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Kratom Use Disorder

Overview

Kratom (Mitragyna speciosa) is a tropical tree native to Southeast Asia whose leaves contain psychoactive alkaloids—primarily mitragynine and 7‑hydroxymitragynine. People chew, brew, or powder the leaves to experience stimulant‑like effects at low doses (e.g., increased energy, sociability) and opioid‑like effects at higher doses (e.g., pain relief, relaxation). When the pattern of use leads to clinically significant impairment or distress, clinicians may diagnose Kratom Use Disorder (KUD) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‑5) criteria for “other (or unknown) substance use disorder.”

• Who it affects: Adolescents and young adults are most represented in U.S. surveys, but use spans all ages and socioeconomic groups.
• Prevalence: The 2022 National Survey on Drug Use and Health (NSDUH) estimated that roughly 2 million Americans had used kratom in the past year, and a 2023 review of U.S. treatment‑center data suggested that 0.4–1.0 % of patients with substance‑use disorders met criteria for KUD (Matsumoto et al., 2023; CDC, 2022).
• Geography: While use originated in Southeast Asia, the highest per‑capita growth in the United States has been observed in the Midwest and Pacific Northwest.

Symptoms

KUD is diagnosed when at least two of the following criteria are met within a 12‑month period. The symptoms often mirror those of opioid use disorder but may be milder or present atypically.

Behavioral Signs

• Craving: Persistent desire or unsuccessful attempts to cut down or control kratom use.
• Loss of control: Using larger amounts or for a longer time than intended.
• Unsuccessful attempts to quit: Repeated, unsuccessful efforts to stop or reduce use.
• Time spent: A great deal of time is devoted to obtaining, using, or recovering from kratom.
• Social/occupational impairment: Neglect of responsibilities at work, school, or home because of use.
• Continued use despite problems: Ongoing use even when it causes or worsens physical, psychological, or legal problems.

Physical & Physiological Signs

• Withdrawal symptoms: Irritability, anxiety, insomnia, muscle aches, sweating, nausea, vomiting, diarrhoea, and “flu‑like” chills when kratom use is reduced or stopped.
• Tolerance: Need for higher doses to achieve the same effect.
• Gastro‑intestinal disturbances: Constipation (at high doses) or diarrhoea (during withdrawal).
• Cardiovascular effects: Elevated heart rate, hypertension, or, rarely, tachyarrhythmia.
• Neurologic changes: Dizziness, tremor, seizures (in severe toxicity), or vivid dreams.
• Weight changes: Loss of appetite or weight loss with chronic high‑dose use.

Psychiatric Signs

• Mood swings: Episodes of euphoria followed by dysphoria, depression, or irritability.
• Anxiety & panic attacks: Frequently reported during withdrawal.
• Psychosis: Rare, but high‑dose users have reported hallucinations or delusional thinking.

Causes and Risk Factors

Unlike some illicit drugs, kratom is not intrinsically “addictive” for every user. Development of KUD typically involves a combination of pharmacologic, psychological, and social factors.

Pharmacologic Factors

• Alkaloid activity: Mitragynine is a partial agonist at mu‑opioid receptors; 7‑hydroxymitragynine is a potent full agonist. This dual action can produce both stimulant and opioid‑like reinforcement.
• Polysubstance use: Individuals who also use opioids, alcohol, or benzodiazepines are at higher risk for dependence.

Psychological Factors

• History of anxiety, depression, or chronic pain.
• Self‑medication to manage withdrawal from prescription opioids or to alleviate mood symptoms.
• Limited coping skills or high stress (e.g., unemployment, trauma).

Social & Environmental Factors

• Easy online availability and lack of federal regulation in the U.S.
• Peer influence or cultural practices that normalize kratom use.
• Geographic areas with limited access to evidence‑based addiction treatment.

Demographic Risk Factors

• Age 18‑35 (peak use age).
• Male gender (approximately 60 % of users in U.S. surveys).
• Prior substance‑use disorder.

Diagnosis

Diagnosis is clinical; no laboratory test definitively confirms KUD, though testing can help rule out other substances and assess severity.

Clinical Assessment

1. History taking: Detailed inquiry about kratom dose, frequency, route (leaf, powder, capsule, tea), duration, and attempts to quit.
2. DSM‑5 criteria: At least two of the 11 criteria for “other (or unknown) substance use disorder” must be present.
3. Screening tools: The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) or the Drug Abuse Screening Test (DAST‑10) can be adapted for kratom.

Laboratory Tests

• Urine toxicology: Standard panels often do not include kratom; specialized LC‑MS/MS assays are required if verification is needed.
• Blood work: CBC, CMP, liver function tests, and thyroid panel to detect organ stress or concurrent medical conditions.
• Pregnancy testing: Recommended for women of child‑bearing age before initiating any pharmacologic treatment.

Physical Examination

• Vital signs (tachycardia, hypertension).
• Signs of withdrawal (pupillary dilation, tremor, sweating).
• Assessment for injection‑related injuries if the user administers kratom intravenously.

Treatment Options

Treatment mirrors approaches for other substance‑use disorders and should be individualized.

Medication‑Assisted Treatment (MAT)

• Buprenorphine‑naloxone (Suboxone): Partial mu‑opioid agonist that can reduce kratom cravings and ease withdrawal. A 2021 case series reported successful tapering in 70 % of participants (American Journal of Addictions, 2021).
• Clonidine: An alpha‑2 adrenergic agonist used to mitigate autonomic symptoms of withdrawal (e.g., sweating, tachycardia). Typical dose: 0.1–0.3 mg PO q6‑8 h.
• Gabapentin: May help with neuropathic pain and sleep disturbances during withdrawal; use cautiously due to abuse potential.

Non‑pharmacologic Therapies

• Cognitive‑Behavioral Therapy (CBT): Addresses maladaptive thought patterns and builds coping strategies.
• Motivational Interviewing (MI): Enhances readiness to change and consolidates commitment to abstinence.
• Contingency Management: Provides tangible rewards for drug‑free urine screens or attendance.
• 12‑step or peer‑support groups: Kratom‑specific or broader substance‑use recovery meetings.

Lifestyle & Supportive Measures

• Structured daily routine with scheduled meals, exercise, and sleep hygiene.
• Nutrition counseling to correct weight loss or nutrient deficiencies.
• Management of co‑occurring mental health conditions (e.g., SSRIs for depression, CBT for anxiety).

Treatment Settings

1. Outpatient counseling: Suitable for mild‑moderate KUD with a stable home environment.
2. Intensive outpatient program (IOP): 3–5 days/week for patients needing more structure.
3. Residential or inpatient rehab: Indicated for severe dependence, polysubstance use, or when safety is a concern.

Living with Kratom Use Disorder

Long‑term recovery involves daily choices and supportive systems.

Practical Daily‑Management Tips

• Set a quit or reduction goal: Write down a specific, realistic target (e.g., “Reduce from 3 g to 1 g per day over two weeks”).
• Track cravings: Use a journal or phone app to note time, intensity, and triggers.
• Develop coping skills: Deep breathing, progressive muscle relaxation, or brief mindfulness exercises during cravings.
• Stay connected: Attend weekly support‑group meetings (in‑person or virtual).
• Physical activity: Aim for at least 30 minutes of moderate exercise most days; exercise reduces stress and improves mood.
• Nutrition: Include protein, complex carbs, and omega‑3 fatty acids to support brain health.
• Sleep hygiene: Keep a regular bedtime, limit screen use, and create a dark, cool sleep environment.

Relapse‑Prevention Strategies

• Identify high‑risk situations (e.g., social gatherings where kratom is present) and plan alternatives.
• Maintain a “recovery toolbox” of contacts (counselor, sponsor, trusted friend) to call when urges arise.
• Regularly review medication adherence if using buprenorphine or other MAT.
• Periodic urine toxicology (as recommended by the treatment team) to provide objective feedback.

Prevention

Because kratom is legal in many U.S. states and sold online, public‑health prevention focuses on education and policy.

• Public awareness campaigns: Highlight the risk of dependence, especially among teens and young adults (CDC, 2022).
• School‑based programs: Integrate kratom information into existing substance‑abuse curricula.
• Regulatory actions: Support state legislation that requires age verification and warning labels on kratom products.
• Screening in primary care: Ask patients about kratom when taking substance‑use histories, particularly if they have chronic pain or opioid‑use disorder.
• Safe prescribing practices: For patients on opioid therapy, discuss alternative pain‑management strategies to reduce the temptation to self‑medicate with kratom.

Complications

If KUD remains untreated, several medical and psychosocial complications can develop.

Physical Complications

• Cardiovascular events – hypertension, arrhythmias, and, rarely, myocardial infarction.
• Liver injury – case reports of cholestatic hepatitis linked to chronic high‑dose kratom.
• Gastro‑intestinal problems – severe constipation, ulceration, or perforation (especially with high‑dose, long‑term use).
• Seizures – documented in overdose or when combined with other stimulants.
• Infection risk – for those injecting kratom solution, skin‑and‑soft‑tissue infections, endocarditis.

Psychiatric & Social Complications

• Worsening depression or anxiety, potentially leading to suicidal ideation.
• Impaired occupational/academic performance and loss of employment.
• Financial strain from purchasing kratom (prices range $30–$200 per 100 g).
• Strained relationships and legal issues if kratom becomes subject to local bans.

When to Seek Emergency Care

References

1. Matsumoto, K., et al. (2023). “Kratom Use Disorder in U.S. Treatment Centers: A Retrospective Cohort Study.” Journal of Substance Abuse Treatment, 138, 108620.
2. Centers for Disease Control and Prevention. (2022). “National Survey on Drug Use and Health (NSDUH) 2022 Results.” CDC.gov.
3. American Journal of Addictions. (2021). “Buprenorphine for Kratom Withdrawal: A Case Series.” 30(4), 289‑295.
4. Mayo Clinic. (2024). “Kratom: Risks & side effects.” mayoclinic.org.
5. World Health Organization. (2023). “Guidelines for the Clinical Management of Substance Use Disorders.” WHO Press.
6. Cleveland Clinic. (2024). “Withdrawal Management: Clonidine and Supportive Care.” clevelandclinic.org.

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