Kratom: An Emerging Issue and Need for Regulations in the United States

Objective: To understand and highlight the current issues, emerging trends, and regulations of kratom in the United States. Data Sources: PubMed and PubMed Central of the National Library of Medicine, MEDLINE, PsycINFO, and ClinicalTrials.gov databases were utilized. Study Selection: Studies published between January 1, 2000, and June 30, 2020, were accessed by using the MeSH term mitragyna in the context of toxicity, safety, and legislation and jurisprudence. Data Extraction: The final qualitative synthesis included 11 studies by following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement guidelines. Results: The US Drug Enforcement Administration (DEA) initially proposed to place kratom under Schedule I of the Controlled Substances Act, but the DEA later withdrew the intent, and kratom is still a legal substance in most of the United States. A low to moderate kratom dose produces mild stimulant properties, whereas large doses produce sedative effects that are identical to opiates. Its regular use at a higher dose is associated with dependence. Management of overdose is similar to that of patients presenting with opioid abuse, although kratom may potentially pose a higher risk for drug toxicity and organ injury compared to opioids due to intrinsic properties and adulteration. There is no clinical evidence for its safety and efficacy. The US Food and Drug Administration and the DEA do not recognize any legitimate medical use of kratom. Conclusions: Kratom is an emerging public health concern and is abused as an alternative to opioids. Stringent policies and public awareness campaigns are required to curb the perception of its safe use, which needs to be substantiated with well-designed clinical trials.