Kratom Use and Suicidal Thoughts and Behaviors in the United States

Abstract

Background:

The rise of suicidal thoughts and behaviors (STBs) in the United States and their association with substance use disorders, including the emerging concern over Kratom—a psychoactive substance—necessitates an investigation into its role in STBs. This study provides the first epidemiologic assessment of the association between Kratom use and STBs in the United States.

Methods:

This study leveraged data from the 2021 National Survey on Drug Use and Health (NSDUH) to examine the association between Kratom use and STBs. The NSDUH was carried out among a representative sample of American individuals. Our study sample comprised 47 291 individuals aged 18 and older across the United States. Lifetime Kratom use was the exposure, while outcomes included past-year suicidal thoughts, plans, and attempts.

Results:

Persons who use Kratom (PWUK) exhibited higher odds of reporting past-year suicidal thoughts (odds ratio [OR]: 2.14), plans (OR: 1.95), and attempts (OR: 2.50) compared to persons who never used Kratom. The associations also varied by sex and race, with pronounced effects among male and Black individuals. Specifically, subgroup analyses revealed higher odds of suicidal thoughts among Black PWUK (OR: 11.00) and among male PWUK (OR: 2.74).

Conclusions:

The findings suggest a significant association between Kratom use and STBs in the U.S. adult population, with variations by sex and race. These results highlight the need for further research examining the causal relationships between Kratom use and STBs, including whether episodic use differs from addiction, as well as assessing the associations of Kratom use with other mental health conditions. This understanding is crucial for informing the development and implementation of targeted interventions, policies, and programs aimed at addressing Kratom use and its mental health consequences.

Introduction

Suicide is a leading cause of death in the United States. Age-adjusted suicide rates have increased by ~36%/100 000 individuals from 2000 (10.4) to 2022 (14.2), with the male rate ~4 times that of the female rate.¹ National suicide trends also differ by race and ethnicity; from 2018 to 2021, non-Hispanic American Indian and Alaska Native and non-Hispanic Black individuals experienced a 26% and 19.2% increase in suicide rates, respectively, while non-Hispanic Whites experienced a 3.9% decrease.² For every death by suicide, there are many more suicidal thoughts and suicide attempts.¹ In 2021, there were ~3 self-injury-related hospitalizations, 8 suicide-related emergency department visits, 38 self-reported suicide attempts, and 265 individuals with past-year suicidal ideation for each of the 46 412 suicide deaths.^2,3 Furthermore, the Centers for Disease Control and Prevention provisionally estimate that 2022 saw the single largest annual suicide rate increase ever, with a record 49 449 suicides.⁴

Existing literature has identified substance use disorders, including opioid misuse, as a significant risk factor for suicidal ideation, plans, and attempts.^5–7 Kratom is a legal herbal substance derived from Mitragyna speciosa, with active compounds mitragynine and 7-hydroxymitragynine which interact with opioid receptors to contribute to its analgesic and stimulant effects akin to opioids and other stimulants.⁸ Its popularity in the United States has surged during the last decade, with a recent study reporting an almost 5000% increase in exposure rate from 2011 to 2017,⁹ alongside a notable rise in related research and online presence.¹⁰ The widespread use of Kratom may be explained by the misconception that natural psychoactive substances are safer to use because they are “natural.”⁹ Surveys of individuals who use Kratom indicate use for managing withdrawal symptoms, chronic pain, fatigue, and other mental health-related symptoms.^11,12 However, the United States Food and Drug Administration has not approved Kratom for medical use, warning against its usage due to the potential for dependence and acute adverse reactions.¹³

Kratom has been associated with suicidal thoughts and behaviors (STBs) in preliminary studies,¹⁴ but the current evidence is limited and mixed.¹⁵ Reports of Kratom-related healthcare admissions with severe adverse outcomes—~30% of 1800 cases between 2011 and 2017—underscores the need for further investigation.¹⁶ Kratom’s opioid-like effects, including withdrawal symptoms and mental health challenges, parallel those observed in opioid use disorders (OUD), which are significant risk factors for STBs. For instance, Settle and Yang¹⁴ documented a case illustrating the addictive potential of Kratom, its withdrawal effects, and its complex relationship with mental health. However, other studies, such as Kittirattanapaiboon et al,¹⁷ have found no significant difference in suicide risk among persons who use Kratom (PWUK) compared to persons who never used Kratom (PWNUK), highlighting the gaps and inconsistencies in current research. Given the adverse outcomes associated with Kratom use, further research is essential to clarify its role in STBs, particularly through investigations into its mental health impacts and potential mechanisms of action. These research efforts will provide critical insights to inform healthcare providers, policymakers, and public health officials in the development of effective interventions and guidelines.

In addition to these research gaps, there are also methodological gaps that need to be addressed. For instance, existing nationwide surveys on STBs predominantly capture data from White individuals, limiting researchers’ abilities to capture representative data for non-White populations.¹⁸ As such, the insufficient assessment of STBs in non-White populations and the significant differences in suicide statistics by sex motivated the stratification by race and sex in our analyses. Overall, our study leveraged data from the 2021 National Survey on Drug Use and Health (NSDUH) to (1) determine the association between Kratom use and STBs and (2) assess the extent to which this association may be impacted by sex and race.

Materials and Methods

Study Design and Participants

Our study involved a cross-sectional analysis of the NSDUH study, an annual survey that collects data on substance use, mental health, and related health behaviors from a nationally representative sample of individuals.¹⁸ In 2021, the NSDUH study comprised 69 850 individuals aged 12 and older across the United States residing in households, noninstitutional group housing, and military bases (civilians) at the time of the survey.¹⁸ Excluded from the NSDUH are active-duty military personnel, homeless individuals, and residents of institutional quarters such as jails or hospitals.¹⁸ Detailed demographic information on the survey population is available in Table 1. For the current analysis, the analytic sample included the NSDUH respondents aged 18 and older who completed responses to the survey questions concerning sex, race, Kratom use, and suicidal behaviors, resulting in a final sample of N = 47 291 (Table 2). Respondents who omitted from responding to any of these questions were excluded from our analyses. Further details on the NSDUH study are available here: https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health.

Table 1.

Participant Characteristics: Unweighted Frequency and Percent of Demographics Overall and by Lifetime Kratom Use, Including P Value Calculated Using Chi-Square Test.

Participant Characteristics	All sample, N = 47 291: frequency (%)	Never used Kratom, N = 46 305: frequency (column %)	Ever used Kratom, N = 986: frequency (column %)	χ2 P value
Age				<.0001
18–25	13 979 (29.56)	13 671 (29.52)	308 (31.24)
26–34	9588 (20.27)	9249 (19.97)	339 (34.4)
35–49	12 561 (26.56)	12 293 (26.55)	268 (27.18)
50–64	5725 (12.11)	5671 (12.25)	54 (5.48)
>65	5438 (11.50)	5421 (11.71)	17 (1.72)
Sex				<.0001
Male	20 901 (44.20)	20 369 (43.99)	532 (53.96)
Female	26 390 (55.80)	25 936 (56.01)	454 (46.04)
Race				<.0001
Non-Hispanic White	29 349 (62.06)	28 585 (61.73)	764 (77.48)
Non-Hispanic Black or African-American	5244 (11.09)	5210 (11.25)	34 (3.45)
Other non-White	12 698 (26.85)	12 510 (27.02)	188 (19.07)
Sexual identity or orientation				<.0001
Heterosexual	39 751 (88.58)	39 050 (84.33)	701 (71.10)
Nonheterosexual	5126 (11.42)	4891 (10.56)	235 (23.83)
Income				<.0001
<$20 000	8412 (17.79)	8217 (17.75)	195 (19.78)
$20 000–$49 999	12 907 (27.29)	12 539 (27.08)	368 (37.32)
$50 000–$74 999	7180 (15.18)	7038 (15.20)	142 (14.40)
$75 000 or more	18 792 (39.74)	18 511 (39.98)	281 (28.50)
OUD				<.0001
No	46 373 (98.06)	45 505 (98.27)	868 (88.03)
Yes	918 (1.94)	800 (1.73)	118 (11.97)

Abbreviation: OUD, opioid use disorder.

Table 2.

Unweighted Frequency of Suicidal Behaviors and Lifetime Kratom Use, Including P Value Calculated Using Chi-Square Test.

Suicidal Thoughts or Behaviors	All sample, N = 47 291: frequency (%)	Never used Kratom, N = 46 305: frequency (column %)	Ever used Kratom, N = 986: frequency (column %)	P value
Thoughts of suicide in past year				<.0001
No	44 114 (93.28)	43 302 (93.51)	812 (82.35)
Yes	3177 (6.72)	3003 (6.49)	174 (17.65)
Made plans to attempt suicide in past year				<.0001
No	44 660 (94.44)	43 773 (94.53)	887 (89.96)
Yes	945 (2.00)	887 (1.92)	58 (5.88)
Attempted suicide in past year				<.0001
No	46 856 (99.08)	45 903 (99.13)	953 (96.65)
Yes	435 (0.92)	402 (0.87)	33 (3.35)

Procedures and Measures

The 2021 NSDUH was a self-report survey that involved interviews with a representative sample of American individuals.¹⁹ In 2021, responses were collected through both in-person (45.4%) and online (54.6%) methods, due to the conditions of the COVID-19 pandemic.¹⁸ The survey aims to assess substance use, mental health, and other psychosocial experiences, providing a quantitative overview of mental well-being in the United States.¹⁹

In the current analysis, Kratom use was ascertained using the following item: “Have you ever, even once, used Kratom?.” Responses to this question were used to derive lifetime Kratom use. STBs were assessed by respondents’ answers to questions regarding suicidal ideation, planning, and attempts in the past year. Past-year STBs were assessed using 3 questions in the NSDUH: “At any time in the past 12 months, did you seriously think about killing yourself?” for suicidal thoughts, “At any time in the past 12 months, did you make any plans to kill yourself?” for suicidal planning, and “At any time in the past 12 months, did you try to kill yourself?” for suicide attempts. Responses to these questions were categorized dichotomously. An affirmative answer to a question was considered positive for that specific suicidal behavior. Sociodemographic and behavioral health characteristics such as age, sexual identity or orientation, income, and OUD were included as covariates (see Table 1).

Statistical Analysis

The analyses were conducted using SAS (Version 9.4M8, SAS Institute Inc., Cary, NC, USA) and used survey commands to accommodate the complex survey design of the NSDUH. Analyses were completed using PROC SURVEYLOGISTIC procedures incorporating analysis survey weights, sampling unit clusters, and strata. Descriptive analyses stratified by Kratom use were performed along with independent sample chi-square (χ²) tests (Table 1). Covariates exhibiting significant associations with Kratom use, namely age, sex, race, sexual identity, income, and OUD were incorporated into the subsequent multivariable analyses. The NSDUH-imputed revised variables were used to account for data missingness. In the event imputed revised variables were not available, missing data were excluded from our analyses.

Univariate and multivariable logistic regressions were computed to determine the unadjusted and adjusted odds ratios (ORs), 95% confidence intervals (CIs), and corresponding P values pertaining to suicidal behaviors in relation to Kratom use. Stratified analyses were also conducted for males and females, as well as White, Black, and other non-White survey respondents, to offer insights into the magnitude of Kratom’s association with suicidal behaviors within sex- and race-homogenous populations. We also adjusted for the following confounders based on the literature: sexual orientation, age, income, and OUD.^20–24

Results

Sociodemographic Characteristics of the Sample

Of the 47,291 respondents, the majority were 18 to 25 (29.56%) and 35 to 49 (26.56%), female (55.80%), non-Hispanic White (62.06%), heterosexual (88.58%), did not report an OUD (98.06%), and had a household income of $75 000 or more (39.74%), as reported in Table 1. Within each of these demographic subcategories, Kratom use was more common among individuals who were 26 to 34 (0.72%; P < .0001), male (1.12%; P < .0001), non-Hispanic White (1.62%; P < .0001), heterosexual (1.56%; P < .0001), reported no OUD (1.84%; P < .0001), and had a household income of $20 000 to $49 999 (0.78%; P < .0001). The remaining frequencies of Kratom use, stratified by demographic variable, are included in Table 1.

Suicidal behaviors were reported in a minority of respondents: 6.72% (n = 3177) reported thoughts of suicide in the past year, 1.63% (n = 945) reported making plans to attempt suicide in the past year, and 0.92% (n = 435) reported attempting suicide in the past year. Tables 3 to 5 illustrate the detailed results of the multiple logistic regression analyses.

Table 3.

Crude and Adjusted ORs for the Association between Ever Kratom Use and Suicide-Related Outcomes.

Outcomes	Crude OR (95% CI)	Adjusted ORa (95% CI)	Adjusted ORb (95% CI)
Any suicidal thoughts (ref: no)
	3.09 (2.61–3.66)	3.23 (2.45–4.24)	2.14 (1.77–2.59)
P value	<.0001	<.0001	<.0001
Made a plan for suicide (ref: no)
	2.44 (2.02–2.94)	2.37 (1.76–3.20)	1.95 (1.44–2.66)
P value	<.0001	<.0001	<.0001
Attempted suicide (ref: no)
	2.14 (1.77–2.59)	1.95 (1.44–2.66)	2.50 (1.64–3.79)
P value	<.0001	<.0001	<.0001

Abbreviations: CIs, confidence intervals; ORs, odds ratios.

^aAdjusted for age, race, income, and sexual orientation;

^bAdjusted for age, race, income, sexual orientation, and opioid use disorder.

Table 5.

Crude and Adjusted ORs for the Association between Ever Kratom Use and Suicide-Related Outcomes by Race.

Outcomes	Crude OR (95% CI)	Adjusted ORa (95% CI)	Adjusted ORb (95% CI)	P value (crude OR)	P value (adjusted ORa)	P value (adjusted ORb)
White
Any suicidal thoughts (ref: no)	3.33 (2.48–4.47)	2.31 (1.69–3.16)	1.98 (1.40–2.80)	<.0001	<.0001	.0003
Made a plan for suicide (ref: no)	4.06 (2.44–6.76)	2.58 (1.53–4.37)	1.89 (1.05–3.42)	<.0001	.0007	.0353
Attempted suicide (ref: no)	4.34 (1.91–9.86)	2.66 (1.12–6.32)	2.34 (0.96–5.70)	.0007	.0279	.0615
Black
Any suicidal thoughts (ref: no)	16.62 (3.78–73.04)	16.73 (3.01–93.11)	11.00 (2.95–41.07)	.0004	.0018	.0006
Made a plan for suicide (ref: no)	3.30 (0.80–13.56)	2.34 (0.64–8.57)	1.84 (0.42–7.97)	.0962	.194	.4088
Attempted suicide (ref: no)	3.96 (0.93–16.85)	2.66 (0.67–10.68)	3.46 (0.62–19.18)	.0620	.1625	.1517
Other non-White
Any suicidal thoughts (ref: no)	3.12 (1.27–7.67)	3.29 (1.48–7.32)	2.62 (1.10–6.22)	.0141	.0044	.0301
Made a plan for suicide (ref: no)	2.72 (0.99–7.47)	2.54 (0.83–7.79)	1.53 (0.34–7.00)	.0527	.1005	.576
Attempted suicide (ref: no)	4.54 (1.62–12.73)	4.55 (1.38–15.06)	2.14 (0.31–14.77)	.0048	.0141	.4323

Abbreviations: CIs, confidence intervals; ORs, odds ratios.

^aAdjusted for age, race, income, and sexual orientation;

^bAdjusted for age, race, income, sexual orientation, and opioid use disorder.

Suicidal Behaviors Among All PWUK

In our NSDUH analytic sample, PWUK showed higher odds of endorsing suicidal behaviors. Adjusting for age, race, sex, income, and OUD, PWUK had 2.14 times higher odds of past-year suicidal thoughts compared to PWNUK (95% CI, 1.77–2.59; P < .0001). The odds of past-year suicide planning were 1.95 times higher in PWUK (95% CI, 1.44–2.66; P < .0001), and the odds of past-year suicide attempts were 2.50 times higher in PWUK compared to PWNUK (95% CI, 1.64–3.79; P < .0001). Further details on the associations between Kratom use and suicidal behaviors are detailed in Table 3, which includes crude, minimally, and fully adjusted models.

Suicidal Behaviors Among PWUK, by Sex

Male PWUK showed higher odds of experiencing suicidal ideation, planning, and attempts compared to male PWNUK. Male PWUK had higher odds of reporting past-year suicidal thoughts (adjusted odds ratio (aOR): 2.74; 95% CI, 1.81–4.14; P < .0001), past-year suicidal planning (aOR: 2.12; 95% CI, 0.97–4.64; P = .0600), and past-year suicide attempts (aOR: 1.85; 95% CI, 0.62–5.55; P = .2648). Similarly, female PWUK had higher odds of reporting suicidal thoughts (aOR: 1.77; 95% CI, 1.10–2.85; P = .0207) compared to female PWNUK. The association between Kratom use and suicidal plans and attempts was not statistically significant among females; however, despite the non-significant results, our findings showed higher odds of suicidal planning (aOR: 1.45; 95% CI, 0.72–2.93; P = .2977), and suicide attempts (aOR: 2.07; 95% CI, 0.89–4.82; P = .0891). These results are further detailed in Table 4.

Table 4.

Crude and Adjusted ORs for the Association between Ever Kratom Use and Suicide-Related Outcomes by Sex.

Outcomes	Crude OR (95% CI)	Adjusted ORa (95% CI)	Adjusted ORb (95% CI)	P value (crude OR)	P value (adjusted ORa)	P value (adjusted ORb)
Male
Any suicidal thoughts (ref: no)	4.44 (2.91–6.77)	3.25 (2.11–5.00)	2.74 (1.81–4.14)	<.0001	<.0001	<.0001
Made a plan for suicide (ref: no)	4.68 (2.38–9.19)	3.40 (1.75–6.60)	2.12 (0.97–4.64)	<.0001	.0005	.0600
Attempted suicide (ref: no)	4.19 (1.73–10.15)	3.12 (1.24–7.84)	1.85 (0.62–5.55)	.0020	.0168	.2648
Female
Any suicidal thoughts (ref: no)	3.00 (1.95–4.62)	2.14 (1.37–3.35)	1.77 (1.10–2.85)	<.0001	.0012	.0207
Made a plan for suicide (ref: no)	2.78 (1.43–5.41)	1.85 (0.96–3.56)	1.45 (0.72–2.93)	.0033	.0663	.2977
Attempted suicide (ref: no)	3.82 (1.91–7.64)	2.61 (1.19–5.73)	2.07 (0.89–4.82)	.0003	.0174	.0891

Abbreviations: CIs, confidence intervals; ORs, odds ratios.

^aAdjusted for age, race, income, and sexual orientation;

^bAdjusted for age, race, income, sexual orientation, and opioid use disorder.

Suicide-Related Outcomes for PWUK, by Race

White, Black, and other non-White PWUK had higher odds of STBs than their counterparts who never used Kratom. Results from White PWUK showed increased odds of suicidal ideation (aOR: 1.98; 95% CI, 1.40–2.80; P = .0003) and suicide planning (aOR: 1.89; 95% CI, 1.05–3.42; P = .0353) compared to White PWNUK. The association between Kratom use and suicide attempts among the White respondents was not significant. For Black respondents, PWUK had higher odds of suicidal ideation (aOR: 11.00; 95% CI, 2.95–41.07; P = .0006) compared to PWNUK. The magnitude of the odd ratios between Kratom use and suicidal ideation in Black respondents is also notably greater than any other odd ratio in these race subgroup analyses among the fully adjusted models. The associations between Kratom use and suicidal planning (aOR: 1.84; 95% CI, 0.42–7.70; P = .4088) and attempts (aOR: 3.46; 95% CI, 0.62–19.18; P = .1517) were not significant for Black PWUK compared to PWNUK. Other non-White PWUK also showed higher odds for suicidal ideation (aOR: 2.62; 95% CI, 1.10–6.22; P = .0301). However, similar to Black respondents, the association between Kratom use and suicidal planning (aOR: 1.53; 95% CI, 0.35–7.00; P = .5760) and attempts (aOR: 2.14; 95% CI, 0.31–14.77; P = .4323) were nonsignificant. Table 5 shows the results of the crude and adjusted ORs in these populations.

Discussion

The study aimed to evaluate the associations between Kratom use and suicidal thoughts, planning, and attempts in the United States. To the best of our knowledge, our study represents the first epidemiologic investigation into the cross-sectional association between Kratom use and STBs. Our analyses revealed significant associations between Kratom use and STBs, with higher odds of suicidality among male and Black PWUK. Specifically, after controlling for age, race, sex, income, and OUD, PWUK were 2 times more likely to have suicidal thoughts, 2 times more likely to plan a suicide, and more than 2 times more likely to attempt suicide compared to PWNUK.

When broken down by sex, both male and female PWUK exhibit increased odds of suicidal thoughts—nearly 3 times higher for males and around 2 times higher for females. Though male respondents reported higher rates of attempting suicide, the odds of attempting suicide comparing female PWUK with female PWNUK were higher than those of males when making the same comparison. The lack of statistical significance between Kratom use and suicidal planning and attempts for both sexes calls for a larger study with a larger sample size of female and male PWUK due to the rare outcomes.

The analysis by race further emphasizes the elevated risk, with White, Black, and other non-White PWUK each showing higher odds of suicidal behaviors compared to their counterparts who do not use Kratom. White PWUK were nearly twice as likely to have suicidal thoughts and make suicide plans. Non-white PWUK were nearly 3 times more likely to experience suicidal thoughts than their counterparts. Black PWUK were 11 times more likely to experience suicidal thoughts. Elevated risk among Black PWUK may be influenced by systemic health disparities, reduced access to mental health resources, and differential stigma associated with substance use in marginalized communities.²⁵ These findings highlight the significant association between Kratom use and STBs, particularly among male and Black individuals, underscoring the need for longitudinal research and preventative strategies.

Alignment With the Literature

Our findings on Kratom use and suicidal behaviors are corroborated by an existing case study that links Kratom use and suicide, as well as the associations between other similar substances with suicidal behaviors.^14,26,27 Namely, the case study by Settle and Yang¹⁴ demonstrated the impact of Kratom addiction on suicidal behaviors by presenting a case of Kratom use leading to a suicide attempt. The literature on synthetic cannabinoids in herbal substances also indicates an association with suicidal ideation.²⁸ Further supporting our findings is a cross-sectional study that found significant associations between co-morbid substance use and major depression with suicidal behaviors.²⁷ Additionally, increased odds of suicidal behaviors among male and Black individuals align with the National Violent Death Reporting System’s annual findings from 2023.²⁶ However, Kittirattanapaiboon et al¹⁷ found that for people who use illicit substances—of which 60% comprised PWUK—there was no significant difference in suicide risk compared to individuals not using any substances, although the study did not solely assess the association between Kratom use and STBs.

Plausible Mechanisms

A plausible explanation for the association between Kratom use and STBs is the substance’s exacerbation of mental health-related symptomatology, especially in psychotic and manic profiles. Bachu et al²⁹ conducted a systematic review that identified a temporal correlation between the use of Kratom and the onset of various psychiatric symptoms such as delusions, hallucinations, paranoia, hypomania, aggressive or agitated behavior, and psychiatric decompensation. Nunez et al³⁰ documented a case in which a patient with bipolar I disorder and OUD used Kratom to alleviate anxiety and manage substance use cravings, resulting in a rapid onset of agitated behavior, verbal hostility, and destructive actions. While this case study and other studies mentioned highlight a potential link between Kratom use, psychiatric symptoms, and behavioral changes, their findings are limited by the inherent constraints of single-case studies and cross-sectional designs, limiting generalizability and causal inference. Nonetheless, they underscore the need for further research, particularly longitudinal studies, to better understand the complex relationships between Kratom use, other opioid-like substances (eg, gabapentin), and mental health outcomes, including STBs.

Limitations and Strengths

Our findings should be considered in light of several limitations. Population constraints from the NSDUH, such as the exclusion of military personnel, the homeless, and institutionalized individuals, may introduce selection bias. Reliance on self-reported data may introduce reporting bias due to inaccurate recollection or sensitivity to the survey’s topics. The cross-sectional design limits causal inferences regarding Kratom use and suicidal behaviors. Additionally, this analysis focuses on lifetime Kratom use and does not differentiate between episodic use and use disorder, which could obscure potential differences in associated risks and outcomes. The dichotomous categorization of complex behaviors like suicidal behaviors oversimplifies the issue, potentially obscuring nuanced relationships. Sample size constraints, particularly in Kratom use prevalence, may affect statistical power and the validity of the findings. Subgroup analyses are beneficial but risk multiple comparison errors, and the assessment of confounding factors is limited to an arbitrary threshold, which may not capture all relevant influences. The generalizability of our findings is also confined to the U.S. population and might not extend to different cultural or national contexts.

However, this study’s strengths include its innovative approach as the first epidemiologic investigation to assess the effects of Kratom use on suicidal behaviors. This study employed data from the 2021 NSDUH to perform multivariable logistic regression analyses, providing substantial evidence of significant associations between Kratom use and STBs, while accounting for relevant confounders. It is notable for its examination of these associations across different sex and racial groups, highlighting important disparities, such as the particularly high ORs observed among Black individuals. The methodology factored in numerous confounding variables, bolstering the robustness of our findings. Stratified analyses by sex and race offered a detailed look into the magnitude of Kratom’s association with suicidal behaviors within specific populations. Our findings call for a nuanced understanding of the association between Kratom use and STBs and lay a foundation for future research directions.

Future Research Directions

The relationship between Kratom use and suicidal behaviors appears to be stronger in certain demographic groups, such as Black individuals, suggesting that the impact of Kratom may not be uniform across all populations. Causality cannot be established in this cross-sectional study; therefore, future research should focus on longitudinal studies to determine the directionality of the relationship between Kratom use and STBs. Future studies should aim to explore the underlying mechanisms of action and include a more diverse study sample to enhance generalizability.

Additionally, expanding the scope to include previously excluded populations, such as active-duty military and homeless individuals, could provide a more comprehensive understanding of the association between Kratom use and STBs. Given this study’s findings on the significant role of mental health conditions and demographic disparities, future work should also investigate how polysubstance use and co-occurring mental health disorders interact with Kratom use to influence STBs. Furthermore, exploring cultural and regional variations in Kratom use could shed light on differential risks and inform tailored prevention strategies for vulnerable populations. Finally, enhancing public health surveillance of Kratom use and its associated health outcomes would facilitate the development of targeted interventions and evidence-based guidance for clinicians and PWUK, ultimately improving prevention and treatment efforts.

Health Policy and Clinical Practice Implications

The findings from this study underscore the importance of targeted health policies and clinical interventions to address the risks associated with Kratom use, particularly among vulnerable populations such as males and Black individuals. Public health strategies should prioritize educating clinicians, policymakers, and the public on the significant association between Kratom use and STBs, with an emphasis on recognizing mental health disparities that contribute to elevated risks. Screening for Kratom use and co-occurring mental health conditions should become a standard part of clinical practice, especially in populations identified as high-risk in this analysis. Additionally, policies aimed at improving access to culturally responsive mental health services for underserved communities could help mitigate the disproportionate impact observed in this study. Finally, enhanced public health surveillance of Kratom-related outcomes should inform the development of regulations and evidence-based interventions that prioritize harm reduction and preventative strategies.

Conclusions

PWUK have higher odds of reporting STBs among the U.S. adult population. This cross-sectional study revealed that PWUK had higher odds of experiencing suicidal thoughts, making suicide plans, and attempting suicide compared to PWNUK. These associations remained after adjusting for demographic variables and OUD, although the strength of the association varied across different sex and racial groups, with the highest ORs observed among Black individuals.

Highlights.

• Significant Association: The study found a strong association between Kratom use and increased risk of suicidal thoughts, planning, and attempts, with especially high risks among male and Black persons who use Kratom.

• Public Health Implications: These findings underscore the need for targeted interventions, public health policies, and clinical practices that address the risks associated with Kratom use, particularly among vulnerable populations.

• Call for Further Research: The study highlights the necessity for more research to understand the causal pathways between Kratom use and suicidal behaviors, including longitudinal studies and diversified study samples to better inform public health strategies.