Kratom-induced transaminitis with subsequent precipitated opioid withdrawal following naltrexone

Abstract

Kratom is an herbal supplement that has gained popularity for recreational use within the United States. Kratom exerts opioid-like effects and, although not US FDA approved, is commonly used for self-treatment of pain, withdrawal management from opioids, and euphoria. Drug-related hepatic injury has been associated with kratom use. All of this raises concern for patient safety and monitoring. The potential for additive liver toxicity must be considered when kratom is used concurrently with hepatotoxic, over-the-counter, herbal, and prescription medications. This case report describes a case of kratom-induced liver inflammation complicated by opioid withdrawal that was precipitated by initiation of IM naltrexone. To our knowledge, there are no published case reports related to opioid withdrawal following naltrexone administration in patients using kratom (without other opioids). The purpose of this case report is to demonstrate potential complications that may arise with kratom use and considerations that should be taken prior to initiation of naltrexone in kratom users.

Presence of kratom in opioid overdose deaths: findings from coroner postmortem toxicological report

“…One case report described an individual self-treating opioid withdrawal with kratom developing a seizure when use was combined with modafinil ( 17 ). Independent kratom use has been reported to induce various medical and psychiatric problems, including seizures ( 18 , 19 ), liver injury ( 20 ), hyperkalemia ( 21 ), acute respiratory distress syndrome ( 22 ), and psychosis ( 23 , 24 ).…”

Precipitated withdrawal with kratom use following naltrexone administration

“…There have been other case reports of precipitated kratom withdrawal with naltrexone use. 8 The novelty of this case is that it describes a situation where naltrexone was used for an off-label indication for weight loss in an individual without a substance use disorder who was consuming high doses of kratom daily. These cases may signify potential changes to common practice.…”

“… 5 Reports of seizures, liver damage, respiratory depression, severe withdrawal, and even death have also been associated with kratom consumption. 6 - 8 The FDA have made several statements warning against the use of kratom. 9 In 2014, the FDA identified kratom as an unapproved drug because of their concern of effects similar to opioids that may expose users to the risks of misuse and addiction.…”

“…11 Given opposing effects at the mu-opioid receptor, withdrawal symptoms from kratom have been reported when used in combination with naltrexone. 8 The risk of withdrawal is increased because of the lack of patient education and counseling upon sale of kratom, as well as increased availability without a prescription. 14 …”

Herbal- and Dietary-Supplement-Induced Liver Injury: A Review of the Recent Literature

“…Kratom, or Mitragyna speciosa, has been increasingly described as a cause of HILI and acts on serotonin and opioid receptors [44]. It is derived from the leaves of a native tree found in Southeast Asia and is composed of alkaloids [45]. However, its use has become more prevalent within the United States in the past few decades and it has become a safety concern in the recent years due to its possible severe side effects of hepatotoxicity, seizures, hallucinations, delusions, and even death when used to ameliorate the effects of opioid withdrawal.…”