A.k.a. thang, thom, ketum, biak, giam, kadamba, kakuam, katawn, Maeng Da leaf, herbal speedball, puri, and many other names

About Kratom

Characteristics

Kratom refers to various preparations of the Southeast Asian tree Mitragyna speciosa, consumed for its psychoactive effects.^1-3 Kratom acts as a mild stimulant at lower doses, but as a depressant with painkilling and sedative effects at higher doses.^1-3 The leaves of the tree can be chewed, made into herbal teas, mixed into drinks and food, or smoked.^1,3 The leaves have a bitter taste, and so are sometimes mixed with sweet drinks and soda to mask the flavour.¹ Kratom is also taken in the form of powders, tablets, extracts, and tinctures.^1,3

Leaves of Mitragyna speciosa. Source: https://en.wikipedia.org/wiki/Mitragyna_speciosa#/media/File:Kratom_leaves.jpg

Some people describe different types of kratom categorised according to its method of preparation or according to different strains of the Mitragyna speciosa plant.⁴ For example, kratom powders are often grouped into green vein, yellow/gold vein, and red vein based on how long the leaves are left to ferment before drying, as well as white vein, which is a mixture of green and red vein plus the dried veins/bones of the leaves.⁴ People report that red vein is more sedating and relaxing, whereas white vein is more energetic and stimulating.⁴ Green and yellow/gold vein are reported to have mixed effects.⁴ People further categorise the vein colours into strains including “Maeng Da”, “Hulu”, “Dragon”, or the place of origin.⁵

History, Social Context, and Legality

Kratom is used in a variety of contexts in Southeast Asia, Australia, New Zealand, the UK, North America, and Europe, with its legality and uses varying across different regions.^1,3 Kratom has a long history of use in Southeast Asia, particularly in Thailand and Malaysia.^1,3 Manual labourers in these countries historically used kratom to combat fatigue and improve productivity.^1,3 In Malaysia, kratom was used as a cheaper and more accessible substitute for opium.^1,3 Kratom has also been used to treat conditions like diarrhea, pain, fever, and wounds as part of traditional medicine.^1,3 In the 2010s, young people in Thailand were using kratom tea as an ingredient in a polydrug cocktail known as ‘4×100’.¹ These dangerous cocktails also contained Coca-Cola, cough syrup, and sometimes other drugs including alprazolam (Xanax) and tramadol.^1,6 In 2021, the Thailand government legalised kratom.⁷

In Western countries, kratom is often purchased online and marketed as a dietary supplement, a natural remedy, or a ‘legal high’.^1,3 In Australia, kratom is illegal to possess, grow, or import.⁸ In contrast, kratom is largely unregulated and easily obtainable from online retailers in the US.^1,3 People report using kratom as an alternative medicine for chronic pain, or as a legal alternative to stimulants or sedatives.¹ Kratom has been sold in some dangerous formulations marketed as ‘legal highs’ such as ‘krypton’—a combination of kratom leaves with O-desmethyltramadol—which was responsible for at least nine overdoses in Sweden between 2009-2010.⁹

Across Southeast Asia and the West, people report using kratom to manage dependence and withdrawal from other drugs (primarily opioids, but also cannabis (https://www.cahma.org.au/article/safer-using-cannabis/), stimulants, and alcohol).^1,3 For many people, kratom’s withdrawal symptoms are milder than the symptoms of opioid withdrawal.¹⁰ However, some people still find it very difficult to quit and experience uncomfortable withdrawal effects, particularly after long-term use.¹⁰ If using kratom for this purpose, it is important to weigh up the risks and benefits. For example, its safety, toxicity, and ability to cause dependence are not well known, but it may be less likely to cause life-threatening overdose and extreme withdrawal symptoms compared to opioids like morphine or heroin (https://www.cahma.org.au/article/safer-using-heroin/) when used on its own.^2,10,11 If you are concerned about your use of opioids or kratom, consider speaking to a peer treatment support worker, such as at the CAHMA drop-in centre (https://www.cahma.org.au/services/peer-treatment-support/), or non-judgemental health professional, such as at the CAHMA clinic (https://www.cahma.org.au/services/cahma-clinic/).

Pharmacology

Like most psychoactive plants, kratom has a complex pharmacology. Researchers have identified over 20 molecules that may contribute to its effects.² Notably, the molecules mitragynine and its active metabolite 7-hydroxymitragynine are thought to be responsible for the majority of its sedative and painkilling (analgesic) effects.¹¹ However, the stimulant effects observed at lower doses of kratom are poorly understood.¹¹ Researchers have observed that 7-hydroxymitragynine interacts with the mu opioid receptor—the main receptor responsible for the effects of opioids such as morphine and heroin.¹¹ However, it may interact with the receptor in a different way, possibly making it is less likely to cause dangerous respiratory depression associated with other opioids (see overdose section for more info).^10-12 Additionally, these molecules interact with other opioid receptors and non-opioid receptors.¹¹  

The main psychoactive components of kratom that have been identified.

Kratom Toxicity and Harm Reduction

To minimise the risk of harm while using kratom, consider the following practices:

• Take a small test dose to check for an adverse reaction.
• Start at a low dose and wait before redosing (start low, go slow).
• Carry naloxone (see overdose section for more info).
• Have a trusted person present while using kratom.
• Avoid mixing kratom with other drugs or medications, especially depressants including alcohol, opioids, benzodiazepines (https://www.cahma.org.au/article/safer-using-benzos/), and dissociatives.

The short- and long-term toxicity of kratom remain poorly understood.¹³ The risk of overdose is relatively low when kratom is taken on its own, however the risk greatly increases when it is combined with other substances. Several people have died after mixing kratom with other drugs and medications including:^3,6,9,13

• “4×100” cocktails.
• O-desmethyltramadol (in a combination called krypton).
• Other opioids including fentanyl (https://www.cahma.org.au/article/safer-using-fentanyl/).
• Propylhexedrine (Benzedrex/Obesin).
• Carisoprodol (Soma).
• Benzodiazepines (https://www.cahma.org.au/article/safer-using-benzos/).
• Deliriants (https://www.cahma.org.au/article/safer-using-deliriants/).
• Modafinil (Modavigil/Provigil).
• Venlafaxine (Efexor).
• Mirtazapine.
• Zopiclone (Imovane/Imrest).
• Citalopram (Cipramil/Celapram/Celexa).
• Lamotrigine (Lamictal).

Some features of toxicity have been described after regular use of kratom. Notably, 8 or more cases of liver injury caused by kratom were reported between 2003 and 2019.¹⁴ In these cases, people experienced symptoms of liver injury after 5 to 30 days of regular kratom use, which resolved after stopping.^14,15 The injury was generally caused by impaired flow of bile inside the liver (intrahepatic cholestasis).^14,15 The symptoms included:^14,15

• Abdominal pain/discomfort.
• Pale, clay-coloured stool.
• Dark urine.
• Itching (pruritus).
• Yellow discoloration of the whites of the eyes and/or skin (jaundice).

Additionally, long-term kratom use—particularly at higher doses—has been associated with:^3,13

• Nausea.
• Weight loss.
• Fatigue.
• Constipation.
• Dry mouth.
• Insomnia.
• Frequent urination.
• Appetite suppression.
• Hair loss.
• Darkening of the cheeks (hyperpigmentation).

In the US, the herbal and dietary supplement market has notoriously poor quality control standards. Many kratom supplements sold online have been found to contain unsafe levels of heavy metals including nickel and lead.¹⁶ Long-term consumption of these metals can cause heavy metal poisoning, damage to the kidneys or nervous system, high blood pressure, anaemia, and increased risk of certain cancers.¹⁶  

Moreover, an outbreak of Salmonella infections across the US were linked to contaminated kratom supplements.¹⁷ The symptoms of Salmonella infection include:

• Fever, chills.
• Headache.
• Muscle pain.
• Severe vomiting.
• Abdominal pain.
• Watery or bloody diarrhoea.

If you or someone you know is experiencing mild adverse effects associated with kratom use, consider seeing a non-judgemental health professional, such as a trusted GP or a health professional at the CAHMA clinic (https://www.cahma.org.au/services/cahma-clinic/). If your concern is more serious, consider seeking medical attention at an emergency department or urgent care clinic.

Effects of Kratom

The effects of kratom vary between low and high doses.

At lower doses, the effects can include:^1-4,13

• Mild stimulation.
• Elevated mood.
• Increased energy.
• Increased alertness.
• Improved focus.
• Nausea.
• Itching (pruritus).
• Supressed appetite.
• Frequent urination.

At higher doses, the effects can include:^1-4,13

• Sedation.
• Pain relief (analgesia).
• Mild euphoria, elevated mood.
• Reduced anxiety.
• Nausea.
• Constipation.
• Low blood pressure (hypotension).
• Fast heart rate (tachycardia).
• Sleep problems.
• Temporary erectile dysfunction.
• Itching (pruritus).
• Dry mouth.
• Sweating (diaphoresis).
• Dizziness.
• Supressed appetite.
• Frequent urination.

Typically, when consumed orally, the effects come on 10-60 minutes after ingestion, peak around 2-4 hours after ingestion, and last about 5-7 hours in total.^13,18 Eating beforehand or taking it as a capsule can make the effects come on more slowly.¹³

Dosing Kratom

The potency can vary between preparations and between batches. Hence, it is always recommended to start at a low dose and wait before redosing (start low, go slow).

The following is an approximate dosage guide for kratom when taken orally:^13,18,19

	Strong powders and extracts	Raw leaves and weaker powders
LOW DOSE	1-2 g	2-4 g
MODERATE DOSE	2-3 g	4-8 g
STRONG DOSE	3-6 g	8-15 g

Kratom Overdose

In rare cases, kratom can cause a severe overdose, particularly when mixed with other drugs.^3,6,9,13

Seek emergency medical attention if you or someone you know experiences any of the following:

• Loss of consciousness.
• Slowed or abnormal breathing.
• Vomiting.
• Seizures.
• Pale, blue-ish, or cold skin (cyanosis). 
• Choking, gurgling or gasping noises. 

If you suspect someone has overdosed on kratom or a combination of drugs, try waking them up with a loud voice, pinching their shoulder or rubbing your knuckle over their chest. If they don’t respond, call 000 immediately.  

Some evidence suggests naloxone may reverse a kratom overdose, although it is still unclear.^11,20,21 Regardless, naloxone should be administered after calling 000 as it will not be harmful to the person.²¹ For more information about naloxone, contact CAHMA or your local harm reduction service provider.

Naloxone breaks down in the body quickly (30-90 minutes), after which the overdose symptoms may return.²¹ Hence, it is important to seek emergency medical attention even if you administer naloxone. Naloxone can sometimes cause withdrawal symptoms when given to someone who is opioid-dependent.²¹ These symptoms will subside after an hour or so as the naloxone wears off. 

Kratom Withdrawal

People can experience withdrawal effects after ceasing kratom use, although the symptoms are generally considered to be milder than other opioids.^1,13 Nonetheless, some people find the symptoms unpleasant and find it difficult to stop using kratom.^1,13

The symptoms of kratom withdrawal can include:^1-3,13

• Irritability.
• Tiredness, lethargy.
• Low mood, dysphoria.
• Aggression.
• Anxiety.
• Supressed appetite.
• Yawning.
• Runny nose (rhinorrhoea).
• Muscle pain.
• Muscle jerking.
• Joint pain.
• Cramps.
• Diarrhoea.
• Difficulty sleeping.

The symptoms often resolve within 1-3 days, but they may last longer depending on the dose, period and frequency of use.¹

If you are concerned about the effects of kratom withdrawal, consider seeing a non-judgmental health professional, for example at the CAHMA clinic (https://www.cahma.org.au/services/cahma-clinic/). 

References

[1] http://dx.doi.org/10.1016/j.brainresbull.2016.05.004

[2] https://www.drugs.com/kratom.html

[3] http://dx.doi.org/10.1155/2015/968786

[4] https://psychonautwiki.org/wiki/Kratom

[5] https://kratom.org/strains/

[6] https://www.thaiscience.info/Journals/Article/JHRE/10893300.pdf

[7] https://www.mondaq.com/food-and-drugs-law/1230728/thailands-new-legal-framework-for-kratom

[8] https://www.legislation.gov.au/F2020L01716/latest/text

[9] https://doi.org/10.1093/anatox/35.4.242

[10] https://doi.org/10.1016/j.drugalcdep.2017.10.012

[11] http://dx.doi.org/10.1016/j.neuropharm.2017.08.026

[12] http://dx.doi.org/10.1021/acs.jmedchem.6b00748

[13] https://doi.org/10.1007/s00414-015-1279-y

[14] https://doi.org/10.1016/j.drugalcdep.2020.108426

[15] https://doi.org/10.1007/s13181-011-0155-5

[16] https://www.fda.gov/news-events/public-health-focus/laboratory-analysis-kratom-products-heavy-metals

[17] https://www.fda.gov/food/hfp-constituent-updates/fda-investigates-multistate-outbreak-salmonella-infections-linked-products-reported-contain-kratom

[18] https://tripsit.me/factsheets

[19] https://wiki.tripsit.me/wiki/Kratom

[20] http://dx.doi.org/10.1021/acscentsci.9b00141

[21] https://doi.org/10.5811/cpcem.2018.11.40588

Written by Darcy Lynch