Abstract
Objectives:
To assess the U.S. lifetime and past-year prevalence of kratom (Mitragyna speciosa) use and its associations with mental health and DSM-5 substance use disorder (SUD).
Methods:
This study examined cross-sectional survey data collected from 169,408 non-institutionalized individuals aged 12 and older in U.S. households between 2021–2024. Measures included kratom use, nonmedical use of cannabis, prescription drugs (opioids, sedatives/tranquilizers, stimulants), other drugs, mental health indicators (serious psychological distress, DSM-5 major depression, suicidal ideation) and DSM-5 SUD.
Results:
Between 2021–2024, lifetime and past-year kratom use was highest among adults aged 21–34, 3.40% (95% CI=3.17–3.65) and 1.01% (95% CI=0.91–1.13), respectively. Among people who reported prior-to-past-year kratom use, most reported past-year cannabis (65.7%; 95% CI=60.4– 70.3) and had a past-year SUD (52.8%; 95% CI=50.1–55.4) while an estimated 37.8% (95% CI=37.2–47.3) experienced serious psychological distress. Similar results were observed for those who reported past-year kratom use. Multivariate logistic regression analysis revealed prior-to-past-year and past-year kratom use was associated with increased adjusted odds of past-year SUD (AOR=4.36; 95% CI=3.89–4.88 and AOR=4.81; 95% CI=3.99–5.80, respectively). Similar results were found for other substance use, DSM-5 major depression, suicidal ideation.
Conclusions:
Over five million people in the U.S. used kratom in their lifetime, with highest use at ages 21–34 years. Kratom use is increasing and strongly associated among individuals who use cannabis, have a DSM-5 SUD, and experience serious psychological distress. These findings reinforce a profile of individuals who use kratom, many with behavioral health symptoms, and need evidence-based treatment warranting consideration in clinical and policy efforts.
Keywords: Kratom, Substance Use Disorder, Mental Health, Epidemiology, Treatment
Introduction
Kratom is an herbal supplement that is legal at the federal level (U.S.) and available over-the-counter and online. The psychoactive substance in kratom (mitragynine) is extracted from the leaves and stems of the (Mitragyna speciosa) evergreen tree of the coffee family (Rubiaceae), which is indigenous to parts of Southeast Asia.1 The U.S. Food and Drug Administration has not approved kratom for medical use and issued several warnings regarding kratom due to its potential for nonmedical use, addiction, and serious side effects (including liver toxicity and seizures);2,3 additionally, the U.S. Drug Enforcement Agency has listed kratom as a Drug and Chemical of Concern.4 In the U.S., kratom products primarily consist of dried leaf material that has been processed into pills, powder, tablets, herbal teas, or extracts.5 Kratom's effects are dose-dependent, with lower doses (<5g) producing a stimulant effect while higher doses (≥5g) produce an opioid effect.1,6 U.S. poison control centers experienced a ten-fold increase in calls for kratom-related exposures between 2010 and 2015 from 26 to 263, respectively.7 Recent U.S. poison control centers indicate a 1200% increase in kratom-related exposures in the past decade, including a marked surge up to 3,434 exposures in 2025.8
Kratom is unregulated in half of states while the others contain or are considering a wide array of bans and regulations including age restrictions, product testing, and labeling.9 Kratom may be used to self-treat various conditions including anxiety, depression, opioid use disorder, and pain.10,11 Oftentimes, individuals purchase kratom as an all-natural herbal remedy and are unaware of the risk of addiction. Research has shown that nonmedical opioid use and prescription opioid use disorder were linked to kratom use, suggesting that previous drug-use may serve as a risk factor and that kratom is often used concurrently with other substances.12,13 Additionally, many who used kratom were in SUD recovery, with some reporting drug substitution as a use motivation.11 This study examines lifetime and past-year prevalence of kratom use and associations with demographic characteristics (eg, age), mental health (eg, major depression), and substance use (eg, cannabis) to inform data-driven clinical and health policy decisions.
Methods
The National Survey on Drug Use and Health (NSDUH), a nationally representative cross-sectional survey of non-institutionalized U.S. individuals aged 12 years and older between 2021–2024 was the primary data source.14 Participant responses were obtained through a multistage design, and surveys were administered via a combination of in-person computer-assisted interviewing and web-based sampling. The sample size was 232,441, and the weighted interview response rate averaged 48%. This secondary analysis was exempt from review by the authors’ institutional review boards.
Age, sex, race/ethnicity, educational attainment, family income, and past-year mental health indicators (ie, DSM-5 major depression, serious psychological distress, suicidal ideation) were assessed via the demographic and psychiatric modules, with the sociodemographic correlates selected based on prior research.15 Lifetime, prior-to-past-year and past-year kratom use was assessed by asking respondents if they had used kratom in any form including powder, pills, or leaf. Respondents were also asked about past-year non-medical use of cannabis, prescription opioids, sedatives/tranquilizers, stimulants, and other drugs (eg, hallucinogens, methamphetamines). Those reporting past-year use of any drug were asked drug-specific questions to indicate whether they met criteria for proxy diagnosis of a DSM-5 SUD.
The lifetime, prior-to-past-year and past-year prevalence of kratom use was estimated overall and by age, mental health, and substance use via bivariate analysis. Next, all covariates were fit into a multivariable logistic regression model, examining links between prior-to-past-year or past-year kratom use and either substance use or mental health indicators. Sample weights were used to account for the complex survey design, non-response, selection probability, and population distribution. Data were analyzed in 2026 using Stata 19.5.
Results
In 2024, the lifetime prevalence of kratom use was 1.9% (95% CI=1.7–2.1) among individuals ages 12 and older, increasing from 1.6% (95% CI=1.4–1.8) in 2021. Between 2021–2024, lifetime and past-year prevalence of kratom use was highest among adults aged 21–34, 3.40% (95% CI=3.17–3.65) and 1.01% (95% CI=0.91–1.13), respectively (Table 1).
Table 1.
Lifetime and past-year prevalence of kratom use in the United States
| 2021 | 2022 | 2023 | 2024 | 2021–2024 | |
|---|---|---|---|---|---|
| n (%, 95% CI) | n (%, 95% CI) | n (%, 95% CI) | n (%, 95% CI) | n (%, 95% CI) | |
| Lifetime Use | |||||
| Overall (12+ years) | 1,022 (1.56, 1.37–1.78) | 1,128 (1.77, 1.59–1.98) | 1,116 (1.82, 1.62–2.04) | 1,204 (1.90, 1.70–2.13) | 4,470 (1.77, 1.66–1.88) |
| 12–17 years | 36 (0.35, 0.21–0.60) | 35 (0.18, 0.11–0.30) | 43 (0.29, 0.17–0.50) | 51 (0.44, 0.28–0.68) | 165 (0.32, 0.25–0.41) |
| 18–20 years | 56 (0.95, 0.58–1.57) | 64 (1.68, 1.16–2.43) | 52 (1.18, 0.69–1.98) | 63 (1.21, 0.77–1.89) | 235 (1.25, 1.02–1.54) |
| 21–34 years | 591 (3.16, 2.70–3.69) | 643 (3.67, 3.22–4.18) | 576 (3.27, 2.85–3.77) | 607 (3.51, 3.04–4.04) | 2,417 (3.40, 3.17–3.65) |
| 35 and older | 339 (1.25, 1.03–1.51) | 386 (1.35, 1.14–1.59) | 445 (1.59, 1.35–1.86) | 483 (1.60, 1.36–1.89) | 1,653 (1.45, 1.34–1.57) |
| Past-Year Use | |||||
| Overall (12+ years) | 377 (0.60, 0.48–0.75) | 409 (0.70, 0.58–0.83) | 384 (0.56, 0.46–0.69) | 411 (0.63, 0.54–0.73) | 1,581 (0.62, 0.57–0.68) |
| 12–17 years | 17 (0.15, 0.06–0.41) | 21 (0.10, 0.06–0.18) | 24 (0.18, 0.08–0.38) | 32 (0.23, 0.14–0.37) | 94 (0.16, 0.11–0.24) |
| 18–20 years | 24 (0.43, 0.22–0.85) | 38 (1.26, 0.75–2.10) | 26 (0.43, 0.21–0.89) | 33 (0.65, 0.37–1.14) | 121 (0.69, 0.50–0.96) |
| 21–34 years | 199 (0.94, 0.74–1.19) | 202 (1.11, 0.88–1.40) | 173 (0.99, 0.77–1.26) | 187 (1.02, 0.81–1.28) | 761 (1.01, 0.91–1.13) |
| 35 and older | 137 (0.56, 0.42–0.76) | 148 (0.60, 0.47–0.77) | 161 (0.48, 0.36–0.65) | 159 (0.55, 0.44–0.70) | 605 (0.55, 0.48–0.63) |
Data Source: National Survey on Drug Use and Health.
Among people who reported prior-to-past-year kratom use, most reported past-year cannabis (65.7%; 95% CI=60.4–70.3) and had a past-year SUD (52.8%; 95% CI=50.1–55.4); also, an estimated 37.8% (95% CI=37.2–47.3) experienced serious psychological distress (Table 2). Similar associations were observed with past-year kratom use. Multivariate logistic regression analysis revealed prior-to-past-year and past-year kratom use were associated with increased adjusted odds of past-year SUD (AOR=4.36; 95% CI=3.89–4.88 and AOR=4.81; 95% CI=3.99–5.80, respectively). Similarly, prior-to-past-year and past-year kratom use was associated with increased adjusted odds of past-year serious psychological distress (AOR=3.20; 95% CI=2.77–3.68 and AOR=4.14; 95% CI=3.39–5.06, respectively). Additional analyses revealed serious psychological distress was lower among those with kratom only use than polysubstance-kratom use but higher than those who never used kratom. Serious psychological distress was 24.7% (95% CI=12.0–43.9) among those who reported past-year kratom use without alcohol or other drug use, compared to 13.6% (95% CI=13.3–13.8) among those who never used kratom.
Table 2.
Substance use behaviors and mental health associated with past-year kratom usea
| Past-year kratom use (n=1,581) | Prior-to-past-year kratom use (n=2,889) | Never kratom use (n=227,971) | Past-year kratom Adjusted ORb,c | Prior-to-past-year kratom Adjusted ORb,c | |
|---|---|---|---|---|---|
|
| |||||
| n (%, 95% CI) | n (%, 95% CI) | n (%, 95% CI) | AOR (95% CI) | AOR (95% CI) | |
| Past-year substance use | |||||
| Binge drinkingd | 608 (36.9, 33.0–41.0) | 1,119 (35.7, 32.4–39.1) | 47,690 (20.9, 20.7–21.2) | 1.82 (1.52, 2.18)*** | 1.57 (1.34, 1.84)*** |
| Cannabis | 1,076 (65.7, 60.4–70.3) | 1,936 (64.2, 60.6–67.6) | 52,655 (20.4, 20.1–20.8) | 6.29 (4.94, 7.98)*** | 5.36 (4.56, 6.30)*** |
| Cocaine | 239 (15.2, 12.2–18.8) | 388 (11.6, 10.0–13.3) | 3,727 (1.5, 1.4–1.6) | 8.74 (6.65, 11.48)*** | 5.51 (4.57, 6.64)*** |
| Prescription opioids | 324 (23.4, 19.4–27.9) | 384 (13.4, 11.4–15.7) | 6,219 (2.7, 2.6–2.8) | 10.01 (7.75, 12.92)*** | 4.87 (4.00, 5.93)*** |
| Prescription stimulants | 233 (11.7, 9.3–14.7) | 327 (9.4, 7.9–11.2) | 3,690 (1.2, 1.2–1.3) | 7.65 (5.72, 10.24)*** | 5.31 (4.17, 6.78)*** |
| Heroin | 70 (3.8, 2.2–6.4) | 87 (2.8, 2.0–4.0) | 528 (0.2, 0.2–0.3) | 12.05 (6.34, 22.90)*** | 8.35 (5.48, 12.71)*** |
| Other drugse | 637 (37.1, 33.2–41.1) | 1,009 (32.3, 29.6–35.2) | 12,936 (4.8, 4.6–5.0) | 9.54 (7.91, 11.50)*** | 6.96 (5.97, 8.11)*** |
| Past-year DSM-5 substance use disorder | |||||
| Alcohol use disorder | 472 (26.5, 23.0–30.4) | 771 (23.3, 20.8–26.0) | 23,769 (10.0, 9.8–10.2) | 2.65 (2.16, 3.24)*** | 2.03 (1.73, 2.40 |
| Cannabis use disorder | 507 (26.8, 22.9–32.7) | 981 (30.2, 27.9–32.7) | 18,331 (6.2, 6.0–6.4) | 4.39 (3.51, 5.50)*** | 4.85 (4.24, 5.55)*** |
| Cocaine use disorder | 72 (5.3, 3.3–8.4) | 107 (3.2, 2.3–4.3) | 934 (0.4, 0.4–0.5) | 10.86 (6.69, 17.61)*** | 5.89 (4.02, 8.60)*** |
| Prescription opioid use disorder | 185 (14.5, 11.1–18.8) | 234 (8.8, 7.1–10.9) | 3,395 (1.7, 1.6–1.8) | 9.85 (7.07, 13.73)*** | 5.51 (4.28, 7.11)*** |
| Prescription stimulant use disorder | 110 (6.5, 4.5–9.5) | 132 (3.4, 2.5–4.6) | 1,743 (0.5, 0.5–0.6) | 10.03 (6.51, 15.44)*** | 4.73 (3.30, 6.79)*** |
| Heroin use disorder | 66 (3.8, 2.3–6.3) | 81 (3.1, 2.2–4.2) | 430 (0.2, 0.2–0.3) | 15.43 (8.24, 28.91)*** | 11.63 (7.94, 17.03)*** |
| Other drug use disordere | 200 (12.9, 10.3–16.1) | 313 (9.8, 8.4–11.4) | 3,298 (1.4, 1.3–1.5) | 8.70 (6.47, 11.69)*** | 6.10 (5.10, 7.30)*** |
| Substance use disorder | 911 (53.3, 48.8–57.7) | 1,633 (52.8, 50.1–55.4) | 40,555 (16.3, 16.1–16.5) | 4.81 (3.99, 5.80)*** | 4.36 (3.89, 4.88)*** |
| Two or more substance use disorders | 310 (24.5, 20.4–29.1) | 463 (18.1, 15.7–20.8) | 6,664 (3.3, 3.2–3.5) | 7.52 (5.77, 9.81)*** | 4.59 (3.72, 5.66)*** |
| Recovery from SUDf | 546 (40.6, 36.0, 45.4) | 1,068 (39.9, 36.7–43.1) | 13,603 (8.0, 7.8–8.3) | 6.66 (5.39, 8.24)*** | 6.13 (5.35, 7.03)*** |
| Mental health | |||||
| Serious psychological distress | 694 (41.6, 37.4–46.0) | 1,171 (37.8, 34.7–40.9) | 34,501 (13.6, 13.3–13.8) | 4.14 (3.39, 5.06)*** | 3.20 (2.77, 3.68)*** |
| DSM-5 major depression | 474 (28.6, 24.9–32.7) | 768 (24.4, 22.1–26.9) | 27,275 (7.8, 7.6–8.0) | 4.17 (3.38, 5.16)*** | 3.15 (2.76, 3.60)*** |
| Suicidal ideation | 355 (17.3, 13.9–21.4) | 496 (14.6, 12.4–17.0) | 18,158 (4.9, 4.7–5.1) | 3.40 (2.59, 4.46)*** | 2.54 (2.12, 3.05)*** |
p < .05
p < 0.01
p < 0.001
The sample sizes for logistic regression models ranged from 180,551 (recovery from SUD because this variable was only assessed in respondents ages 18 and older) to 232,441 (all other substance use and SUD models).
Odds ratios are also adjusted for sex, race, age, education, income, urbanicity, and insurance status. The results for these variables are not shown in this table and available in online supplemental tables (eTables 1–4).
The reference group for each logistic regression model were those who did not report lifetime kratom use.
The timeframe of the binge drinking variable is based on past 30 days rather than past 12 months.
Other drug use and other drug use disorder variables are based on methamphetamines, hallucinogens, inhalants, and nonmedical use prescription tranquilizers or sedatives.
The recovery from substance use disorder (SUD) variable is not assessed in adolescents aged 12–17 and only assessed in respondents ages 18 and older.
Discussion
In 2024, over five million U.S. people aged 12 or older have used kratom in their lifetime. Among those who reported prior-to-past-year kratom use, most reported past-year cannabis use and had a past-year DSM-5 SUD, though kratom-SUD links were heterogeneous and likely reflect many underlying factors (e.g., self-treatment of opioid use disorder). These findings, along with high levels of serious psychological distress, mirror previous work indicating that individuals may self-treat behavioral health issues with kratom and need professionally delivered evidence-based treatment.10,11 Over a third of kratom users also reported being in SUD recovery here, and the potential role of kratom in drug use repertoires can be challenging to assess in clinical settings.
Kratom use is likely underdiagnosed in many clinical settings because it is difficult to detect; kratom is not included in standard urine drug screens and requires specialized techniques for identification, which may be unavailable or have a prolonged turnaround time.6 Moreover, kratom is not universally recognized as harmful as it remains unregulated in many states, sold in retail environments, and individuals may not always recognize they are using kratom.9 Finally, healthcare professionals may not recognize risks associated with kratom use and there is no specific diagnostic coding for kratom outside of opioid or another SUD.
The results of the present study should be considered within the context of its limitations. The NSDUH cross-sectional design precludes any causal determinations regarding the temporal associations between kratom, other substance use, and mental health. Secondary analyses were limited to the available variables and some factors that may influence the associations were not assessed (eg, kratom use motivations). Some high-risk institutionalized sub-populations (eg, incarcerated) were not included which likely led to conservative estimates.14
Conclusions
Kratom use is at an all-time high and is most prevalent among those who have a SUD and serious psychological distress. The increasing trend and high-risk in young adults is notable considering several states have passed or are considering legislation to ban or regulate various aspects of kratom. Future research is needed to examine the impact of state regulations on kratom products and kratom-related consequences using causal inference methods to investigate the relationship between kratom use and mental health. Clinicians, researchers, and policymakers should keep in mind the multifactorial nature of kratom use when considering future practice and health policy efforts to support individuals in need of evidence-based treatment.
Supplementary Material
Acknowledgements
Role of the Funder
The FDA, NIDA and NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the FDA, NIDA, NIH, or the US Government.
Footnotes
Conflicts of Interests and Source of Funding
Dr. SE McCabe is currently receiving a grant (R01DA031160) from the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH) and an award 75F40124C00131 from the US Food and Drug Administration (FDA). Dr. Schepis is receiving a grant (R01DA043691) from NIDA of the NIH. For the remaining authors none were declared.
Data Availability Statement
The 2021, 2022, 2023, and 2024 National Survey on Drug Use and Health Public Use Files are available for download at https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health/datafiles.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The 2021, 2022, 2023, and 2024 National Survey on Drug Use and Health Public Use Files are available for download at https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health/datafiles.