Addiction treatment is not one-size-fits-all, a disclaimer often stated by health professionals and recovery advocates alike. And it’s true.
Phil Krauss, from Ohio, told ThinkProgress he kicked heroin three years ago through medical detox, followed by a short stint on addiction treatment medication, Suboxone, but largely maintains sobriety through a 12-step abstinence program. Adam Winepol, from Maryland, said he weaned off heroin by taking the medication methadone daily. Unlike Suboxone — a partial opioid agonist — methadone, a full opioid agonist, is only available through specially designated treatment facilities. (Agonists activate the opioid receptors in the brain, resulting in a full opioid effect.) For both Phil and Adam, medication was coupled with counseling.
Different recovery processes, but both avenues of treatment are widely considered effective by the medical community in treating heroin and prescription opioid dependence. And federally-sponsored studies have helped shape this opinion. The National Institute on Drug Abuse (NIDA) sponsored studies are furthering understanding of medication assisted treatment; a study released Wednesday reported there’s a major caveat to the effectiveness of naltrexone, an opioid antagonist.
There isn’t robust, federally sanctioned research on the effectiveness of kratom, a plant with opioid-like effects, for addiction treatment; even so, people struggling with addiction are self-medicating. “I don’t want to go to rehab. I’ve done Suboxone, I’ve done methadone, this time I want to try kratom,” Adrian Quiroga, a 6-year heroin user, told VICE.
Citing 36 deaths linked to products containing kratom, the Food and Drug Administration (FDA) issued a public health warning Tuesday about the plant-based substance. Kratom (mitragyna speciosa), which originates in Southeast Asia, has become widely popularized in the United States for treating pain or weaning people off opioids — a trend FDA Commissioner Scott Gottlieb hopes to mitigate.
“We’ve learned a tragic lesson from the opioid crisis: that we must pay early attention to the potential for new products to cause addiction and we must take strong, decisive measures to intervene,” Gottlieb said in a statement.
His denunciation was applauded by former FDA commissioner Robert Califf, who served under President Barack Obama. “False marketing of medical products with risk to people is one of the lowest forms of human [behavior] — glad to see FDA taking action!” Califf said in a tweet.
False marketing of medical products with risk to people is one of the lowest forms of human behaior–glad to see FDA taking action! https://t.co/feuz3cilkW
— Robert M Califf (@califf001) November 14, 2017
Gottlieb said, “There’s clear data on the increasing harms associated with kratom.” But it’s important to understand that kratom is only lethal when adulterated, which occurs because the drug is unregulated in the United States. It’s a discombobulated market; people can buy kratom in vending machines in Arizona, but it’s banned in some states like Vermont.
A recent study found several commercially-available kratom products had “artificially elevated concentrations” of 7-hydroxy than those found in the raw plant leaves. Mitragynine and 7-hydroxy are the two main psychoactive compounds of kratom. Mitragynine is not addictive, whereas 7-hydroxy is.
“If we go back and look at traditional use, there’s never been one reported death in Thailand, or Malaysia, or Southeast Asia, from kratom alone,” president-elect to the American Association of Pharmaceutical Scientists (AAPS) Christopher McCurdy told VICE. McCurdy has studied the plant for more than a decade and co-authored the aforementioned study.
In the natural product, mitragynine is at least 23 times greater in amount than 7-hydroxy, a ratio of about 23:1, McCurdy told ThinkProgress. “Some of the products in the commercial market have a greater amount of 7-hydroxy in them than this natural ratio,” he said. “We do not know where the ratio can become problematic.” His team is studying this because mitragynine has the potential to help combat the opioid epidemic.
Qualitative analysis published in the Journal of Psychoactive Drugs found that kratom may be useful for analgesia, mood elevation, anxiety reduction, and opioid withdrawal management. The often cited unfavorable side effects included upset stomach and vomiting. Instances of withdrawal from addiction were also noted. The study analyzed accounts on the popular drug website Erodwid, as there’s been little scientific research into short- and long-term effects on U.S. users.
The FDA said it remains open to the potential medicinal uses of kratom, but that the uses need to be backed by sound-science and assessed accordingly for potential drug abuse. Ed Baker, licensed alcohol/drug counselor and education specialist at Aspenti Health, told ThinkProgress he agrees with this assessment.
“Kraton is on the borderline of legality. The [commercial manufacturers] are entirely motivated by self interest only,” said Baker. “They are preying on a vulnerable population in our country.”
He recalled a man he knew who suffered from Crohn’s disease and took kratom to alleviate the pain. The man went into withdrawal from the product. Baker acknowledged that this is just more anecdotal evidence, albeit contrary to stories of success, which is why he supports further research into the substance.
Baker added that Kratom should not be a schedule 1 drug — a sentiment echoed by kratom researchers, advocates, and consumers alike. The Drug Enforcement Administration (DEA) reserves this category for highly addictive, dangerous drugs. The DEA temporarily banned the drug a year ago, which also temporarily halted McCurdy’s own research into the drug.
Gottlieb said the FDA and the DEA are further evaluating kratom and determining how it should be scheduled. But while the FDA is looking to protect people struggling with addiction, they could — if they decide to ban the drug — hinder the progress for treatment opportunities.