Case Report: Treatment of Kratom Use Disorder With a Classical Tricyclic Antidepressant

Abstract

Kratom or Mitragyna speciosa (Korth.) is an evergreen tree of the coffee family native to South-East Asia and Australasia. It is used by locals recreationally to induce stimulant and sedative effects and medically to soothe pain and opiate withdrawal. Its leaves are smoked, chewed, or infused, or ground to yield powders or extracts for use as liquids. It contains more than 40 alkaloids; among these, mitragynine and 7-hydroxymitragynine are endowed with variable mu, delta, and kappa opioid stimulating properties (with 7-hydroxymitragynine having a more balanced affinity), rhynchophylline, which is a non-competitive NMDA glutamate receptor antagonist, but is present in negligible quantities, and raubasine, which inhibits α1-adrenceptors preferentially over α2-adrenceptors, while the latter are bound by 7-hydroxymitragynine, while mitragynine counters 5-HT2A receptors. This complexity of neurochemical mechanisms may account for kratom's sedative-analgesic and stimulant effects. It is commonly held that kratom at low doses is stimulant and at higher doses sedative, but no cut-off has been possible to define. Long-term use of kratom may produce physical and psychological effects that are very similar to its withdrawal syndrome, that is, anxiety, irritability, mood, eating, and sleep disorders, other than physical symptoms resembling opiate withdrawal. Kratom's regulatory status varies across countries; in Italy, both mitragynine and the entire tree and its parts are included among regulated substances. We describe the case of a patient who developed anxiety and dysphoric mood and insomnia while using kratom, with these symptoms persisting after withdrawal. He did not respond to a variety of antidepressant combinations and tramadol for various months, and responded after 1 month of clomipramine. Well-being persisted after discontinuing tramadol.

For Better or Worse: Self-reported Changes in Kratom and Other Substance Use as a Result of the COVID-19 Pandemic

“…Because we assessed SUD criteria only for some drugs (which did not include kratom for most respondents), we cannot directly compare our findings to those of studies that attempted to operationalize kratom-use disorder. 35 , 55 , 85 - 87 …”

Kratom abuse as an emerging issue of addiction, overdose toxicities and deaths: a review

“…Long-term use of kratom may produce physical and psychological effects that are very similar to its withdrawal syndrome, that is, anxiety, irritability, mood, eating, and sleep disorders, other than physical symptoms resembling opiate withdrawal (Vento, et al, 2021) A cross-sectional clinical study in Malaysia found that chronic abusers on kratom don't have significant social functioning impairment and kratom is a less harmful substitute to opioids (Singh et al, 2015). Additionally, chronic heavy mitragynine consumption was not associated with altered biochemical levels, although it may propably increase cardiovascular risks (Singh et al, 2020).…”

Narrative Review of Kratom, an Emerging Psychoactive Substance With Perianesthetic Implications

“…30,54,63 Maintenance treatment for kratom dependence and addiction has also been investigated, with reports of success using buprenorphine-naloxone, naltrexone, and clomipramine. 11,54,55,62,64…”

“…30,54,63 Maintenance treatment for kratom dependence and addiction has also been investigated, with reports of success using buprenorphine-naloxone, naltrexone, and clomipramine. 11,54,55,62,64 GOVERNMENTAL REGULATION In 2016, the DEA announced aggressive plans to classify mitragynine as a schedule I substance, but vocal kratom advocates effectively thwarted this effort. 70,71 The following year, the DEA took less aggressive measures and listed kratom as a "drug of concern," released a warning against its use, and cited high potential for developing dependence, addiction, overdose, and withdrawal, after identifying more than 50 deaths associated with kratom.…”