patient," Dr. Eggleston.

Willie Eggleston, PharmD: Thanks for having me back.

Host Amber Smith: Compared with prescription medications and illegal street drugs that people may turn to to help with chronic pain, kratom is a lot easier to obtain. What can you tell us about it?

Willie Eggleston, PharmD: Kratom is an herbal supplement. It's a product that's derived from a plant. The plant is mostly grown in parts of Southeast Asia, like Vietnam, and generally the plant makes its way over into the U.S. That plant is dried and then turned into a powder. And folks who are using this are either using the powder to make a tea that they would then drink, or the powder is put into empty capsules, so it can be taken more like a pill that you would take for a disease. And you can buy it pretty much anywhere online and at stores that sell kratom supplies.

Host Amber Smith: Is there any age limit, or can anyone buy it?

Willie Eggleston, PharmD: Currently in the United States, federally, it's an unregulated product. So there's no rules or regulations around kratom, including that technically it's not a legal product to have in the U.S.

It's just that that's not typically something that's enforced. There are certain states and counties that have set age restrictions that have made it impossible to buy if you're under 18 or 21, but it varies from region to region.

Host Amber Smith: Now, some states have banned it, though, right?

Willie Eggleston, PharmD: Yes, there are states that have outright banned it.

We don't know how effective that is, when the state next door has not done so, or you can buy it online. But some states have banned the product entirely.

Host Amber Smith: How expensive is it?

Willie Eggleston, PharmD: It really depends on where you're purchasing it and what type you're purchasing, but, generally speaking, it's not something I would consider like a really expensive product. It's not something that you're paying hundreds and hundreds of dollars for. It's a reasonably priced product, where you may pay anywhere from $25 to $100 for your normal supply.

Host Amber Smith: Now, do you get calls about kratom at the Upstate New York Poison Center?

Willie Eggleston, PharmD: We do. It's not a big group of our calls, but, generally speaking, over the last few years, we get anywhere from 20 to 25 calls a year related to kratom use. And usually what it is, is either someone with questions wanting to know what the heck is this, and is it safe or something that I should be using, or what we've been seeing more of, is folks who are using the product, they don't realize that, like other opioid drugs, it has addictive properties, and they're in withdrawal when they've stopped using it.

Host Amber Smith: So it is here in Central New York in some capacity?

Willie Eggleston, PharmD: Oh, absolutely. You can go into a shop here in Central New York and buy kratom products fairly easily.

Host Amber Smith: So it's considered an herbal product. Does that fall under the FDA (Food and Drug Administration) or the USDA (U.S. Department of Agriculture) or the DEA (Drug Enforcement Administration) or ... who regulates this?

Willie Eggleston, PharmD: Yeah, herbal product is an unfortunate term that normally gets used for it because it's a term we use to describe that it comes from a plant, but it does not mean that it's regulated as a dietary supplement, the way our other dietary supplements that we buy over the counter are in the U.S.

So, for example, if you go to buy your multivitamins at the grocery store or local pharmacy, those are regulated as a dietary supplement. Kratom doesn't have any status in the U.S. under the FDA, and so it's not regulated as a dietary supplement. It just exists as an unregulated product, so essentially no one's setting the rules on it unless a certain state has put some rules in place.

Host Amber Smith: So would it be seen the same as a candy bar?

Willie Eggleston, PharmD: It's not considered a food, either. It's completely unregulated, which can be a confusing proposition for folks, that you want to put it in some sort of bucket, but right now it doesn't exist in a bucket.

But I think the concerns around that are the way that it's sold and the way that it's marketed. I think most folks sort of make the conclusion on their own that it is a dietary supplement, you know, it is like the melatonin or the vitamins that you go and buy at your pharmacy, because it comes from a plant, and it's generally viewed there as safe.

But I did want to be clear: Unlike vitamins and unlike melatonin, the FDA has not said that this is a dietary supplement, and it's not something the FDA has said is generally recognized as safe at this point.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Willie Eggleston. He's a toxicologist from the Upstate New York Poison Center, and he's also a clinical assistant professor of emergency medicine at Upstate..

So how does kratom work? What does it do in the body? You told me people will either make it into a tea, or it might be in a capsule. So once they ingest it or eat it, what does it do?

Willie Eggleston, PharmD: The plant itself has several different compounds within it that can affect the body in different ways, but the most important ones to be aware of are that it does have a compound that acts in the body just like an opioid would. So that compound is called mitragynine, and it works in the same receptors in your brain that opioids act with. And so people will use it as a way to potentially treat chronic pain or longstanding pain issues. And they will also report using it if they are stopping an opioid, and they're having withdrawal symptoms to try to manage those withdrawal symptoms.

But just like an opioid, it also carries the same risk of potentially causing an opioid use disorder or addiction. And when you stop it after a long period of use, you can experience some of the same withdrawal symptoms that you would experience if you were stopping an opioid after long-term use.

Host Amber Smith: So do you have to be careful if you're already taking a prescription opioid? Is it safe to add this to that?

Willie Eggleston, PharmD: I would definitely recommend against adding it to that.

We know that a prescription opioid on its own has an increased risk for side effects, like slowed breathing, that can be very dangerous and potentially life threatening.

When you're adding another opioid-acting product on top of that, that can increase that risk.

So just to be clear, when we're talking about opioids like fentanyl, which is an opioid people use illicitly, I think most of us realize that's a very dangerous drug. It has a high risk for overdose, a high risk for slowed breathing.

Prescription opioids at the appropriate dose still have that risk. It's just less. And then kratom still has that risk, but it appears that it's even smaller than prescription opioids. But when you mix those things together, it's just a recipe for a bad outcome.

Host Amber Smith: So would kratom make a person high, or does it just relieve anxiety?

Willie Eggleston, PharmD: Like any other opiate, it can make you high. When you talk with folks who are using opiates for the sensation they get when, say, they use fentanyl, the high is very different with kratom. It's not the same head rush, it's not something they would seek out, right? They're going to seek out fentanyl first. They're going to seek out prescription opioids second. And they're going to seek out kratom last. And they're probably not, honestly, going to be able to get enough of a high to make it useful, so they're really just using it for withdrawal in that case.

But if it's someone who's never used an opioid in their life, and they don't have a tolerance, and they take a bunch of kratom, they'll definitely have the same sort of euphoria that you would have with another opioid. It's just not quite as strong.

Host Amber Smith: I guess this is a bit of a trick question: Is it safe to take this if this is the only thing you're taking? And if so, if you do take it, does it work? Is there any evidence that it reduces pain or anxiety?

Willie Eggleston, PharmD: So, to answer your first question, I think that the risks with kratom use on its own are low, but they're not zero.

We do know that it has some side effects. It can cause injury to the liver. It can cause, as I mentioned earlier, addiction and potentially withdrawal. And in really high doses, just like an opioid, it potentially could slow someone's breathing to a dangerously low level.

And then because of the other compounds that are there in the plant, there's other side effects that we see as well that are not consistent with an opioid, things like increased heart rate or, in severe cases, maybe even like a seizure. And so, for those reasons, because we don't have a lot of information at this point as to potential side effects, and because it's unregulated, so it's unlikely that the dose that it says it is is probably not what it actually is, there's a lot of inherent risks with using the product.

As far as does it work? We just don't know. It's very possible it could be a reasonable option sometime down the road for patients suffering with pain or for patients suffering with opioid use disorder or addiction. But no one has done those trials, that research, to figure out does it actually work.

That's the take-home point I have for folks who are curious about it, is that it does appear to be safer than prescription opioids for risk for slowed breathing. But as far as other side effects, we really just don't know, and then we have no idea if it works.

Host Amber Smith: So how addictive is it? Is it as addictive as a prescription opioid?

Willie Eggleston, PharmD: That's another one we don't know because the research hasn't happened yet. From anecdotal experience in talking with patients who are stopping kratom, they do describe the withdrawal symptoms as more mild than the withdrawal symptoms that they experience with stopping something like heroin or fentanyl.

But that doesn't necessarily give us a lot of information as far as how potentially addicting this product is. Certainly, it's not as safe as other dietary supplements like vitamins and melatonin, where we know that those side effects are mild to nonexistent, and we know there's not a risk for addiction or withdrawal.

Host Amber Smith: So when you hear about people who have taken kratom, is it usually mixed with other drugs or alcohol, or is it usually people just taking a high dose of it, where they would end up calling the poison center, maybe?

Willie Eggleston, PharmD: So, for folks who are using it for pain management or management of withdrawal or addiction, in my experience, those individuals are using it on its own. They're not mixing it with other substances. And in those cases, the common question that we get is about the withdrawal when they stop the product.

Now, there are also cases of folks who do mix the drug with other substances, and in those cases it's probably more likely they're using the kratom as a means to get a high sensation, as opposed to using it for chronic pain or treatment of a substance use disorder.

And in those cases where you are mixing it, we do know there's risks. And when you look at the overall number of opioid overdose deaths reported by states, about 2% of those have kratom involved.

It's along with other substances a lot of the time, like fentanyl or other sedatives, but it's certainly involved in that process.

Host Amber Smith: What happens if someone takes too much and overdoses? What does that look like, and what do you do to help that person?

Willie Eggleston, PharmD: For someone who has taken too much kratom and is experiencing symptoms of an overdose, we can see mild opioid effects, like they're being sleepy or, difficult to wake up. At very large levels, potentially slowed breathing.

But then because of the other compounds in the plant, we do also commonly see things like increased heart rate, anxiety, seizures. In fact, we see seizures more frequently than we see slowed breathing, so the stimulant effects of the other compounds in the plant can play a role in dictating how someone comes into the hospital with toxicity.

Host Amber Smith: Would naloxone be used for someone who overdoses on this?

Willie Eggleston, PharmD: If someone is having symptoms of slowed breathing from the opioid effects of kratom, the information that we have up to this point suggests that naloxone would work just fine. It will reverse the effects and allow that person's breathing to go back to normal.

It's just not something we have to do very frequently, because it doesn't seem that that's a big risk factor with kratom, like it is with other substances like fentanyl.

Host Amber Smith: We probably don't know the answer to this, but do we know if there are longer-term effects on the body of someone who uses kratom?

Willie Eggleston, PharmD: We don't have a full picture at this point, but the two that we do know are, the longer you're using the product, the more likely you are to develop an opioid use disorder or addiction to the product, and to develop a withdrawal when you stop the product. And in cases where patients have developed liver injury, it has been in people using the product for longer periods of time.

Aside from those two risk factors, at this point, we don't really have any data to suggest there are other potential long-term complications.

Host Amber Smith: So that liver toxicity, can that be a real serious problem for someone?

Willie Eggleston, PharmD: Oh, it definitely can, and it would require a good amount of time in the hospital to get treatment and to make sure that your lab values go back to normal.

But it's not something that we're seeing every other day. It's a less common side effect that we see with long-term use.

Host Amber Smith: Well, that's good to know. I appreciate you making time for this interview, Dr. Eggleston.

Willie Eggleston, PharmD: Of course. I appreciate you having me, and I hope the folks learned a little more about kratom today.

Host Amber Smith: My guest has been toxicologist Willie Eggleston from the Upstate New York Poison Center and the department of Emergency Medicine at Upstate University Hospital.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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