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Psychiatrist, internist, and addiction medicine specialist Muhamad Aly Rifai discusses his article “Why kratom addiction is the next public health crisis.” Muhamad explains how kratom, a botanical imported from Southeast Asia, has rapidly spread across the U.S., marketed as a natural remedy for pain and opioid withdrawal. He warns that its potent alkaloids act directly on opioid receptors, leading to dependence, withdrawal, psychosis, and even fatalities. Muhamad outlines the surge in use during the COVID-19 pandemic, the risks to youth, and the dangers of contamination and unregulated production. He also highlights the lack of tailored treatments for kratom dependence, the need for stronger regulation, and the importance of educating the public about its hidden dangers. Listeners will gain a deeper understanding of why kratom’s growth poses urgent challenges for both clinicians and policymakers.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai, a psychiatrist and addiction medicine specialist. Today’s KevinMD article is “Why kratom addiction is the next public health crisis.” Muhamad, welcome back to the show.

Muhamad Aly Rifai: Thank you very much for having me to talk about this timely topic on kratom, which has been heavily used by the U.S. population and is posing a significant problem for the addiction community as an upcoming public health issue.

Kevin Pho: All right, so before talking about your article, to get everyone on the same page, just tell us what kratom is.

Muhamad Aly Rifai: So kratom is the name of a substance. It is a plant that grows in Southeast Asia. The name of the plant is *Mitragyna speciosa*. It is a large, leafy plant that is tall, about 15 to 20 meters. The leaves look like mint leaves, though they are a little bit larger, and it belongs to the same family as a distant cousin of coffee. It grows in Cambodia, Thailand, Malaysia, Indonesia, Myanmar (which is Burma), and Papua New Guinea.

It is pronounced kratom, K-R-A-T-O-M. The American population may pronounce it as kratom with a D. In fact, in Southeast Asia, some of the French colonies pronounce it differently; they pronounce it kratom, so it is a totally different pronunciation for the same substance.

Over the last 10 to 15 years, this has been recognized as an herbal substance. People started using it in Southeast Asia, probably in the late nineties, and its popularity took off. It can be used as leaves, which people brew into teas. It can also be made into a powder that can be taken or smoked. Most recently, over the last five to 10 years, the powder is being turned into tablets for consumption, which are available in different shops in the United States.

It is a significant plant. There are reports that the United States imports about two to three metric tons of kratom per month. The usage is significant, and there are estimates that about 2 to 3 percent of the U.S. population is using kratom on a regular basis. So we are seeing this as a significant public health issue.

Kevin Pho: For the people who use it, what are the alleged benefits or medicinal qualities that they are going for?

Muhamad Aly Rifai: Sure. When people started using kratom in Southeast Asia 100 to 150 years ago, when the plant was discovered along with tea and coffee, it was found to be a plant that could be used as a tea that had stimulant effects at smaller doses. We know biochemically that it hits certain receptors that give it stimulant properties. At higher doses, it hits the mu-opioid receptor, so it had a pain relief quality.

Workers in Southeast Asia utilized the Mitragyna speciosa plant leaves during long days of labor. It gave them a bit of energy. Then, toward the end of the day, as their brew matured into a larger dose, it provided pain relief after a long day of work. They were using small amounts at that time, and people did not become dependent on it. Now, what happens is that these leaves are purified and concentrated into larger doses, causing them to immediately hit the mu-opioid receptors, which produces an opioid-like effect. That is how people are becoming dependent on them.

Kevin Pho: And tell us about some of the side effects of taking kratom. Would it be similar to opioid-like toxicity?

Muhamad Aly Rifai: Yes. We are seeing a large chunk of the population that pursues kratom. They purchase it in different areas, either as a powder or pills, or they smoke it, and they are utilizing it daily. They are becoming dependent on it and experiencing significant issues with withdrawal. There are two levels: toxicity and withdrawal. Many people who overuse it experience a significant amount of toxicity. The poison control centers in the United States have seen significant numbers of toxicity cases and even deaths.

There are between 2,000 to 3,000 reported deaths from kratom toxicity, which can present like an opioid overdose. Sometimes when people overuse kratom, they require resuscitation and naloxone to be revived, which dissociates the kratom from the opioid receptors. The symptoms of using kratom are the same as those seen with opioids, though it is a little weaker. While it is definitely weaker than fentanyl, its effects are on the same level as other opioids and street heroin. So that is a significant issue.

People become dependent on it. They use it regularly, and when they stop, they experience symptoms that are very similar to opioid withdrawal and often end up being admitted to inpatient drug and alcohol rehabilitation, where we have to treat them in a similar way that we treat individuals addicted to opiates.

Kevin Pho: And where can one find kratom? I see it in the grocery store; they have kratom seltzers and drinks. Sometimes I see kratom bars. How easily accessible is kratom?

Muhamad Aly Rifai: It is available. In fact, kratom and its products are illegal in seven states. The last state that completely banned it was Florida last month. The Attorney General and the Surgeon General in Florida moved it to a Schedule I substance, so kratom is not available in Florida; it was completely banned. There are other states where kratom is not available, but that is only about six or seven states.

In most of the country, it is available in smoke stores and in supermarkets with multiple formulations, like tablets. You see those little five-hour energy bottles; they produce similar ones with kratom. Sometimes kids or young adults may purchase them without realizing they are using kratom. They become dependent on them because they hit the opioid receptors.

Last month, the Food and Drug Administration called on the Drug Enforcement Agency to ban kratom and list it as a Schedule I substance. The kratom plant has two distinct neurochemicals. It is an alkaloid with about fifty different compounds, but the two major ones are mitragynine and 7-hydroxymitragynine. 7-OH, as they call it, is the substance that is very potent and hits the mu-opioid receptor. It is actually about forty times stronger than hydrocodone or morphine. Mitragynine is not as strong. So, 7-hydroxymitragynine is the substance that the FDA and the DEA are targeting.

Unfortunately, manufacturers have departed from using just the natural kratom leaves. They now resort to chemically manufacturing 7-OH in those tablets and small bottles, significantly increasing the potency of those compounds to hit the opioid receptors with significant strength. They are getting close to the strength of heroin and fentanyl in those available products.

There is also a large movement in the United States of natural kratom users who swear by its properties in helping them with energy, fatigue, and pain. Unfortunately, that movement may be swept away by what we are seeing from the DEA and the FDA because of their inability to specifically say, “Well, we are going to ban only 7-OH.” The problem is that 7-OH is part of the kratom plant. So once you ban that, you have effectively banned the natural plant. It is very hard for these agencies, which do not have surgical scalpels, to say, “We are banning this substance, but not this substance.” So, we are probably heading toward kratom being banned completely in the United States. Hopefully, it will happen soon enough before this becomes a more significant public health issue.

Kevin Pho: You said some states have put kratom on a Schedule I drug. Can you remind us what that means?

Muhamad Aly Rifai: That means it is an illegal substance. A Schedule I substance is one that has no pharmaceutical benefit whatsoever. For example, heroin and LSD are Schedule I substances. They are illegal in the United States. Some states are moving kratom to that category, though it has not been done federally. So kratom is still available in at least 43 states that I know of, where you can find it in shops, grocery stores, and in different compounds, doses, and formulations. The danger is that people do not know what they are using or how much they are using until they get in trouble or feel withdrawal symptoms when they stop.

Kevin Pho: For those kratom users listening now who might get an occasional kratom drink from the supermarket, how much is actually in that drink, and is there a real risk of addiction from just a supermarket kratom drink?

Muhamad Aly Rifai: We do not know. The answer is we do not know the dosage. They may list the dosage of kratom in the drink, but because of the variety of these formulations, we do not know the actual dose of mitragynine or 7-hydroxymitragynine. People who use it regularly may be consuming a significant amount of a substance that hits the opioid receptors and may create a dependence. Individuals who are susceptible to addictive disorders may use it two or three times and like the effect of the opioid receptors being stimulated.

It is a partial agonist for the opioid receptors, and people just become dependent on it. They say, “Oh, well, it is just a drink. It is just an energy drink that I am using on a regular basis.” Then they feel the urge to continue using it because they become physically dependent. The next thing you know, they start having side effects and withdrawal symptoms and need to be treated medically. So unfortunately, we do not have a lot of answers, and we really need to be able to tell the public that, given the current situation, any use may be dangerous.

Kevin Pho: You mentioned that seven states have put kratom on Schedule I, and you alluded that it may be banned in the near future. Do you see any middle ground where it is just more heavily regulated?

Muhamad Aly Rifai: It could be more heavily regulated. To their credit, the FDA brought in some advocates who talked about the beneficial effects of botanical kratom for pain relief. But we are also seeing many individuals who are dependent on opiates resorting to using kratom to manage their withdrawal, which is another dangerous trend. We are seeing multiple dangerous trends happening simultaneously.

An intervention will definitely be needed. The question is what form that will take. Whatever they ban will likely sweep the botanical use of kratom with it, simply because botanical kratom contains 7-OH, which is the substance that was declared a public health emergency. I do not see a middle ground where they will be able to exclude one substance but not the other.

Kevin Pho: We are talking to Muhamad Aly Rifai, a psychiatrist and addiction medicine specialist. Today’s KevinMD article is “Why kratom addiction is the next public health crisis.” Muhamad, let us end with some take-home messages for the KevinMD audience.

Muhamad Aly Rifai: Kratom is a botanical substance that has some beneficial effects. Unfortunately, over the last few years, we have seen an exploding phenomenon of young Americans using kratom in unintended ways, such as in tablets, capsules, teas, and drinks. This creates a significant health hazard because it leads to a dependence on kratom that affects opioid receptors. The regulatory agencies, the Food and Drug Administration, the Centers for Disease Control, and the Drug Enforcement Agency rallied last month to make decisions about kratom. Unfortunately, because of the significant chemical entities involved, there may not be a middle ground.

We have seen that seven states have declared kratom and 7-hydroxymitragynine as Schedule I substances. I hope there may be a middle ground for the botanical users of kratom, but I think we are heading toward a complete ban, and it will be declared a Schedule I substance.

Kevin Pho: Muhamad, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Muhamad Aly Rifai: My pleasure. Thank you.