At the end of this month, kratom will be illegal throughout the United States thanks to the Drug Enforcement Administration (DEA), which last week announced that a ban is necessary "to avoid an imminent hazard to public safety." The way the DEA reached that conclusion provides an illuminating window on the prohibitionist mindset, which dresses pharmacological phobias in the garb of science.
Kratom is a pain-relieving leaf that acts as a stimulant or a sedative, depending on the dose. But the most important thing to know about kratom, if you want to understand the DEA's reasoning, is that it's not from here. Kratom comes from a tree, Mitragyna speciosa, that is native to Thailand, Malaysia, Indonesia, Myanmar, and Papua New Guinea. It has gained a following in the United States only recently, hawked by online merchants and head shops as an herbal medicine, "dietary supplement," or legal high. As far as the DEA is concerned, the fact that people in other countries have used kratom for centuries to ease pain, boost work performance, and wean themselves from opiate addiction counts for nothing. All the DEA needs to know is that our shores have been invaded by a foreign drug that is increasingly popular among Americans as a home remedy and recreational intoxicant. From the DEA's perspective, that is intolerable, regardless of the drug's hazards or benefits.
If you think I'm exaggerating, consider how the DEA decided that kratom meets the criteria for "temporary" placement in Schedule I of the Controlled Substances Act, the law's most restrictive category. The DEA has at least two years to make that designation permanent, which it almost certainly will do after going through a somewhat more elaborate process of bureaucratic self-justification. For the time being, it need only consider three factors: "the substance's history and current pattern of abuse; the scope, duration and significance of abuse; and what, if any, risk there is to the public health."
That exercise is easy, because according to the DEA all use of kratom is abuse and the substance has no benefits. That means any hazards associated with kratom pose an unacceptable risk to public health, even if they compare favorably to those associated with legal intoxicants, over-the-counter remedies, and prescription drugs.
"Kratom is abused for its ability to produce opioid-like effects," the DEA says. "Kratom is misused to self-treat chronic pain and opioid withdrawal symptoms, with users reporting its effects to be comparable to prescription opioids." So if you use kratom to relax, relieve pain, or get off heroin, that's abuse.
"Kratom is an increasingly popular drug of abuse and readily available on the recreational drug market in the United States," the DEA says. So if you use kratom for fun, that's abuse.
Any medicinal use of kratom has to be abuse, the DEA figures, because kratom has not been approved for any indication by the Food and Drug Administration. Nor has the government approved kratom as a recreational intoxicant or a utilitarian stimulant (possibly because no such regulatory categories exist for new drugs), so those uses are also beyond the pale.
The DEA's blinkered thinking is especially glaring when it frowns on kratom as a substitute for heroin. "Kratom has a history of being used as an opium substitute in Southeast Asia," it says. "Especially concerning, reports note users have turned to kratom as a replacement for other opioids, such as heroin." So if a heroin addict switches to a less dangerous drug, that is "concerning," even if the switch enables him to taper off his drug use and ultimately stop completely. In other words, even using kratom to reduce drug abuse is drug abuse.
With logic like that, it's a cinch for the DEA to conclude that mitragynine and 7-hydroxymitragynine, kratom's main active components, have "a high potential for abuse." In the DEA's view, kratom's only potential is for abuse.
Since the DEA assumes there is no rational, morally acceptable reason to use kratom, it does not need to muster much evidence that kratom is intolerably dangerous. That's a good thing for the DEA, because the evidence indicates that kratom is less hazardous than drugs that are legally used for similar purposes.
"Serious toxicity is rare and usually involves relatively high doses (more than 15 g) or coingestants," says a 2014 article in the journal Pharmacotherapy by clinical pharmacologist Megan Rech and four of her colleagues at the Loyola University Medical Center in Maywood, Illinois. "Fatalities typically involve coingestants…. Withdrawal has been described as less intense but more protracted than with prescription opioids."
A 2015 literature review in the International Journal of Legal Medicine offers a similar assessment. "Kratom is considered minimally toxic," write Florida forensic scientist Marcus Warner and two co-authors, although they add that "research evaluating its toxic effects on humans is limited, with the vast majority of studies involving animals." Warner et al. say "withdrawal symptoms are generally nonexistent to mild, even for heavy users" and note that two Florida counties "have deemed kratom not ready for regulation due to the lack of information demonstrating the substance as being unsafe or hazardous."
Warner and his colleagues concur with Rech et al. that there's little evidence kratom is lethal by itself. "Although death has been attributed to kratom use," they write, "there is no solid evidence that kratom was the sole contributor to an individual's death. In most documented instances, mitragynine was detected in combination with other drugs."
Pascal Tanguay, a program officer for PSI, an international health promotion organization, in Thailand, was more emphatic in a 2013 interview with MinnPost. "There's never been a single death associated with kratom," Tanguay said. "People have been chewing this for thousands of years with no cases of overdose, psychosis, murder, violent crime. Never in all of recorded history."
Although the DEA claims there have been "numerous deaths associated with kratom," it does not cite any deaths where kratom was the only factor. The agency cites 14 deaths "reported in the scientific literature," plus 16 others that "have been confirmed by autopsy/medical examiner reports," meaning that "mitragynine and/or 7-hydroxymitragynine were identified in biological samples." It is not safe to assume, as the DEA does, that every person who ever died after consuming kratom died because he consumed kratom. But even if you overlook that logical fallacy, a grand total of 30 "deaths associated with kratom" in the whole world over the course of centuries is hardly "numerous," and it pales beside the number of deaths associated with myriad legal drugs. Alcohol, for instance, is implicated in about 88,000 deaths a year in the U.S. alone, while 28,000 deaths were attributed to heroin and opioid painkillers in 2014.
The DEA plays a similar trick when it cites a report on kratom-related calls to poison control centers that the U.S. Centers for Disease Control and Prevention published in July. From January 2010 through December 2015, the DEA notes, "U.S. poison centers received 660 calls related to kratom exposure." It adds that "during this time, there was a tenfold increase in the number of calls received, from 26 in 2010 to 263 in 2015." Reported symptoms included "agitation or irritability, tachycardia, nausea, drowsiness, and hypertension."
An average of 110 cases a year may sound like a lot, but it's not. It represents about 0.004 percent of the 3 million or so calls received by poison control centers each year. By comparison, exposures involving analgesics accounted for nearly 300,000 calls in 2014, while cosmetics and personal care products, cleaning solutions, antidepressants, and antihistamines each accounted for more than 100,000. The DEA not only fails to put the number of kratom-related calls in perspective; it does not mention that two-thirds of the cases were deemed "minor" or "moderate," while only 7 percent (eight per year) were described as "life-threatening." The CDC noted a single death in six years, "reported in a person who was exposed to the medications paroxetine (an antidepressant) and lamotrigine (an anticonvulsant and mood stabilizer) in addition to kratom."
These numbers are pretty reassuring, especially since the DEA says "millions of dosage units" are imported into the U.S. each year. But the agency draws the opposite conclusion, saying "such alarming quantities create an imminent public health and safety threat."
The DEA makes at least one valid point about the risks of using kratom, which is available from many different vendors, some more reliable than others. "Since abusers [i.e., users] obtain kratom…through unknown sources," it says, "the identity, purity, and quantity of these substances are uncertain and inconsistent." Does anyone outside of the DEA think prohibition will take care of that problem?
by Jacob Sullum
September 5, 2016
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The DEA Thinks All Kratom Use Is Abuse