THE BITTER PLANT THAT COULD HELP OPIOID ADDICTS
I do a lot of research on Kratom. I want to know what its fate will be. It is seldom that I run across and article with information that is correct and unbiased. This particular article seems to do that. It makes the case that Kratom is probably one of the best natural medications ever discovered and that it is totally effective against opioid addiction. I do however want to point one inacuracy, I have never, nor has any of my customers ever felt as if they were dizzy. Most of them are not looking for the euphoria which happens from higher dosages. Euphoria is a misleading description and is most likely the keyword that the FDA is looking to use to ban it.
AUTHOR: MATT SIMON, NICK STOCKTONMATT SIMON AND NICK STOCKTON
11.30.16 07:00 AM
KRATOM: THE BITTER PLANT THAT COULD HELP OPIOID ADDICTS—IF THE DEA DOESN'T BAN IT
ARIANA CAMPELLONE GREW up in East Greenwich, Rhode Island. It is a small community, affluent and charmingly New England. Heroin was very available there, and very good.
By age 15, Campellone was a daily user. She stopped going to school, stopped doing much of anything besides scoring drugs, doing drugs, stealing stuff, selling stuff, scoring more drugs, doing more drugs. "This was the beginning of the New England heroin epidemic," she says. "Everyone I knew was overdosing, dying, lives falling apart, people contracting diseases from sharing needles."
That experience was mirrored around the country. In 2014, overdoses from heroin or prescription opioids killed 30,000 people—four times as many than in 1999. Today, 3,900 new people start using prescription opioids for non-medical purposes every day. Almost 600 start taking heroin. The yearly health and social costs of the prescription opioid crisis in America? $55 billion.
Campellone kicked her habit at 19—with rehab, suboxone, and a lot of willpower—and moved out west, to the San Francisco Bay Area. She began working at a natural remedy shop in Berkeley. Her bosses and co-workers introduced her to a plethora of plant-based products, among them a tart-tasting leaf called kratom. It gives a slight, euphoric high. Like the feeling that remains when you spin around in circles, after the dizziness wears off. It was also a decent painkiller, so she'd take it when she was hurt, or on her menstrual cycle. And, on two occasions, she used it to help with the withdrawal symptoms following heroin relapses. "Nothing really feels good when you're withdrawing from heroin, so no matter what you're taking, you're still in pain and it's pretty excruciating," says Campellone. But kratom helped some.
Campellone never needs a prescription to get kratom. Nor does she have to visit a dealer. She buys it from an herbal remedy store—about $20 for a 4 ounce packet, which lasts about a week. When she takes too much, she gets a stomach ache. And when she does not take it, she doesn't crave it like she craved heroin. Mostly she doesn't think about it; it just sits in her cabinet. So, she was surprised when, on August 30, the DEA announced that it was pursuing an emergency scheduling of mitragynine and 7-hydroxymitragynine, the active alkaloids in kratom. Campellone was one of perhaps 4 or 5 million Americans who were being told, for maybe the first time, that this leaf posed an "imminent danger to public safety."
The DEA Takes an Exception to Kratom
Biologically, kratom acts enough like an opioid that DEA considers it a threat to public safety. The agency planned to use a regulatory mechanism called emergency scheduling to place it in the same restrictive category as heroin, LSD, and cannabis. This category, Schedule I, is reserved for what the DEA considers the most dangerous drugs—those with no redeeming medical value, and a high potential for abuse.Before they finalized the scheduling, something surprising happened. An advocacy group called the American Kratom Association (yes, AKA) raised $400,000 from its impassioned membership—impressive for a nonprofit that typically raises $80,000 a year—to pay for lawyers and lobbyists, who got Congress on their side.
On September 30, representatives both conservative and liberal—from Orrin Hatch to Bernie Sanders—penned a letter to the DEA. “Given the long reported history of kratom use, coupled with the public’s sentiment that it is a safe alternative to prescription opioids, we believe using the regular review process would provide for a much-needed discussion among all stakeholders,” they wrote.
It worked. The DEA lifted the notice of emergency scheduling, and opened a public comment period until December 1. When was the last time the DEA backed off anything? "This is unusual," says Gantt Galloway, a Bay Area pharmacologist specializing in treatments for addictive drugs. Galloway could not recall another instance when the DEA responded to public outcry like this.
As of this writing, those comments number nearly 11,000. They are from: people who use kratom to relieve chronic pain or endometriosis or gout; people who use kratom to treat depression or wean off opioids or alcohol; people who said it saved their life. “It doesn't allow you to escape your problems,” says Susan Ash, founder of the AKA, who used kratom to treat pain and escape an addiction to prescription opioids. “It instead has you face them full on because it doesn't numb your brain at all, and it doesn't make you feel stoned like medical marijuana does. And yet it's effective on so many things, like pain and anxiety and depression.”
That promise is part of the problem. Scientists know practically nothing about kratom—how its compounds work in concert, what it can actually treat, how addictive it might be, what counts as a safe dose. And certainly not enough to back up all the life-changing claims extolled in public comments, and by the many kratom users we interviewed. In the absence of good science and the slightest hint of regulation, Ash and potentially millions of other users are winging it. And should the DEA follow through on its promise to schedule kratom, these people will become criminals overnight.
For Ash, that’s completely unacceptable. “I want the future to look like this is your next coffee,” she says. “I'd like it to be sold in Starbucks. I'm not even kidding.”
An Herb Wades Into an Opioid Crisis
Kratom is not an opioid—actually, it is in the coffee family—but its active molecules bind to the same neuronal receptors as opioids like heroin, codeine, oxycodone, and morphine. Typically, those drugs give users a feeling of euphoria and dull their pain—that’s why David*, a former boarding school teacher, started using prescription opioids to treat his discomfort from ski injuries. He became addicted, and when his prescriptions ran out, he switched to heroin. "I became a high functioning user,” he says. "My addiction was never detected at my place of employment, although I do think my behavior became more erratic."
When David eventually committed himself to rehab, his doctors weaned him off heroin using suboxone, a combination of two drugs—buprenorphine, a partial opioid that quenches the body's chemical thirst, and naltrexone, which blocks any euphoric opioid feelings. But suboxone can give users symptoms of withdrawal, not to mention a dulled sense of reality. And users like David can still find ways to abuse it. "Dependence on that was different from heroin, and it became easier to take more suboxone to a higher high, or selling it to score heroin again," he says.
As of this writing, though, David has been clean for 18 months—success that he attributes to kratom. Since it binds to the same receptors as opioids, kratom users report similar euphoric and pain-killing effects, but they’re muted. After other 12 step recovering addicts introduced David to the plant, it helped him rebuild his life—he did eventually lose that boarding school teaching job—and deal with the physical pain that got him hooked on opioids to begin with.
Since it mirrors opioids in other ways, the concern is that kratom is also addictive. But again, the real science is sparse. David and several other users we spoke with said kratom is habit forming, to some degree, though one survey in Southeast Asia found that for people using it to kick an opioid addiction, the dependence is far less likely to disrupt their lives. "When I take kratom, that addictive part of me kicks in and it becomes habitual," says Jeffrey*, another former opioid addict. "It doesn’t throw my life out of control, but it bugs me when people say things like, 'it’s not more addictive than coffee.' I think that hinders us making inroads with the regulators.”
There is no doubt, however, that kratom is less harmful than opioids—even take-home synthetics like suboxone. When opioids kill, they do it through respiratory depression—they slow your breath until you stop breathing entirely. But kratom’s chemical composition doesn’t appear to produce the same effects. “The two main alkaloids in kratom, mitragynine and 7-hydroxy, appear to have a low ceiling for respiratory depression,” says pharmacologist Jack Henningfield of the Johns Hopkins School of Medicine, who with the consulting firm Pinney Associates has advised the AKA on kratom scheduling. “And that's why if you look hard, it's very difficult to find deaths attributable purely to kratom.”
Notice he said "purely." In its initial notice of emergency scheduling for kratom, the DEA did link the drug to 15 deaths between 2014 and 2016. But that accounting ignores the fact that all but one of those people had other substances in their systems. Folks using kratom to wean themselves off opioids may still be taking those opioids.
And some deaths could be attributed to contamination: Because kratom isn’t strictly regulated, bad actors can and do lace the plant with actual opioids, like the extremely powerful synthetic opioid fentanyl. “You can just imagine, ‘Oh you got pain? Well, we've got a special kratom product,’” Henningfield says. “Maybe it has fentanyl in it. That's scary.” Clearly, the plant needs some kind of regulation. The question is whether the DEA’s scheduling is the right kind.
The FDA could help prevent contamination-related deaths by strictly regulating kratom as a supplement, as opposed to the DEA scheduling it as a drug. "FDA has a lot of authority to actually help consumers know that what they're buying is what is labeled, and have at least some level of assurance," Henningfield says. "It's not close to the drug standard, but it's much better than something that's illicitly marketed."
But the FDA is actually also pivotal in advising the DEA on the scheduling of drugs. "The decision to permanently schedule any drug is not a DEA unilateral decision," says Steve Bell, a DEA spokesperson. Consider the regulatory pathway of suboxone. The FDA approved the drug in 2002, and the Department of Health and Human Services recommended that the DEA put it in Schedule III, which the DEA accepted. This puts the drug in the same category as Tylenol with codeine: It’s available for doctors to prescribe for narcotic addiction, but is still a controlled substance.
Schedule I, though, is an entirely different rodeo. If the DEA places kratom here, nobody can touch the stuff. Current users, should they continue to use, will be forced to even sketchier sources. And scientists will have a harder time learning how kratom works, and supporting, or refuting, the claims users make with hard data. (Consider marijuana, also a Schedule I drug. Science has a dearth of data on it because getting permits to study the drug is an exercise in bureaucratic insanity.)
All that research costs money. Which is kratom's catch-22: The DEA wants to schedule the drug because they think it might pose a danger to public health, but the only way to confirm (or refute) the DEA's worries is with more research—which will be next to impossible should the DEA follow through on its promise to schedule.
One of the few scientists studying kratom is the University of Florida’s Oliver Grundmann, who is finishing up an online survey of nearly 10,000 users. And the data (preliminary, though Grundmann plans to publish a paper in the coming months) reveals a different profile of kratom users than you’d expect from an “illicit” recreational drug.
“The age range is more geared toward an older population," says Grundmann, "which is more likely to experience work related injuries or acute or chronic pain from another medical condition." Over half of users are between the ages of 31 and 50. Eighty-two percent completed at least some college. Nearly 30 percent of respondents pull in a household income of over $75,000 a year. Not quite the party drug demographic. And the public comments on the DEA’s scheduling notice reflect that population. Many of those folks are using kratom to either wean themselves off prescription opioids or use the drug alone to treat pain.
Still, that's self-medication using a product that may be contaminated. "The industry needs to come together," says Susan Ash of the AKA. "There's no way the FDA is going to feel comfortable not seeing this as a scheduled controlled substance without a commitment from the industry that there will be proper measures put in place." Better labeling, for instance, would be a start.
Grundmann says he understands the DEA's motivation. "They do not want to have another drug out there that could potentially contribute to the already devastating opioid epidemic that some communities are experiencing,” he says. “But on the other side, we also need to consider that the 4 to 5 million estimated users of kratom may face a health crisis of their own if kratom becomes scheduled.”
Anecdotes and Evidence
Ariana Campellone takes her kratom with coconut milk and protein powder. Then, she mixes, diluting with water to take the lumps out of the mixture. By itself, the stuff tastes awful. Like oversteeped tea, or a mouthful of peat. She thinks the comparison to coffee is a bit overstated. "Coffee gives me a noticeable spike and high, and can feel when I'm coming down," she says.
The DEA’s public comment period closes tomorrow. The agency says it will consider those comments alongside the FDA's scientific and medical evaluation before proceeding to schedule. The FDA did not respond in time to comment on this story.
However, if the DEA follows through on its previous intent to schedule, Campellone says she'll still continue to use kratom. "Just like people have continued to use cannabis where it's not legal," she says. In practical terms, it means getting ahold of kratom would probably get more expensive and personally risky. Those costs, those risks—those hassles—might not be worth it to some kratom users. And then the not-so-small community of recovering opioid addicts lose something available, and possibly quite good.