‘It’s an opioid’: My patients are becoming addicted to this ‘supplement’
Kratom is fueling a rise in opioid addiction. The DEA should regulate it.
Andrew Kolodny is medical director of the Opioid Policy Research Collaborative at Brandeis University’s Heller School for Social Policy and Management.
Twenty years ago, almost every patient I treated for opioid use disorder had become addicted after taking prescription opioids. Today, a growing share of my patients are developing the disorder by consuming kratom — the dried leaves of a Southeast Asian tree, sold legally at gas stations and convenience stores.
Earlier this month, the Drug Enforcement Administration announced a plan to ban a class of kratom products known as 7-OH, made by chemically treating kratom leaf to boost its opioid potency. The DEA’s action may help save lives. But it will do little to slow the broader public health problem, because ordinary kratom leaf — sold as powders, capsules and extracts — will remain widely available and legal in most states. Yet it shouldn’t.
The DEA’s limited action reflects its acceptance of a narrative pushed by the kratom industry: that public health problems involving kratom are limited to 7-OH products, while the ordinary version is simply a natural, nonaddictive wellness product that relieves pain and boosts mood.
But the chronology tells a different story. Poisonings and hospitalizations involving kratom have risen 1,200 percent over the past decade — a rise that predates 7-OH products, which entered the market only about two years ago.
In contrast to the DEA, the Food and Drug Administration has long taken the broader view: The danger is kratom itself, not just 7-OH. In 2018, the agency sought to classify kratom as a Schedule I controlled substance after concluding that kratom leaf contains opioid compounds. The kratom industry’s lobbying helped stop that effort, but the FDA website still warns Americans “not to use kratom because of the risk of serious adverse events, including liver toxicity, seizures, and substance use disorder.”
That warning reflects a basic pharmacologic fact. Kratom’s principal active compound is an opioid that activates the same brain receptors as heroin and prescription painkillers. Like other opioids, kratom is highly addictive: Repeated use leads to tolerance, dependence and the need for progressively higher doses. As the FDA put it, kratom “isn’t just a plant — it’s an opioid.”
Advocates for keeping kratom widely available argue that for some people, it serves as a lower-risk alternative to prescription opioids for managing chronic pain, and that restricting it would push these users toward riskier options. This concern deserves serious consideration. People who believe they have found relief with kratom shouldn’t be dismissed. But scientific evidence that it is safe or even effective is lacking, and it carries risks that aren’t fully understood: Case reports have linked its use to sudden cardiac arrest.
For many daily users, relief is illusory. Because kratom is an opioid, the calm many feel after their morning dose is often just the reversal of withdrawal symptoms from their evening dose that cause the same pain and anxiety that kratom appears to relieve.
The misunderstanding starts even before withdrawal does. I have treated patients who were hospitalized for an unrelated condition, tested negative for opioids on admission and then, within days, were in severe opioid withdrawal — sweating, vomiting, in agonizing pain. Medical staff are stunned every time; kratom doesn’t register on standard drug screens. These patients had bought kratom at a convenience store as a wellness supplement or an energy shot, never imagining it was an opioid capable of producing the same withdrawal as heroin. And some have ultimately needed treatment with the same medications used for addiction to other opioids.
Kratom’s danger doesn’t lie just in its role in overdose deaths — it’s fueling a rise in opioid use disorder itself. Two decades of rising prescription opioid use created a large population of Americans with opioid addiction — and that population is why overdose deaths reached record highs, why fentanyl has flooded the illicit supply and why so many infants are born dependent. Ending the epidemic means preventing new cases of the disorder itself.
State-level evidence supports this. States that have outright prohibited kratom — including Vermont, Indiana and Alabama — have seen far fewer kratom-related poisonings and deaths than states where it remains available. States that adopted the kratom industry’s preferred approach — sales with age restrictions, labeling requirements and testing standards — have fared no better than states with no restrictions.
We have been offered this lesson before: When an opioid becomes readily available and its addictive potential is minimized or denied, more people use it, more develop opioid use disorder, and the health and social harms follow close behind.
That is exactly what is happening with kratom. Banning 7-OH is a start, but it is not the problem — kratom is. The DEA should control kratom in all its forms. Until it does, an opioid will be available for purchase without a prescription, the number of Americans suffering from opioid use disorder will keep rising, and there will be no end to the opioid crisis in sight.
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