Kratom Use in the United States: A Diverse and Complex Profile

Schimmel et al. (1) evaluated the prevalence and substance-abuse profile of kratom users through the Non-Medical Use of Prescription Drugs (NMURx) Program, part of the Research Abuse, Diversion, and Addiction-Related Surveillance (RADARS) system. The study compared Drug Abuse Screening Test (DAST-10) scores of kratom users with non-users, finding users significantly more often in the substantial/severe category and suggesting that kratom users are therefore more likely to suffer from adverse substance-use problems (1). Unfortunately, these findings may be misinterpreted to infer a cause-effect relationship between kratom use and substance-use disorders or to support the suggestion that kratom may increase the risk of drug abuse.

Such conclusions are decidedly inconsistent with prior studies on kratom users, who report using kratom to mitigate drug-dependence and reduce the frequent use and severe problems associated with classical opioids and other common drugs of abuse (2–8). For example, a US sample of polydrug users with opioid use disorder (OUD), reported their motivation for kratom use was to reduce or quit opioid use, and that kratom did not typically produce a preferred “high” compared to prescription opioids or heroin (2). Although Schimmel et al. point to FDA-approved medication-assisted treatment (MAT) for OUD as an alternative to kratom, accessing MAT can be challenging for many people with OUD (9, 10). Further, the authors extrapolated a sample of 59,714 respondents, of which only 490 reported kratom use, to the general population. A false generalization results from sampling only non-medical users of prescription drugs, which likely excludes large numbers of people who use kratom for self-treatment of pain and/or psychiatric disorders (3, 5, 6), falsely inflating the perceived potential for abuse by selection and attribution biases. Published data from more than 20,000 kratom users (3, 5, 7), suggests that the proportion of kratom users in the general population is far higher, and the consequences of its use far less severe. Opioid overdose mortality data in the US indicate that the risk of death is more than 1000 times greater for illicit opioids than for kratom (11). Some user reports suggest that regular kratom consumption carries risks of dependency and addiction, though with generally self-manageable withdrawal (12).

The Schimmel et al. study does provide additional information about a defined sub-population of kratom users who are also non-medical prescription drug users; however, it has significant methodological limitations that preclude its applicability in defining kratom’s medicinal potential or (ab)use in a broader population. The authors’ essential point, that “kratom users tend to have a more serious substance-abuse profile”, is unsurprising if drug users experiencing the most serious negative consequences seek to mitigate those consequences with kratom. Indeed, the current weight of evidence indicates that for users with extensive drug use (more “serious” abuse profiles), kratom is not the abused drug of choice, but instead tempers problematic use of other substances. Although kratom is not devoid of abuse potential (4, 6, 13), and the broader societal implications and potential negative impacts of its use are still under study, the science suggests that kratom’s risks are substantially lower than those of the drugs it is used to replace. The bottom line is that further investigations are needed to clarify the therapeutic potential and risks associated with kratom use across populations.