Addressing issues related to addictive behaviors and diagnoses
Kratom, an herbal drug that originates from the leaves of Mitragyna speciosa (M. speciosa), is a tropical plant growing 4 to 16 m high and is a cousin of the coffee and gardenia plant (White, 2018). Kratom is indigenous to Southeast Asia, primarily Thailand, Malaysia, New Guinea, and the Philippines (Griffin, Daniels, & Gardner, 2016). Other names for kratom include biak, ithang, thang thom, ketum, kakaum, and herbal speedball (Fluyau & Revadigar, 2017; National Institute on Drug Abuse [NIDA], 2019).
Kratom has been widely used for centuries because of its medicinal and anesthetic properties. In Southeast Asia, kratom has been used medicinally for a variety of different health ailments. Kratom leaves may be used whole, chopped, powdered, or as concentrated extracts in the form of tea-like brews; capsules and tablets are also available. Most often consumed as a tea, kratom has been used as a treatment for acute and chronic pain syndromes, anxiety, and depression; to enhance mood; and for self-management of opioid withdrawal (Grundmann, 2017; Henningfield, Fant, & Wang, 2018).
During the 1990s, kratom use increased outside of Southeast Asia and rapidly spread to the United States. Since the early 2000s, the U.S. Drug Enforcement Administration (DEA) listed kratom as a “drug of concern” (White, 2018). In 2016, the DEA recommended kratom as a Schedule I drug; however, researchers and the public protested this proposition, and the ruling was delayed (White, 2018). The opposition to the DEA recommendation to classify kratom as a Schedule I drug was concern that this action may promote a black market for the product and increase the use of prescription opioids, which in turn may increase unintentional deaths. In addition, individuals who are long-term kratom users often use this substance as a method to avoid other opioid-like substances and are fearful of losing sobriety (Henningfield et al., 2018). As of July 2019, kratom remains a drug of concern (Post, Spiller, Chounthirath, & Smith, 2019) and is not regulated, but it can potentially cause risks to individuals who are using this substance. The DEA continues to work closely with the U.S. Food and Drug Administration (FDA) and NIDA along with the input derived from the public to determine the abuse potential of this drug (Henningfield et al., 2018). Currently, kratom is legal in most states in the United States. Several states, including Alabama, Arkansas, Indiana, Vermont, and Wisconsin, have deemed kratom illegal (Prozialeck et al., 2019). There is no approved use of kratom in the European Union, and several Asian countries, including Thailand and Malaysia, have criminalized its use (Prozialeck et al., 2019).
According to Post et al. (2019), the number of kratom exposures reported to U.S. Poison Control Centers increased 10-fold from 2010 to 2015. The Centers for Disease Control and Prevention (CDC) reported 152 unintentional deaths caused by kratom between July 2016 and December 2017 (Kuehn, 2019). Other co-occurring substances, such as fentanyl, fentanyl analogs, heroin, benzodiazepines, prescription opioids, and cocaine, have been implicated in approximately 80% of the unintentional drug overdose deaths with kratom (O'Malley Olsen, O'Donnell, Mattson, Schier, & Wilson, 2019).
Factors contributing to the increased incidence of kratom use in the western world have been attributed to the relocation of Southeast Asian individuals to the United States, rising internet sales, misleading marketing strategies, and lack of government regulation, thus leading to uncontrolled sales of kratom-containing products in legitimate local tea and head shops, bars, and gas stations (Post et al., 2019; White, 2018). Kratom is marketed as a legal psychoactive product, novel psychoactive herbal product, and dietary supplement for weight loss. The absence of federal regulations of kratom sales in the United States enables kratom and its extracts to be bought, sold, and handled without a license or prescription. However, kratom sold as a dietary supplement in the United States must conform to U.S. supplement laws (Cinosi et al., 2015). The current estimated annual market of kratom sales is $207 million and is currently rising (Post et al., 2019). Kratom use continues to be an emerging trend in the United States, and the drug's tolerance and dependency profile create a potential for misuse as well as act as contributors to the growing opioid crisis.
Kratom is a unique drug that exerts different effects based on dosage. The exact mechanism of action is not definitive. Although some sources consider kratom an opioid agonist, additional human subject research is required to determine the exact actions because the science is not definitive at this time (Prozialeck, Jivan, & Andurkar, 2012). When taken in low to moderate doses (1 to 5 g), a mild stimulant effect is produced. However, when taken in moderate to high doses (5 to 15 g), the individual experiences opioid-like effects. At very high doses (>15 g), the drug produces sedative effects (Post et al., 2019). Kratom's stimulant effects have been used to help with fatigue and increase productivity. Its opioid-like properties have led the drug to become a popular self-treatment to ease opioid and heroin/morphine dependence symptoms (Tayabali, Bolzon, Foster, Patel, & Kalim, 2018). Despite few studies on kratom's active ingredients, its unique or atypical properties can act as stimulants as well as analgesics and serve to lessen opioid withdrawal symptoms (Griffin et al., 2016; Henningfield et al., 2018). Kratom's properties can best be explained by its main psychoactive alkaloid compounds: mitragynine and 7-hydroxymitragynine (Matson & Schenk, 2019). Mitragynine consists of abundant alkaloids found in the leaves of M. speciosa in addition to other analogues such as mitraciliatine, speciogynine, and speciociliatine, as well as the related compound paynantheine. Yusoff et al.'s (2016) study suggested mitragynine, the alkaloid found in kratom, demonstrated abuse and possible addictive-like properties on rodent models. As mentioned previously, additional research is necessary in humans to precisely ascertain how kratom works and understand its potency.
According to Kiefer (2018), individuals most often ingest <8 g per dose of kratom, delivering 120 to 180 mg of mitragynine into their system for its opioid effects to self-treat acute and chronic pain syndromes. As mentioned previously, kratom effects are dose dependent. Doses ≥8 g have been known to also help with opioid withdrawal symptoms. An average green leaf weighs approximately 1.7 g, a dry leaf weighs approximately 0.43 g, and 20 kratom leaves contain approximately 17 mg of mitragynine (Cinosi et al., 2015). Kratom leaves can be chewed, brewed into tea, or smoked. Smoking kratom is the least common method of ingestion due to the increased amount of leaf required to achieve a desired response. Most commonly, dependent users of kratom chew one to three leaves, three to 10 times per day (Cinosi et al., 2015). Once ingested, the onset of action of kratom is 10 to 15 minutes and the effects last approximately 2 to 5 hours (White, 2018).
According to Cinosi et al. (2015), kratom ingested in smaller doses creates stimulant-like effects. Higher doses of kratom generate a sedative-type response, mirroring reactions associated to ingestion of sedative narcotic or opiate agents. Matson and Schenk (2019) stated that based on findings from comparative testing in a mouse model, mitragynine and 7-hydroxymitragynine may have lethal doses similar to heroin. Users of kratom may experience a sympathetic nervous system response such as hypertension, tachycardia, agitation/irritability, seizures, gastrointestinal system effects, anorexia, cognitive changes, and dependency. There have also been reported cases of complications related to unintentional death from kratom use (Kuehn, 2019).
Prevalence and Impact of Kratom Use
A paucity of information exists on the use and prevalence of kratom in the United States. It has been estimated that 4 to 5 million American individuals currently use kratom and are purchasing products from more than 10,000 retail outlets (Henningfield et al., 2017). Currently, kratom is not detected on standard drug screening tests and it is not listed in the NIDA survey that is administered to high school students (White, 2018). Since 2015, the FDA has made several unsuccessful attempts to block kratom imports into the United States. FDA efforts to control kratom use and sales failed due to the actions of kratom lobbyist and kratom support groups. Pro kratom lobbyists argued that bans on kratom were enacted without sufficient evidence and support preventing important research on the drug's ability to ameliorate opioid withdrawal symptomology (Gianutsos, 2017). There is speculation that adolescents and young adults are at increasing risk for kratom use and possible misuse due to lack of government controls on kratom sales (White, 2018). Rising internet sales also point to increased availability for younger individuals to purchase a variety of substances and/or age-restricted products such as tobacco. Another concern regarding kratom misuse is the misrepresentation as being a safe and natural substance. For example, individuals sometimes correlate the natural or herbal nature of kratom as a plant-like substance along with its legality in the United States to its safety; therefore, its use is increasing and is often referred to as a “legal-high” or “herbal-high” (Ismail, Jayabalan, Mansor, Müller, & Muzaimi, 2017). Quality control measures and guidelines for safe use are currently lacking (Prozialeck et al., 2019).
Currently, there are no FDA– approved uses for kratom. Henningfield et al. (2017) reported that the most common motivations for kratom ingestion are its functional and social benefits. Kratom is most commonly used for mood enhancement and its stimulating effects to sustain and achieve occupational demands and goals. Similarly, the regular use of kratom is attributed to its ability to help with syndromes and lessen opioid withdrawal symptoms (Post et al., 2019). Socially, kratom is used for its euphoric and hallucinogenic effects (Henningfield et al., 2017).
Health Care Implications
Health care professionals are in a strategic position to identify at-risk patients and provide interventions in the early stages of kratom-related problems and misuse; therefore, substance use screening and assessment that includes kratom and other trending herbal drugs should be integrated into routine care. The increasing popularity of kratom use within the United States requires health care professionals to be aware and familiar with the pharmacology, adverse effects, and potential complications of its use. Kratom's side effects profile along with its use, misuse, tolerance, and dependency potential (especially for those who self-medicate without medical supervision) require health care professionals to be able to recognize and respond to adverse effects related to kratom ingestion. As nurses and other health care professionals are in the forefront of health care, ensuring education on kratom is imperative to assist in engaging in health-promoting interventions, identifying individuals at risk, and ensuring patients receive appropriate care.
To identify kratom-related complications, a thorough patient assessment should be performed, including an evaluation of the patient's symptoms and a thorough medical, social, psychological, and substance use history. As discussed previously, unintentional drug overdoses with kratom almost always include co-occurring substances such as opioids including fentanyl and heroin. Therefore, kratom adverse effects may appear similar to an opioid overdose that includes respiratory depression, pupillary constriction, diaphoresis, tachycardia, hypertension, nausea, constipation, confusion, hallucinations, sedation, seizures, psychosis, and death (Matson & Schenk, 2019; White, 2018).
Health care providers can assess for use and approach patients from the same perspective as other substances, including alcohol and opioids, to determine if substance use disorder criterion is met. Clinicians can assess individuals for opioid dependence through the use of several standardized assessment tools, such as the Drug Abuse Screening Test, which is a 10-item self-report tool that has been found to be valid, sensitive, and reliable for the screening of substance use disorders (Yudko, Lozhkina, & Fouts, 2007). The CAGE-AID is a screening tool used to assess for drinking and drug use (Brown & Rounds, 1995). An additional short self-reporting screening tool, which only takes a few minutes to complete, is the Opioid Risk Tool (ORT; Webster & Webster, 2005). The ORT assesses risk for opioid use among individuals prescribed opioids for treatment of chronic pain.
Unfortunately, kratom is not present in routine drug screens (White, 2018). Therefore, use or misuse of kratom may not be identified consistently. A separate screening urine analysis for kratom is available that detects the presence of 7-hydroxymitragynine and mitragy-nine. However, this urine test may not consistently be performed because the expected turnaround time may be between 5 and 10 days, thus rendering it not as useful during acute management phases of a potential kratom overdose. To date, official toxic levels of kratom have not been established (Matson & Schenk, 2019); therefore, if kratom overdose is suspected, treatment may be similar to an opioid overdose. The priority for a suspected opioid drug overdose is maintaining airway patency, breathing, and circulation (Parthvi, Agrawal, Khanijo, Tsegaye, & Talwar, 2019). Unintentional drug overdoses with kratom often frequently involve opioids; therefore, naloxone may be considered for administration either intravenously, intramuscularly, or intra-nasally to reverse the opioid-like effects after the patient is stabilized (O'Malley Olsen et al., 2019).
Other treatment strategies may include oxygen, intravenous fluids, benzodiazepines, high-dose clonidine, anti-emetics, and hydroxyzine (Galbis-Reig, 2016; White, 2018). Given the broad range of potential complications associated with kratom use and to ensure an abrupt kratom withdrawal does not occur, vital signs need to be monitored closely along with the patient's level of consciousness and changes in cognition need to be assessed.
Kratom can cause tolerance and withdrawal symptoms, which makes it difficult for the individual taking this drug to stop without professional assistance (White, 2018). Once kratom dependency has been identified, nurses and health care providers can work together as interprofessional teams to implement substance treatment protocols in conjunction with effective, health-promoting communication and provide patient education to best develop a therapeutic treatment plan for these patients. Strategies such as motivational interviewing (MI) can then be used along with advice about precautions and risks associated with kratom use.
MI is a client-centered counseling strategy that health care providers may use to assist individuals in making behavioral changes to promote abstinence (Substance Abuse and Mental Health Services Administration, 2013). This evidence-based approach is based on four principles that include: expressing empathy, developing discrepancy, managing resistance, and increasing self-efficacy (DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017; Mallisham, & Sherrod, 2017). It is imperative that health care providers display a non-judgmental attitude and express empathy toward patients to develop a therapeutic relationship. Health care providers facilitate patients' expression of perceived discrepancies between their present behavior and their future personal goals. Patients are the source of identifying needed behavioral changes. MI endorses health care providers to possess self-awareness in communicating with patients, for example, by avoiding direct confrontation and opposition to patients. Lastly, MI supports patient self-efficacy, which is a key component in the change process. Motivation and self-efficacy are significant predicators of reduction and abstinence for substance use (Yakovenko, Quigley, Hemmelgarn, Hodgins, & Ronksley, 2015).
It is important for health care providers to collaborate with patients about their treatment plan and help them create realistic goals based on their diagnosis, lifestyle, and behaviors. As health care providers increase their understanding of the risks associated with kratom, they can better educate patients and the public about the potential dangers of kratom misuse (Matson & Schenk, 2019).
As new trends in drug misuse emerge in the United States, and as new information about kratom use is reported in the literature, nurses and other health care providers need to receive educational training to keep them informed on methods to best identify, assess, and provide evidence-based practice management for patients. Currently, there are no established guidelines for management of kratom overdose, withdrawal, or any other complications associated with its use. As previously discussed, the effects of kratom are dose-dependent; thus, health care providers must know the range of dosages and related effects to better counsel patients on potential risks. Because there is limited information available in the literature, interventions to treat these patients should be documented for future studies on best practice management. Over time, as information about kratom becomes available and shared, the clinical practice management for kratom-related problems will likely improve.
It is imperative that nurses and other health care providers understand the motivations of kratom use. Commonly, individuals take kratom as a method of self-medicating to bypass medical personnel for the treatment of pain syndromes, for the stimulant properties, or to manage opioid withdrawal symptoms. Nurses' knowledge and awareness of the stigmas associated with drug use and dependence can help them understand the importance of maintaining an unconditional positive regard for patients' well-being when providing care. Nurses and all health care providers must foster an environment of trust and safety, so patients feel comfortable to share their history, express their concerns, and seek treatment solutions.
Substance use disorders are a major public health problem in the United States. Kratom has been receiving national attention because it has become increasingly more popular and used more often in this country. Kratom is a drug that exerts dual effects depending on the dose. Individuals can purchase this drug at legitimate stores. Currently, lack of regulations often misleads an individual who takes kratom to believe the product is safe and lacks possible significant adverse effects. Although outcomes from taking kratom vary from minor to moderate adverse effects, unintentional drug overdose deaths have been associated with kratom. As with other substances, there is a continuum of usage, ranging from occasional use to overuse. There continues to be debate over balancing the possible medical benefits of kratom use with the potential for abuse and complications. Although the use of kratom remains controversial, there is an overall consensus that additional research is necessary to establish safety, dosage standardization, and effective use guidelines (Prozialeck et al., 2019).
Health care providers should receive education on kratom's adverse effects, especially when used with other drugs such as opioids, and be knowledgeable of the appropriate treatment strategies. It is imperative that all health care providers assist in educating and protecting the public from kratom misuse.
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