Kratom: Is it safe for pain or a dangerous opioid?

ASHEVILLE - Matthew McGrory says kratom keeps some of his customers going, some of whom send him everything from thank you cards to homemade spaghetti to express their gratitude.

"People have said it's given them a quality of life back they wouldn't have otherwise," he said. 

McGrory, with Ryan Leonard, is an owner of Pious Lion, an Asheville purveyor of organic kratom. Used for centuries, the botanical is native to tropical Southeast Asia and related to the coffee plant. It also can be found in head shops, kava bars and other retailers.

Supporters say the plant gives them relief from chronic pain and helps ease opioid withdrawal. It can be sold in powders, capsules or steeped like loose-leaf tea.

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Kratom triggers the same opioid brain receptors as morphine and, according to the FDA, it appears to have properties that expose users to the risks of addiction, abuse and dependence. The FDA now classifies it as an opioid with deadly potential.

The Drug Enforcement Agency is considering whether to classify kratom as a Schedule 1 Drug under the Controlled Substances Act, putting it in the same group as heroin.

The biggest debate now is whether kratom is a weapon in the fight against opioid addiction, or a deadly opioid itself. 

Some doctors caution clients against its use, primarily because kratom's long-term effects aren't widely understood.

"What we do know is dangerous, what we don't know, we don't know," said Dr. Don Teater, who specializes in pain management with fewer opioids and works with patients with addictions. 

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The American Kratom Association, which counts 3-5 million regular users,  acknowledges kratom's compounds bind to the same receptor sites in the brain as opioids. It also maintains that chocolate, coffee and exercise affect the brain in a similar fashion.

The FDA says side effects associated with kratom included seizures and respiratory depression - and even death. Forty-four people have died as a result of using kratom since 2011, the agency says.

Many of McGrory's clients say kratom's effects on chronic pain and the pangs of addiction outweigh any potential side effects.

Leonard questions the reported kratom deaths, which he said included a person who fell out a window and others who had multiple drugs in their system.

A recent Washington Post report found nine cases in Sweden where kratom was laced with a powerful opioid, and a single death in which kratom was the only substance detected in the body.

Pious Lion has 200-300 regular customers across the country, with the majority in WNC. The company ships some kratom by mail, but delivers direct to more than 100 clients. 

Some use the leaf recreationally, or as a replacement for alcohol, but the majority of Pious Lion's clients either suffer from chronic pain or are looking to wean off what they consider more dangerous drugs. 

"I have someone who has fibromyalgia and herniated disks, who was taking prescription pills, and couldn't take them anymore," McGrory said. "It's getting hard for doctors to write those prescriptions with the opioid epidemic. Luckily, a lot of people found kratom, and it's what keeps them going."

Lalena Settlemyre is one such client. 

Settlemyre, 47, suffers from scoliosis. She started using kratom three years ago to manage the muscle spasms in her back that almost ended her career running her one-person salon.

"My muscles are trying so hard to keep my spine straight," she said. "I was taking so much ibuprofen, I was worried about my kidneys."

Her father was addicted to opioids, so she refused to go the pharmaceutical route.

Since starting kratom, which she takes in two-gram servings mixed in juice, she's given up ibuprofen, and she no longer drinks her two daily beers. 

As for its addictive properties, she's discontinued kratom several times to see how her body would react. She reports no problems. 

Kratom saved her career, Settlemyer said, but she knows others for whom it's saved their lives. Some she knows have used it to wean off suboxone. 

But not everyone's experience with kratom has been positive.

Polly McDaniel's 21-year-old son has chronic insomnia and is also epileptic. He took a large dose of kratom he purchased from a head shop to help him sleep, which caused "a seizure that would not stop," she said. 

"When the paramedics came they had to use two doses of Narcan to revive him. This was in December. It scared hell out of all of us and, fortunately, it scared the hell out of my son."

A drug test at the hospital showed only kratom and marijuana in his system, and no other drugs, other than his prescribed medication for seizures. "So it wasn't even laced with anything," she said. "But he took an outrageously high dose, thinking the substance was safe."

Leonard said many of his clients trying to extricate themselves from a destructive drug dependence see kratom as a safer, natural solution. 

"We know it's helped a tremendous amount of opiate addicts get off opioids safely," said Leonard. "People with chronic pain who have gotten off opioids or had them taken away, many have found kratom and they're able to continue living their lives."

But FDA Commissioner Scott Gottlieb questions the efficacy of kratom as a treatment for opioid addiction.

"We recognize the need and desire for alternative treatments for both the treatment of opioid addiction, as well as the treatment of chronic pain," he said in a recent release.

The FDA, he said, stands ready to evaluate evidence that could demonstrate a medicinal purpose for kratom. "However, to date, we have received no such submissions and are not aware of any evidence that would meet the agency’s standard for approval."

Kratom deserves deeper study, but Dr. Blake Fagan, assistant director of the Family Medicine Residency Program at MAHEC, warns against its use for pain management, as he does with opioids.

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Not only is it unregulated by the FDA, but its potential for addiction is high, particularly for people with chronic pain disorders, such as fibromyalgia, said Fagan, who has made the opioid epidemic a focus since a former patient died from addiction.

"I feel really bad for the patients who have (fibromyalgia) because there's not a shot or a medication, a cure or even a surgery you can do for it," he said. 

Fagan instead recommends regular exercise, which he said hurts initially, but often leads to improvement. Cognitive behavioral therapy, which treats the perception of pain rather than the pain itself, has also proven helpful. 

The therapy can get expensive, he said.

"Our system is set up for us to dispense medications and you can pick them up relatively cheaply on your insurance, but as soon as you say, 'My doctor recommended I go to behavioural health therapy, (insurance companies) say 'We don't support that, you just have to pay out of pocket.'"

Group therapy, volunteering, or other social activities can also be helpful for sufferers of fibromyalgia, he said, as well as some medications including Lyrica and Cymbalta.

Dr. Teater echoed the notion that kratom's effect on pain and addiction should be studied.

But he also said it's appropriate that the FDA has classified it as an opioid.

"It affects the same cells, the same receptors, has the same actions as morphine and heroin does," he said.

Fentanyl, morphine and methadone, all classified as opioids, all have different chemical makeups too, he said. "But they're called opioids because they work on those opioid receptors in the brain." 

But he's hesitant to say kratom should be classified as a Schedule 1 drug. "Because then it's hard for people to study it and see what its actions are."

It's possible kratom has a partial opioid effect, like buprenorphine or suboxone, that makes it safer to use, he added.

"So there might be some advantages to it that need to be studied, but from what we know now, it appears to be addicting, it appears to be possible to overdose on it, and it appears to be as dangerous as the other opioids."

Teater said kratom's availability makes it particularly dangerous, and he fields many questions from patients about its use.

"I tell my own patients, if I'm treating them for addiction, that they can't be doing this drug. It's just something that may have its benefits, but we just don't know, and we do know it's dangerous."

But Leonard thinks it's dangerous for the FDA and DEA to take a hardline stance on something he said might be a useful tool in the ongoing opioid crisis. 

He stands to lose his livelihood if kratom becomes a Schedule 1 drug. But he said some of his clients stand to lose more. "There's going to be a lot of suffering if this goes through."