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Can kratom kill?

The medical examiner for the state of Connecticut says kratom killed my nephew, but the kratom industry claims that is impossible. Who’s right?

This is the first of a four-part series examining kratom, a plant traditionally used as a medicine but in recent years has gained popularity as a recreational drug.

(CN) — I first heard of kratom on the morning of Feb. 5, 2021, when my sister called to say her firstborn son James had died from an overdose. He was 21 years old.

James started using kratom in 2019 to quit drinking — and it worked — but he was soon addicted, gobbling down heaps of the bitter, pulverized leaf to enjoy what some users describe as a safe, legal high. He had been hospitalized twice before after suffering seizures from taking the drug, which is illegal to import to the U.S. but legal to sell in 44 states.

My sister found James in his bed when she went in to feed the cats. He’d been dead for hours; his body was cold.

“His face was caked in vomit,” she told me. “It looked like he was wearing a mud mask.”

Like most kratom addicts, James thought it was safe. The industry insists kratom is neither deadly nor especially addictive, and that any claims to the contrary are part of a conspiracy between the overzealous federal government and law enforcement (and maybe Big Pharma) to disparage and suppress a natural and potential miracle cure that offers relaxation, pain relief, athletic performance enhancement, a path away from opiates and, according to some vendors, even a cure for Covid-19.

The U.S. Drug Enforcement Administration announced its intention to place kratom on Schedule 1 — making it as illegal as heroin — in 2016. Thousands of kratom users and sellers flooded the government with comments supporting kratom, and 62 members of Congress, including Senators Bernie Sanders and Orrin Hatch, signed a letter advising the DEA to stand down. The agency quietly backed away. Nothing like that had ever happened before.

“It’s never really killed anyone,” says Chris Bell, whose 2018 documentary “A Leaf of Faith” evangelized use of kratom for pain management and chronicled the uprising to prevent its prohibition.

This past August, the U.S. Food and Drug Administration asked the World Health Organization to assess kratom, and the kratom movement responded again. At least 75,000 people reportedly testified to kratom’s medicinal value, hoping to sway the WHO’s drug dependence committee conducting a “pre-review” of kratom as a drug of potential abuse. On Dec. 6, the WHO announced that it would keep kratom “under surveillance” — the lowest rung of its regulatory ladder.

“Kratom can produce serious toxicity in people who use high-doses, but the number of cases is probably low as a proportion of the total number of people who use kratom,” the WHO’s assessment reads.

It was another victory for the kratom industry.

Backed by a professional lobbying outfit and a shadowy array of nonprofits, kratom users and sellers claim the federal government is on a yearslong vendetta against their drug of choice, akin to the “reefer madness” that put marijuana on the DEA’s list of most dangerous drugs decades ago. They want kratom, currently illegal in a long list of countries, six U.S. states and a fistful of individual counties, to be regulated as food.

“You just cannot, at multiples that are 40 times the average dosage… you have no deaths,” Mac Haddow, the kratom industry’s chief lobbyist, said, referring to a study conducted on mice. “The safety profile of kratom is very safe.”

During a 10-month investigation, Courthouse News found eight fatalities in which medical examiners listed mitragynine — the main psychoactive element in kratom — as the sole cause of death. Six of the cases have spurred lawsuits against kratom sellers. Two resulted in settlements, and four are ongoing.

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There are certainly other victims: as of Sept. 21, the FDA’s Adverse Event Reporting System had tallied 423 kratom-related deaths.

“This reminds me of the early days of tobacco litigation,” said Robert Mongeluzzi, a Pennsylvania lawyer suing a kratom producer on behalf of the family of Caleb Sturgis, a 25-year-old man who died of a kratom overdose in 2018. “Tobacco was in the early days marketed as safe. It is a leaf, it’s addictive and kills people.”

While banning kratom outright might cause more problems than it solves, the industry’s focus on denying overdose deaths raises questions about its credibility and motives.

Virtually everyone you ask about kratom believes it can’t kill you. That appears to be in large part because the industry’s main nonprofit lobbying group — The American Kratom Association — monopolizes both public discussion and scientific study of the drug, dominating websites, podcasts, legislatures, and even connecting researchers with users for polls. This calls into doubt researchers’ conclusions that pro-kratom policymakers and other scientists routinely cite as proof that kratom is benign.

Mitragyna speciosa — common name kratom — the leaves of which are used to make the supplement kratom. (Uomo vitruviano/Wikipedia via Courthouse News)

A tree native to Indonesia, Thailand and other tropical regions of the Pacific and a relative of the coffee plant, kratom has been chewed or brewed into a tea for hundreds of years to improve alertness and stamina. At low doses — say, a quarter to a full teaspoon stirred into a cup of boiling water — kratom acts much like coffee: there’s a little buzz, maybe some pain relief and a tendency to want to get things done. The effect wears off after a few hours.

Unlike caffeine, however, kratom keys to the same part of the brain as opioids like Oxycontin and heroin. That makes it an interesting compound to drug researchers, and it may be a helpful substance for people trying to kick opioid addictions.

At high doses — four, five teaspoons, say — kratom can cause a mild opioid-like high. Cares melt away, aches and pains disappear and all is right with the world. Until it wears off.

Then you want more. Or at least some people do.

As with almost any psychoactive substance, kratom affects different people in different ways. Some people crave high doses, many do not. Some people can’t stomach the stuff at all, vomiting up even tiny amounts.

“Had to stop taking it altogether,” one anonymous user on a Reddit kratom forum told me. “Never found out why it was making me sick. I was down to one capsule twice a day and that was still making me sick.”

According to surveys of users, most people who use kratom report few serious side effects and, like the documentarian Chris Bell, many say the drug is a life saver. (Bell said he doesn’t use kratom anymore, however, since he’s found a powerful hallucinogen called ibogaine).

“It’s been a part of my wellness for 10 years,” Robin Watson Blackwood, a former high school English teacher of Catonsville, Maryland, told a panel of state senators at a 2020 legislative hearing, adding she uses it for pain management. “Don’t make Maryland a state that forces me to suffer needlessly.”

Other kratom advocates told lawmakers they’d used the drug to get off opiates, become productive citizens, relieve severe depression and anxiety and “help me be the mother that I always dreamed to be.”

The proposal to outlaw kratom was quickly amended to an age-based regulation, then scuttled.

The nonprofit Kratom United touts "zero deaths" from kratom. (Screenshot via Kratom United)

Getting unfiltered information about kratom is difficult. The moderator of r/kratom, the anonymous Reddit community for users of the drug that boasts 124,000 members, routinely locks or removes threads questioning the substance’s safety or mentioning fatalities. It banned me when I announced myself as a journalist soliciting sources.

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Many Reddit posters want advice on dosing, and those dosages tend to be on the order of heaping tablespoons and multi-grams — far more than what’s required for a coffee-like pick-me-up. Tolerance is also a recurring theme. In post after post people complain they can’t get the effects they had previously enjoyed, even after switching strains and colors. The general advice is to lay off for a few days and start again. A third common concern is side effects. Constipation, nausea, even “record-breaking fart volume” are cited alongside testimonials of “it saved my life.”

There is testimony that kratom doesn’t show up on drug tests — especially appealing for the subset of people who say they take kratom mainly to get high (“I get good burns all day long,” says one user). It actually can show up, though few employers and law enforcement agencies test for it. And there are complaints about “trash” product, and endless threads about dosing and paraphernalia — scales, capsules, oblate discs, even spreadsheets charting dosage and effects from various strains and batches.

In short, r/kratom reads much like the Reddit forums devoted to illegal drugs.

This past April, someone posted a new topic titled “Daily Kratom Use — The Bad?” Moderators removed it within hours. An archived thread from 2019 asking “Has kratom ever caused any fatalities?” has six responses concluding that there are no deaths attributable to kratom. The first response cites a 2018 report from the U.S. Centers for Disease Control and Prevention in which 152 deaths were found to be kratom-related, though at least 80% involved people with “a history of abusing substances, primarily heroin and fentanyl,” and that almost all the others had other drugs in their bodies when they died, “meaning that kratom was not necessarily the sole culprit.”

The poster cites a 2018 report by Jane Babin concluding that all these deaths were actually caused by other drugs, mainly opioids.

Babin is a San Diego-based patent lawyer with a doctorate in molecular biology. She examined an initial 44 deaths the FDA categorized as “kratom-related” during and after the 2016 effort to persuade the DEA to ban it under Schedule 1. It’s one of the primary documents of the kratom industry, cited widely by other kratom researchers and often referenced by the American Kratom Association as proof of the FDA’s malignant sloppiness.

Indeed, some of the FDA’s data was bogus. Among the 44 supposed kratom deaths, it initially included a gunshot victim and at least one suicide.

Babin concluded that only one of the deaths for which data was available involved kratom alone, and that even in that case other causes could not be ruled out. Most of the decedents had a history of drug abuse, she found.

“​​A review of the available FDA data reveals the overwhelming majority of the cited deaths fails to provide a cohesive or reasonable scientific basis to conclude any of the deaths was caused by kratom, nor does the information released conclusively support any conclusion that kratom was associated to the cited death other than coincidentally,” she wrote.

The 108 deaths the CDC subsequently reported haven't changed her mind.

“Generally speaking, most of the cases DEA and FDA was citing weren’t kratom deaths,” Babin said in an interview. “I’m not excluding the possibility that there will ever be a death that could be attributable to kratom, but they didn’t prove the case to me.”

Babin believes a single toxicology lab — Pennsylvania-based NMS Labs — may have biased hundreds of medical examiners across many states by saying in a memo or bulletin that there had been reports of kratom toxicity deaths at blood concentration levels of 600 nanograms per milliliter. “If you tell someone that 600 nanograms of this would kill you, they’d laugh,” she says. “I mean maybe with 10 other substances!”

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Dr. Barry K. Logan, who developed the test for NMS Labs, said the 600 nanogram figure came from available data. “We certainly had calls from AKA about our reference comment but we looked over what we were listing in the reference comment and we were confident that it was accurate at the time,” he said in a December phone interview. “So we didn’t make any changes.” He says the figure is still accurate, though it’s based on a small number of deaths.

When asked what concentration of kratom in a dead person’s blood might move her to consider it a potential toxin — for instance, a young man with no known medical issues and no significant other drug use with 1,700 or 2,200 nanograms per deciliter of krakom in his bloodstream — Babin said, “I don’t think that that’s a lethal level. But they haven’t done the studies.”

I sent Babin the autopsy reports of my nephew and Caleb Sturgis, with their names and other identifying information redacted.

She emailed back two hours later. “I believe I’ve looked at the Philadelphia case before,” she wrote, referring to Sturgis. “One comment off the top of my head is that you have to ask the question of what the coroners/MEs did not test for. As I recall, there was information on this decedent’s social media indicating that he had used other substances that would not be detected in a routine tox screen.”

Babin speculated independent testing could not have been done when the blood was fresh enough to still contain the relevant chemical markers. But the lawyers for the Sturgis family say Caleb’s blood was tested immediately by the medical examiner to rule out other drugs.

“This is the lie that the kratom industry has been peddling, that kratom can’t kill you and there are other reasons for their deaths,” attorney Sam Dordick, who also represents the Sturgis family, said in a phone interview. “The only thing in his system was kratom and it killed him.”

Caleb Sturgis’s blood kratom level was 2,700 nanograms per milliliter.

“Then two years later we tested again,” Dordick said. “We wanted to make sure that kratom was the only thing in his system.”

Mongeluzzi, the attorney, noted NMS did the bloodwork, calling the lab “probably the most sophisticated drug testing lab in the country.” The Sturgis family and the kratom producer recently reached a "resolution" in the case.

Babin said kratom did not kill my nephew either.

“Looking very quickly at the Connecticut case, what immediately jumps out at me is that he vomited and had other findings that could be considered consistent with aspiration of vomitus,” she said in the email. “Taking ‘too much’ kratom orally is known to make individuals nauseous and sometimes vomit. This known side effect can occur with much lower quantities of kratom than the amount that would lead to what the coroners consider ‘high’ or ‘toxic’ concentrations of mitragynine.

“The theory of kratom toxicity postulated by the FDA and DEA is that kratom alkaloids act as opioids, and thereby depress respiration if the concentrations are high enough, and they believe that when individuals die from kratom it is due to respiratory depression similar to heroin or fentanyl or oxycodone ODs. This is different than aspirating vomitus.”

I then sent an email asking how kratom can be absolved as a cause of death if it makes someone vomit and simultaneously renders them unable to wake up and turn their head when choking on that vomit. Babin did not respond.

My nephew’s blood kratom level was 2,200 ng/mL.

Walter Prozialeck, a professor of pharmacology at Midwestern University who has studied kratom for a decade — and takes it sometimes for pain management — also looked at the autopsies. He concluded both Sturgis and my nephew took way too much.

“I did several basic pharmacologic calculations,” he wrote in an email. “Even with my most conservative estimates . . . it is apparent that both of these poor guys were using ridiculously high levels of kratom. To reach those high blood levels, the doses of kratom had to be at least 40-80 grams of leaf material consumed in a very short time (maybe an hour at most). Not even the most ardent kratom advocate would claim that level of intake is safe.”

But on its “Top 10 Kratom Questions” page, the American Kratom Association website advises consumers to take as much kratom as they wish. “Consumers can harm themselves from overusing virtually any product,” the association advises, “but research shows kratom does not cause overdose deaths like opioids do.”

On Tuesday: Addiction and the business of kratom.

Collage of James Reilly at various ages. (Courtesy family of James Reilly)

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