Update on Kratom

 

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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 21^st 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.