A recent Centers for Disease Control and Prevention (CDC) report indicates that since 1999, over 165,000 people have died from prescription opioids, prompting the CDC to tackle this public health issue with new guidelines for opioid prescribing in chronic pain. Here is one story of risk, withdrawal and addiction:
Herbal Opioid Alternative | Given the current climate surrounding the use of these agents, clinicians may be hesitant to prescribe opioids and patients may turn to alternative sources to help deal with their pain. A recent case published in the Wisconsin Medical Journal shows that these sometimes easily accessible alternatives may carry substantial risks as well, leading to another type of addiction, one without much regulation (nih.gov). Here is her story:
In this case, a 37-year-old woman presented to an inpatient mental health clinic after admitting to an addiction to kratom, an herb used for hundreds of years in Southeast Asia to manage pain, opioid withdrawal, fatigue, and cough. Medical history showed the patient had suffered from postpartum depression at one point and was prescribed sertraline which she had discontinued on her own; no previous treatment for substance abuse was noted.
The patient reported that she had been taking kratom for two years after being introduced to it by a coworker who used it for fibromyalgia pain. She was convinced that kratom could be an effective alternative to opioids to treat the pain she experienced after a recent carpal tunnel surgery. The kratom was supplied as dried, crushed leaves in a capsule formulation; after starting the herb, the patient reported a reduction in pain and an increase in energy.
Because the herbal opioid alternative was expensive, the patient decided to purchase the kratom off the Internet; this kratom was more concentrated and she assumed less would be needed to get the desired effect.
Over the 2-year period, the patient continued to buy kratom online ($150 for a 20mL bottle) but after six months she realized she had been taking too much and wanted to cut back. While trying to reduce her intake, the patient began to experience withdrawal symptoms including severe abdominal cramps, nausea, vomiting, diarrhea, sweats, and blurred vision. Using low-dose clonidine, provided to her by two outpatient clinicians, she tried to detoxify over the next 1.5 years.
The patient's weight had also decreased over this time period as the kratom tended to reduce her appetite; insomnia, cravings, and decreased energy were also side effects. Her relationship with her husband deteriorated as she hid the fact that she was still using kratom, going to significant lengths to ensure he never found out.
An ultimatum from her family eventually led to her contacting the inpatient mental health clinic to help with her addiction.
At admission, the patient revealed that her last dose of kratom was at 5am that day; she also brought with her 2mL of kratom extract in a bottle that was diluted with water but there was not enough left to do lab analysis. Clinical evaluation showed the following:
- Pupils measured approximately 2–3mm in diameter
- Mild diaphoresis of palms and back of neck
- Significant cachexia
- Electrolytes, renal function, hemogram, liver studies: within normal limits
- Urine toxicology: negative for oxycodone, opioids, methadone, other drugs of abuse
- Liquid chromatography-mass spectrometry for mitragynine (active alkaloid in kratom): positive at a cutoff value of 10ng/mL
- Side effects of mitragynine (ie, Torsade de Pointes) appear to be dose dependent, although an exact toxic concentration has not been clearly identified. The patient was initiated on symptom-triggered clonidine 0.1–0.2mg every 2 hours based on the COWS (Clinical Opioid Withdrawal Scale) Score; in addition, hydroxyzine 50mg every 6 hours and clonidine patch 0.1mg/day were started to assist with withdrawal symptoms.
By the afternoon, the patient's withdrawal symptoms increased and she developed bone pain, myalgia, abdominal pain, and blurred vision; this evolved to even more severe withdrawal symptoms requiring up to 2mg of clonidine over the next 36 hours as noted by the COWS Scores.
Her physical symptoms began to improve over 2–3 days, however there was concern for possible depression and anxiety as the patient mentioned these were side effects of her previous attempts at detoxification.
Given her history of postpartum depression and minimal efficacy with sertraline, the patient was started on venlafaxine extended-release 37.5mg and titrated to 150mg daily for depression and pregabalin 25mg every 8 hours, titrated to 50mg every 8 hours to treat anxiety. The patient was discharged after three days in the hospital. Her condition was considered stable and after a meeting with her family, she was given an appointment to begin a dual partial hospital program and a prescription for naltrexone 50mg daily to take no sooner than 7 days after discharge.
Kratom (Mitragynia speciosa Korth) is not a well known herb in the United States, but in the past decade its popularity has increased due to its availability over the Internet as an opioid alternative. Mitragynine, the plant's primary alkaloid, produces the majority of its pyschoactive effects; when ingested, onset of action is approximately 5–10 minutes. The effects of kratom appear to last over several hours, with withdrawal symptoms occurring within 12–24 hours. At high doses, mitragynine works as an agonist at both the mu and kappa-opioid receptors. While not currently scheduled by the Drug Enforcement Agency (DEA), the substance is part of a list of "Drugs and Chemicals of Concern." Mitragynine is currently being investigated as a possible therapeutic agent, one that can produce analgesic effect without the risk of respiratory depression, but these endeavors are still in the early stages.
- There have been previous reports of kratom toxicity both in the U.S. and Europe; one such case reports on a patient who mixed kratom with modafanil and suffered a seizure, however it is unclear whether the herb or the mixture of the two agents was the cause.
Other cases have included the use of krypton, a mixture of kratom and O-desmethyltramadol, another mu-opioid receptor agonist; fatal effects of kratom have also been reported. Investigation into the addictive potential and toxicity of kratom, while still not fully understood in humans, shows the possibility for addiction and severe withdrawal syndrome is real and very similar to opioid withdrawal syndrome.
- Not enough evidence exists at this time to recommend appropriate treatment for kratom withdrawal, but as in this case, the use of high dose alpha-2 agonist plus hydroxizine may aid in relieving the physical and mental symptoms.
Because kratom is not currently classified as an opioid, but rather as a distinct chemical entity, the use of buprenorphine and methadone, while possibly appropriate for use in long-term maintenance of sobriety, could present regulatory issues. In this case, the patient was given naltrexone instead to help with craving and sobriety maintenance.
The authors conclude that given the increased popularity of the herb in the U.S., "physicians should be aware of the growing availability of kratom and its potential adverse health effects, especially its toxicity, addictive potential, and withdrawal syndrome."
This article was previously published in empr.com
