Kratom: a dangerous player in the opioid crisis

Abstract

Kratom use as a herbal supplement is on the rise in the United States, with reported medical outcomes and lethal effects suggesting a public health threat. Even though the Drug Enforcement Administration has included kratom on its drugs of concern list and the FDA has published a press release to identify it as an opioid with a potential for abuse, its therapeutic and side effects are still not well defined in the literature. Here, we present a case of a 32-year-old man with a history of kratom use who became acutely ill with a brief prodromal illness, followed by jaundice and elevated liver enzymes showing a cholestatic picture, and his successful treatment. In this case, we emphasize the need for awareness of kratom exposure as a key contributor in the expansion of the opioid crisis, with therapeutic benefits earned at the expense of potentially lethal side effects.

Kratom from Head to Toe—Case Reviews of Adverse Events and Toxicities

“…Jaundice was reported in four cases where the total bilirubin was the highest of all KIH cases, ranging from 6.5 mg/dL to 33.7 mg/dL (reference < 1 mg/dL) [58,59,63,64]. After kratom cessation, total bilirubin decreased within 2 days to 7 days [58][59][60][61][62][63][64]. The highest alkaline phosphatase recorded was 790 units/L (reference 35-129 units/L).…”

“…Overall, there were 41 cases on kratom-associated adverse events or toxicities (Table 1). Kratom-associated adverse events were as follows: kratom-associated withdrawal symptoms (KAWS) in adults [41][42][43][44][45][46][47][48][49][50][51][52], kratom-associated neonatal abstinence syndrome (KANAS) [48,[52][53][54][55][56], hypothyroidism [43], hypogonadism [57], kratom-induced hepatoxicity (KIH) [58][59][60][61][62][63][64][65], CNS effects causing seizure and coma or posterior reversible encephalopathy syndrome (PRES) [39,66,67], acute respiratory distress syndrome (ARDS) [68,69], overdose toxidrome [70,71], and fatalities [72][73][74][75][76][77][78][79][80]. There were six case series of aggregated patient's data [48,…”

“…Kratom-Induced Hepatoxicity [58][59][60][61][62][63][64][65] Kratom-induced hepatotoxicity (KIH) has been reported after 2 to 4 weeks of use and rechallenge has led to recurrence [59,65]. The reported dose resulting in KIH was 14 to 21 g per day.…”

“…Yellow skin, scleral icterus, and pruritus were also reported. Most patients were hemodynamically stable on presentation; one case showed mildly elevated blood pressure at > 140/80 mmHg in a patient with chronic hypertension [64]. The diagnosis of KIH was made on the basis of exclusion of all other causes of hepatotoxicity.…”

“…An extensive workup for acute viral hepatitis A, B, and C and assays of hepatotoxic substances such as salicylates, acetaminophen, and CNS medications were used to determine if the exhibited hepatotoxic effects were correlated. Four case reports studied the likelihood of KIH using association scales in which all found a 'probable' association [62][63][64][65]. Scales used included the Roussel Uclaf Causality Assessment Method, World Health Organization Uppsala Monitoring Centre and the International Organizations of Medical Sciences Scale.…”