Kratom (Mitragyna speciosa) dependence, withdrawal symptoms and craving in regular users
Introduction
Kratom, also known as Ketum or ‘biak’, is an indigenous plant (Mitragyna speciosa Korth) of Southeast Asia. Kratom has gained widespread popularity as a folk remedy among the rural population of Malaysia and Thailand (Adkins et al., 2011, Hassan et al., 2013). People use Kratom leaves for their energising and pain relieving effects which are reported to have psychostimulant-as well as opiate-like character, depending on the dose consumed (Babu et al., 2008, Vicknasingam et al., 2010). The plant preparation is also used for opiate withdrawal and as substitution for the more expensive heroin (Suwanlert, 1975, Assanangkornchai et al., 2007a, Assanangkornchai et al., 2007b, Vicknasingam et al., 2010, Ahmad and Aziz, 2012).
The main psychoactive alkaloid of Kratom is mitragynine while the strongest pain relieve is induced by the less abundant 7-hydroxy-mitragynine (Matsumoto et al., 2005, Hassan et al., 2013). Herbal preparations of Kratom are increasingly found and used in Europe and the US, either as pure preparation (Cornara et al., 2013, Forrester, 2013) or as one herbal ingredient of ‘legal-’ or ‘herbal high’ preparations, which are distributed under various names such as Krypton, K2, or Spice (Dresen et al., 2010, Arndt et al., 2011). While the main psychoactive components of these preparations are believed to be synthetic cannabinoids and herbs only being used as carriers (Cornara et al., 2013), a recent report identified a series of K2 products that did not contain any known cannabinoid, but did contain mitragynine as psychoactive compound (Logan et al., 2012). Also purified mitragynine becomes increasingly available on a worldwide scale via the Internet (Boyer et al., 2008, Hillebrand et al., 2010, Schmidt et al., 2011). Emerging reports of Kratom use in the US and Europe suggest a considerable abuse potential with adverse health effects (Boyer et al., 2007, Boyer et al., 2008, Havemann-Reinecke, 2011, Ward et al., 2011). Single case reports from Europe and the US are currently accumulating (Boyer et al., 2007, Boyer et al., 2008, McWhirter and Morris, 2010, Havemann-Reinecke, 2011, Sheleg and Collins, 2011) which suggest an abuse and addiction potential, toxicity, and fatal interactions with other psychoactive drugs (Kapp et al., 2011, Neerman et al., 2013). A considerable addiction potential is now also supported by systematic animal studies (Yusoff et al., submitted for publication).
Kratom preparations are widely available on the Internet (Hillebrand et al., 2010, Schmidt et al., 2011). They are offered as resin, dried leaf, or powder under the names ‘Kratom’, ‘Mitragyna’, ‘Concentrated Kratom’, ‘Plant sample Kratom’, and many more. However, qualities vary considerably (Hanna, 2012). The long history of Kratom use in Southeast Asia allows western users via the Internet to access balanced and occasionally scientifically confirmed information on safety issues, dose patterns, potential side effects, and addiction potential of the drug (Siebert, 2012). In Malaysia, Thailand, and many EU countries, mitragynine and Kratom preparations are controlled drugs. In the US, UK, and Germany, they are currently not controlled substances but under surveillance awaiting more scientific evidence (EMCDDA, 2012, DEA, 2013, Hassan et al., 2013). Here we present the first systematic study of Kratom dependence, withdrawal symptoms, and craving in a human population of regular Kratom users in Malaysia.
Section snippets
Study design
A cross-sectional study was conducted between January and December 2012 in three northern states (Penang, Perlis, and Kedah) of the peninsular Malaysia which neighbour the border of south Thailand. These are the states where Kratom is most prevalent in Malaysia. A total of 293 male Kratom users from various community settings were recruited through purposive sampling. Staff from the National Anti-Drug Agency and village heads helped introducing key informants who were familiar with the Kratom
Sociodemographic characteristics of Kratom users
Respondents in this study were all male Kratom users (n = 293), with the majority of Malay ethnicity. Respondents mean age in this study was 28.9 years. Nearly half were 18–25 years old. Less than 58% (171/293) were single. Two thirds have completed upper-secondary education (193/293) and more than two thirds held an employment (248/293). The majority worked as fisherman, farmers, drivers, and manual labourers. More than half earned between RM 100 and 1000 a month (the average monthly income in
Discussion
Kratom is a widely used psychoactive drug in Southeast Asia which is currently spreading to other parts of the world (e.g., Forrester, 2013). Although anecdotal reports are available (Suwanlert, 1975), this study is the first to measure systematically Kratom dependence, withdrawal symptoms, and craving in regular Kratom users in the northern states of the peninsular Malaysia. All the respondents in this study were dependent on Kratom and also encountered unpleasant withdrawal symptoms and
Role of funding source
The funders had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
DS and BKV designed the study. DS, BKV, and CPM obtained the funding. DS performed the experiment. DS, BKV, and CPM analysed the data and wrote the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors reported no biomedical financial interests or potential conflicts of interest.
Acknowledgements
The authors wish to thank Firdaus Ramli and Vemala Devi for their expert technical assistance. This study was funded by the Ministry of Science Technology and Innovation Malaysia (MOSTI) 304/CDADAH/650444/K105 and a Research Grant from the Academy of Sciences for the Developing World (TWAS; No. 10-115RG/PHA/AS_C-UNESCO FR: 3240246309). This work was further supported by funds of the Friedrich-Alexander-University of Erlangen-Nuremberg (Germany).
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