The Centers for Disease Control (CDC) announced last month that an herbal supplement has been cited as a cause of death in 91 cases around the country in 2016 and 2017.
The substance, kratom, only recently came to the attention of local law enforcement when a pound bag of kratom powder was examined during a traffic stop.
“That was my first exposure to it,” said Corey Murphy, chief of police in Tioga. When they found the bag of kratom on the floor of the vehicle they questioned the passenger about it. “He admitted it was his. Recently purchased online.”
Murphy researched the substance, discovered it was legal and returned it to the owner.
Kratom is an extract of a plant that grows naturally in southeast Asia and has a long history of providing pain relief in that region of the world. The lack of research on the substance has raised safety concerns about its use in the United States.
“Kratom carries a lot of controversy,” said Mark Hardy, executive director of the North Dakota Board of Pharmacy. “There’s no real good research on it.”
The CDC’s recent report notes that kratom acts as a stimulant in low doses and provides “some opioid-like effects at higher doses.”
“People that take it seem to indicate they get some sort of release from that substance,” said Hardy. “As far as the exact mechanism of how that works, is pretty unclear.”
Kratom is available for sale at Pinnacle’s Tioga location. Todd Busche, Pinnacle’s operations manager, declined to comment on its availability at the store.
Although local law enforcement has only recently had experience with the substance, Hardy has been generally aware of its growing popularity for a few years and it has gotten the attention of the Drug Enforcement Administration (DEA).
In August 2016 the DEA used its emergency scheduling power to temporarily reclassify kratom as a Schedule 1 drug, restricting its sale and use until more research could be completed. Two months later it retracted the decision as a result of widespread public backlash.
While the DEA reversed its decision, at least six states and Washington, D.C., have banned the sale and use of kratom. It is also illegal in Thailand, one of the plant’s native countries.
The use of the substance has not attracted widespread attention in North Dakota at this point.
“We haven’t had any specific situations that have come up that have caused the overdose situation or have been reported as that, that we are aware of,” said Hardy. “However we have had some salmonella infections that have been tied to kratom.”
Kratom was linked to a salmonella outbreak in early 2018. More than 130 people across 38 states became ill, including at least one case in North Dakota.
Dr. Robert Rotering, Tioga, first encountered kratom when he discovered a patient had become dependent on it.
“My impression of it from this one patient was that it had addiction potential, abuse potential and that it basically offered nothing,” said Rotering.
That patient is the only case Rotering has dealt with.
“My impression with that one patient was — and it was his impression — that he had gotten himself into something that was trouble and was having a difficult time getting off of it,” said Rotering.
The Mayo Clinic published a fact sheet in March declaring kratom “unsafe and ineffective.”
“Kratom is believed to act on opioid receptors,” the Mayo Clinic’s website said. “Some people who practice Asian traditional medicine consider kratom to be a substitute for opium.”
Opium is a plant used to create morphine and heroin.
“At one time, some researchers believed that kratom might be a safe alternative to opioids and other prescription pain medications,” according to the Mayo Clinic website. “However, studies on the effects of kratom have identified many safety concerns and no clear benefits.”
Of particular concern is the danger of mixing kratom with other substances such as illegal drugs or prescription medication.
Between July 2016 and December 2017 the CDC said the decedents in 152 overdose deaths in 27 states tested positive for kratom. Of those, 91 cases listed kratom as a cause of death and seven of the decedents tested negative for any other drugs.
The other 84 cases reported the decedents tested positive for kratom in combination with another drug such as fentanyl, heroin, prescription opioids or cocaine.
“What we’re unfortunately seeing is it is being laced into substances that may be sold on the black market maybe like fentanyl,” said Hardy.
He said he is keeping an eye on the substance moving forward. The lack of substantial research on kratom, unlike the thorough clinical trials prescription drugs go through, makes its effects unpredictable.
“You can’t say for certain whether it is truly effective,” said Hardy. “That’s just the nature of nutritional supplements.”
He said he isn’t aware of any pharmacies selling it.
“I’m sure there’s a lot of different health stores that may sell it and promote its effects,” said Hardy. “From a pharmacist’s perspective, I don’t know of any pharmacies that are actively selling the product in my awareness.”
Pharmacist Tim Joyce, owner of Tioga Drug, doesn’t carry many herbal supplements. Although he doesn’t know much about kratom, word of its local use has reached his ear.
“Somebody was telling me about it. If they couldn’t get their hydrocodone, their opioid for their pain, they were going to try that because it was supposed to be an opioid,” said Joyce. “I thought, ‘How the heck can that be on the market?’”
He said the kratom issue reminded him of the 1990s when a herb called ma huang was being marketed as a diet pill.
“It was herbal but it broke down to pure ephedrine,” said Joyce. “They advertised it as a herbal diet pill. But people were having strokes and overdoses.”
Joyce questioned why anyone would sell the product if it has been linked to deaths.
“You don’t want to have a reputation for selling stuff like that if it’s not going to be totally good for people,” Joyce said.
Rotering advises people to exercise great caution when dealing with kratom and to think twice before using it for pain relief.
“I think it’s trouble and I think it’s suspicious,” said Rotering. “To my knowledge it offers nothing that cannot be offered with safe, proven, evidence-based tried and tested American-system medications.”