Medications typically used to treat opioid use disorder (OUD) may also be effective for the growing public health problem of kratom addiction, new research shows.
Results of a comprehensive literature review and an expert survey suggest buprenorphine, naltrexone, and methadone are effective for kratom use disorder (KUD) and that the indication for these medications “should be extended to [treat] cases of moderate to severe kratom addiction,” study investigator Saeed Ahmed, MD, medical director of West Ridge Center at Rutland Regional Medical Center, Rutland, Vermont, told Medscape Medical News.
Ahmed, who practices general psychiatry and addiction psychiatry, presented the findings at the virtual American Psychiatric Association (APA) 2021 Annual Meeting.
Emerging Public Health Problem
Kratom can be ingested in pill or capsule form or as an extract. Its leaves can be chewed or dried and powdered to make a tea. It can also be incorporated into topical creams, balms, or tinctures.
Products containing the substance are “readily available and legal for sale in many states and cities in the US,” said Ahmed, adding that it can be purchased online or at local smoke shops and is increasingly used by individuals to self-treat a variety of conditions including pain, anxiety, and mood conditions, and as an opioid substitute.
As reported by Medscape Medical News, a 2018 analysis conducted by the US Food and Drug Administration showed kratom is, in fact, an opioid, a finding that garnered significant push-back from the American Kratom Association.
Kratom addiction, said Ahmed, is an “emerging public health problem,” noting that in recent years the number of calls to poison control centers across the country has increased 52-fold — from one per month to two per day. He believes misinformation through social media has helped fuel its use.
In addition, Ahmed points out that kratom is addictive and carries a high relapse rate; to date, however, there are no guidelines on how to maintain long-term abstinence.
To investigate, the researchers conducted a systematic literature search for cases pertaining to maintenance treatment for kratom addiction. They also tapped into case reports and scientific posters from reliable online sources and conference proceedings. In addition, they conducted a survey of members from the American Society of Addiction Medicine (ASAM).
The researchers found 14 reports of long-term management of kratom addiction, half of which did not involve an OUD. It’s important to exclude OUDs to avoid possible confounding, said Ahmed.
In most cases, buprenorphine was used, but in a few cases naltrexone or methadone were prescribed. All cases had a favorable outcome. Ahmed noted that buprenorphine maintenance doses appear to be lower than those required to effectively treat OUD.
With a response rate of 11.5% (82 respondents) the ASAM survey results showed 82.6% of respondents (n = 57) had experience managing KUD, including 27.5% (n = 19) who had kratom addiction only. Of these, 89.5% (n = 17-19), used buprenorphine to manage KUD and of these 6, combined it with talk therapy.
Ahmed cautioned that the included cases varied significantly in terms of relevant data, including kratom dose and route of administration, toxicology screening used to monitor abstinence, and duration of maintenance follow-up.
Despite these limitations, the review and survey underscore the importance of including moderate to severe kratom as an indication for current OUD medications, said Ahmed.
Including kratom addiction as an indication for these medications is important especially for patients who use high doses of kratom and meet DSM-5 diagnostic criteria for moderate or severe SUD, said Ahmed.
In addition, clinicians should consider referring patients with moderate to severe KUD for counseling or enrollment in 12-step addiction treatment programs, he said.
A Separate Diagnosis?
Ahmed said he would like to see KUD included in the DSM-5 as a separate entity.
“This will not only help to better inform clinicians about a diagnostic criteria encompassing problematic use and facilitate screening, but it will also pave the way for treatments to be explored for this diagnosable condition.”
Commenting on the study for Medscape Medical News, Petros Levounis, MD, professor and chair, Department of Psychiatry, and associate dean for professional development, Rutgers New Jersey Medical School, Newark, said the authors “have done a great job reviewing the literature and asking experts” about kratom addiction treatment.
“The punchline of their study is that kratom behaves very much like an opioid and is treated like an opioid.”
Levounis noted that kratom dependence is so new that experts don’t know much about it. However, he added, emerging evidence suggests that kratom “should be considered an opioid more than anything else,” but added it does not warrant its own diagnosis of KUD.
He noted that individual opioids don’t have their own diagnostic category and that opioid use disorder is an umbrella term that covers all of these drugs.
Ahmed and Levounis have disclosed no relevant financial relationships.
American Psychiatric Association (APA) 2021 Annual Meeting: Poster #5284. Presented May 2, 2021.