The Ohio Board of Pharmacy (BOP) has proposed that the active compounds in kratom—a recreational herbal supplement—be classified as a Schedule I controlled substance in the state.
Kratom is derived from the leaves of a tropical tree of the same name that is indigenous to Southeast Asia. Already banned in several US cities and states and listed by the DEA as a “Drug of Concern,” mitragynine and 7-hydroxymitragynine, the two major active components of kratom, are the compounds under consideration for Schedule I classification in Ohio.
In response to the Schedule I requirement that a substance have a “high potential for abuse,” the BOP cites studies that suggest kratom users can develop a dependency on the drug. It also points to six deaths in Ohio that list “kratom as the primary cause of death.” Yet according to documents provided by the Ohio Department of Health to HuffPost, “none [were] conclusively caused by mitragynine alone.” Rather, the deaths occurred in the context of pre-existing medical conditions, or the combination of kratom with prescribed drugs, over-the-counter drugs, and illicit opioids like fentanyl.
In addition to the BOP’s contention that kratom has a “high potential for abuse,” it asserts that kratom has “no accepted medical use in treatment,” another requirement for Schedule I classification. The latter claim is based on the results of a February 2018 FDA report, which was based on the results of something they call “Public Health Assessment via Structural Evaluation” (PHASE)—a “3-D computer technology” that predicts how chemical molecules may behave in the body. At the time of the assessment’s release, FDA Commissioner Scott Gottlieb stated that “there is no reliable evidence to support the use of kratom as a treatment for opioid use disorder.”
Yet the BOP’s own assessment of kratom reveals its potential as a medicine: “People addicted to heroin,” reads the report, “use [kratom] to alleviate opiate withdrawal symptoms.”
Kratom advocates may also have grounds to fear that the Ohio proposal is the precursor to a similar move at national level. The DEA held off on classifying kratom as a Schedule I substance in 2016, after a wave of pushback from experts and users of the substance. But it may now be ramping up to reconsider. In addition to the FDA’s February assessment, on October 5 the Substance Abuse and Mental Health Services Administration (SAMHSA) requested “emergency approval” to add two questions about kratom to the 2019 National Survey on Drug Use and Health.
These questions, SAMHSA says, will “provide the first national, systematic epidemiological or survey data on [kratom’s] use in this country and establish a baseline for the use of kratom—an easily accessible, unregulated, opioid-like drug.” SAMHSA’s motivation for gathering this data does not seem to be a desire to encourage research on a possible tool to combat the opioid overdose crisis. Instead, they simply write: “Some users of kratom products reported becoming addicted to the drug.” The Office of Management and Budget (OMB) has until October 25 to approve the “emergency” request.
The Ohio BOP report additionally states a concern that heroin dealers supply kratom. Yet it somehow fails to connect the dots between that finding and kratom’s harm reduction function. As Edward Boyer, a Harvard professor of emergency medicine and a leading kratom researcher, explained to HuffPost: “If a customer didn’t have enough money for their next fix, the dealer might at least be able to offer them enough kratom to stave off a withdrawal […]But just because the two substances are appearing in similar settings doesn’t mean they have similar effects.”
Although mitragynine bonds to opioid receptors in the brain, according to recent FDA research, kratom is not equivalent to opioids like heroin in its effects. There have been no reported fatal overdoses attributed to kratom alone—unlike, say, methadone, a Schedule II opioid.
The fact that kratom appears to carry less risk than methadone—which itself cuts mortality from opioid addiction by half or more—could potentially help to qualify it as a useful opioid cessation or maintenance option. A 2008 study in the peer-reviewed journal Addiction found that kratom “attenuates potentially severe opioid withdrawal,” although “cessation of kratom administration itself appears to be associated with modest abstinence symptoms.”
Additionally, a 2017 survey was conducted at a 12-step-oriented residential program where 500 participants with a substance use disorder were asked about their use of kratom in relation to their opioid use. A majority of the kratom-using participants reported that they used kratom as a “means of reducing or abstaining from” and “substituting for” non-prescription opioids and heroin.
These studies demonstrate kratom’s potential medical uses. By classifying the active compounds in kratom as Schedule I substances, Ohio’s BOP would prevent further medical research into its benefits (similar to the obstacles the DEA has imposed on research of marijuana, a Schedule I substance).
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