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I started writing about kratom on this blog 7 years ago
after I noticed more people having problems with it. One of the main themes of this blog is that
any substance that reinforces its own use is a most important property that
cannot be denied at the individual, societal, or medical level. The most successful approaches to limiting
the consequence of excessive use are cultural change, limiting access, and
criminal penalties. Without those
deterrents the progression from increased use to commoditization and use on a
much larger scale is predictable. It
turns out that this extends beyond addictive compounds to behavioral addictions
as well. Examples include gambling, sex and pornography addiction, and social
media addiction. Rather than acknowledging this reality – the typical way these
problems are approached in the US is rationalization, denial, and inadequate
remedies.
The examples available just in the past 2 decades are
striking. We entered the 21st century on the cusp of an opioid
epidemic. That was based initially on more
liberal prescribing by physicians of compounds that were highly addictive – but
those properties were denied using this medication for maintenance
treatment. They were also sold based on
the idea that chronic pain was better treated with opioids and that it was
possible to eliminate pain. From there
cannabis was sold as the next great universal cure – even though its medicinal use has
been in existence for about 2,500 years. That led to a confusing decade of
state-by-state regulations for so called medical cannabis. Some of those states considered non-medical
use illegal. Some states took that a
step farther by decriminalizing cannabis typically based on personal use. Other states eventually legalized
recreational cannabis. It is currently legal
in 40 of 50 states for medical use, in 24 of 50 for recreational use, and
decriminalized in 6 states.
Over the past decade the evidence for medical applications
of cannabis have been increasingly sparse.
It appears that the initial hype about it being a miraculous medicinal
have not played out and it looks like that approach was established to
facilitate a path to legalization. Now that medical applications are vanishing,
we see it being sold as an industry and even a source of equity for oppressed
minorities.
The next frontier seems to be convenience stores. About 50 years ago, gas stations in the
Midwest began selling bread and milk in addition to gasoline. In those days they were open longer than most
grocery stores and people got accustomed to picking up these necessities at odd
hours. As more people used them the
stock expanded to the point where today you can get prepared hot food 24 hours
a day at some of these stores.
Some but not all these stores are selling compounds like kratom and other potentially problematic compounds. Many of these drugs being sold fall into
loopholes in state statutes and despite warnings from federal agencies are
still available for over-the-counter purchase.
They are not FDA approved prescription drugs, so they are not available
though pharmacies. In the case
of kratom 30 of 50 states regulate it to some extent, it is illegal as a
Schedule 1 drug and banned in 6 states, and in 20 states it is neither
controlled or regulated. I live in one
of the states where it is regulated to some extent and it is available for
purchase at gas stations. It is only illegal to sell to a person less than the
age of 18 years or possess kratom if you are less than age 18. Both are considered misdemeanor crimes.
That brings me to the current update (3) from the Mortality
Morbidity Weekly Report (MMWR). The
authors analyze data from the National Poison Data System (NPDS) from 2015 to
2025 and have several outcomes and demographics available from that
system. The system depends on self
report so mild cases may be minimized, the type of formulation (leaf versus
other formulations) was not available, multiple exposures can be reported so
causality may be undetermined and repeat calls and misclassification can
occur.
A further analysis problem is that in many cases there are
more drugs present than just kratom. The
authors analyze the data about whether there is single substance or multiple
substance exposure leading to the morbidity or mortality event. The case selection and outcomes of interest
are illustrated in the top graphic for this post. The NPDS database tracks deaths and other outcome
categories. Hospital admissions are tracked including psychiatric admissions. Major, moderate, and minor effects. Major effects are considered life-threatening
or resulting in permanent disability or disfigurement. Moderate effects are systemic, prolonged and
require some treatment but are not life threatening. The authors define serious
as lethal, major, or moderate for the purpose of their outcomes.
Kratom exposure rates were calculated per million drug
exposures in the NPDS database. They
document a 1200% increase in kratom exposures from 2015 (n=258) to 2025
(n=3434). Multiple substance exposures
exceeded single exposures over the same period.
Males had consistently higher rates of kratom only and multiple drug
exposures. Hospitalizations had similar
increases of 1200% increase over the study interval. There were 233 deaths over the period with 49
(21%) due to kratom exposure alone and 184 (79%) due to multiple exposures including
opioids, benzodiazepines, and stimulants.
That last mortality statistic is important because many users believe
that kratom is a benign substance. That
belief hinges on the amount of raw material (as leaves) that can be used for
effect. Any concentrated form should be viewed as potentially as toxic as any
other opioid receptor agonist and easily complicated by the use of any other
opioids.
The authors attribute the significant increase in 2025
reports to the availability of concentrated semi-synthetic forms like 7-hydroxymitragynine. It is important to note that persons with
substance abuse disorders are not necessarily risk averse. The progression of
any addictive process generally involves using more concentrated or
bioavailable forms. That process is not rational – so if you have that kind of
problem and know this data – you will not necessarily avoid more potent forms
of kratom or avoid mixing them with other intoxicants like opioids or benzodiazepines.
The authors also point out that persons
with multiple exposures are more likely to require hospitalizations and have
more serious outcomes.
Total lifetime use of kratom increased from 4 million to 5
million persons between 2019 and 2023 and that increase was across all
demographic groups.
The overall impact of increased exposure to a drug that
reinforcers it own use is expected. Over
time in every case there will be increasing morbidity and where possible
mortality. The exposure to multiple
substances is expected, since people using substances for their reinforcing
effects tend to use more, make substitutions, and use by routes that lead to
increased bioavailability and impact. No
matter who you are this needs to be remembered at every policy debate. The ideas about raising more revenue form
these kinds of compounds and reducing taxes is a pipe dream. The societal costs of these compounds are
always high. The more widely available
they are – the higher the costs.
George Dawson, MD, DFAPA
References:
1: Crocq MA. History
of cannabis and the endocannabinoid system
. Dialogues Clin Neurosci. 2020
Sep;22(3):223-228. doi: 10.31887/DCNS.2020.22.3/mcrocq. PMID: 33162765; PMCID:
PMC7605027.
2: Legislative
Analysis and Public Policy Association.
Kratom: Summary of State Laws.
January 2026. https://legislativeanalysis.org/wp-content/uploads/2026/02/Kratom-Summary-of-State-Laws.pdf
3: Towers EB, Thomas
YT, Holstege CP, Farah R. Increases in Kratom-Related Reports to Poison Centers
- National Poison Data System, United States, 2015-2025. MMWR Morb Mortal Wkly
Rep. 2026 Mar 26;75(11):139-145. doi: 10.15585/mmwr.mm7511a1. PMID: 41886310.
4: US Food and Drug
Administration. Import Alert 54–15: detention without physical examination of
dietary supplements and bulk dietary ingredients that are or contain kratom (Mitragyna
speciosa). Silver Spring, MD: US Department of Health and Human Services,
Food and Drug Administration; 2026. https://www.accessdata.fda.gov/cms_ia/importalert_1137.html
“FDA has seen an
increase in the number of shipments of dietary supplements and bulk dietary
ingredients that are, or contain kratom, also known as Mitragyna speciosa,
mitragynine extract, biak-biak, cratom, gratom, ithang, kakuam, katawn,
kedemba, ketum, krathom, krton, mambog, madat, Maeng da leaf, nauclea, Nauclea
speciosa, or thang. These shipments of kratom have come in a variety of forms,
including capsules, whole leaves, processed leaves, leaf resins, leaf extracts,
powdered leaves, and bulk liquids made of leaf extracts. Importers' websites
have sometimes contained information about how their products are used.”
5: Substance Abuse and Mental Health Services Administration.
National Survey on Drug Use and Health (NSDUH): key resources and tools for
NSDUH. Rockville, MD: Substance Abuse and Mental Health Services
Administration; 2025. Accessed July 27, 2025. https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
This reference says nothing about the prevalence of kratom use.
Graphics Credit:
Lead summary graphic was done by me. Bar graphs of annual outcomes is form reference 3 and open access as an official government publication.
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