Study Warns of ‘Kratom Use Disorder’

By Pat Anson, PNN Editor

Nearly a third of people who use the herbal supplement kratom develop symptoms of withdrawal and tolerance that could be signs of kratom use disorder (KUD), according to a small survey by the National Institute on Drug Abuse. Withdrawal symptoms included gastrointestinal upset, restlessness, anxiety, irritability and fatigue.

Kratom comes from the leaves of a tree that grows in Southeast Asia, where it has been used for centuries as a natural stimulant and pain reliever. An estimated two million Americans use kratom to self-treat their pain, depression, anxiety and addiction.

NIDA researchers recruited 129 past and current kratom users in the U.S. to participate in the online survey, asking them about their symptoms and demographic information.

The study findings, recently published in the Journal of Addiction Medicine, found that over half of kratom users showed no signs of addiction. But 29.5% met the diagnostic criteria for KUD, such as increased use, tolerance, withdrawal, unsuccessful attempts to quit, and craving. Most reported KUD symptoms that were mild or moderate, with about one in four with KUD having severe symptoms.  

Nearly 10% of participants also reported “psychosocial impairments,” such as decreases in social, occupational, or recreational activities because of their kratom use.

“As assessed here, tolerance and withdrawal are primary KUD features rather than psychosocial impairments. As kratom is often used among persons with a myriad of health conditions, clinicians should be aware of and assess for kratom use and withdrawal,” wrote lead author Kirsten Smith, PhD, who heads much of the kratom research at NIDA.

Federal health officials have long taken a dim view of kratom and made unsuccessful attempts to ban it. In 2018, former FDA Commissioner Scott Gottlieb, MD, claimed that kratom was an opioid, addictive, and should not be used to treat any medical condition.

“Kratom use disorder” is a relatively new diagnosis and does not appear often in medical literature.  One of the first references to it is in a 2019 study that called kratom an “emerging public health threat.” Researchers said healthcare providers need to be aware that kratom use was “typically accompanied by increasing tolerance and dependence making it highly problematic.”

A kratom advocate said the new NIDA study shows the risk of kratom addiction is low and that symptoms are often mild. 

“I thought the results of this research were particularly interesting because of the growing number of addiction recovery centers expanded their service-for-hire to include kratom use disorder (KUD) and characterizes this condition as mirroring opioid use disorder (OUD) that requires intensive drug interventions of different substances,” said Mac Haddow, a lobbyist and Senior Fellow for the American Kratom Association, which represents kratom vendors and consumers.  

“Importantly, the study concludes that tolerance of kratom over time, and withdrawal from that level of dependence are the primary outcomes rather than psychosocial impairments that are largely debilitating among drug addictions. The study also recognizes that kratom continues to be a harm reduction alternative for those suffering from polydrug use addiction issues and that accounts for its increasing use as the drug overdose crisis deepens in the U.S.” 

Kratom is often used as a treatment for addiction. A 2016 PNN survey of over 6,400 kratom users found that nearly 12% used it to reduce their cravings for alcohol or opioids. Nine out of ten said kratom was “very effective” at treating their substance use disorder. And over 98% of all respondents don’t believe kratom is harmful or dangerous.

Precautions Needed for Medical Cannabis

By Roger Chriss, PNN Columnist

Medical cannabis continues to thrive. Older Americans are flocking to cannabis dispensaries and more states are considering legalization or adding approved indications.

But there is relatively little information about the potential risks and pitfalls of medical cannabis. The New York Times reports that “researchers are uneasy about the fact that older people essentially are undertaking self-treatment, with scant guidance from medical professionals."

There are three broad categories of precautions that people who are using or considering medical cannabis should be aware of.

Product Quality and Reliability

Reliably sourcing a high-quality cannabis product can be difficult. Product labels are often inaccurate. A 2015 survey of cannabis edibles in Seattle, San Francisco and Los Angeles found that only 13 of the 75 products tested (17%) had labels that accurately indicated their THC content.

More recent testing in California found that about a quarter of the cannabis-infused cookies, candies and tinctures failed safety tests because of improper labeling or because they contained pesticides.

One lab in Sacramento was even found to be falsifying test results. A spokesman for the California Cannabis Industry Association said it's an open secret in the industry that companies have been paying for favorable test results.  

States from Massachusetts to Nevada are also seeing problems with pesticides, mold and heavy metals contaminating medical-grade cannabis.

DRUG POLICY ALLIANCE

Interactions and Contraindications

Cannabis consists of over 100 cannabinoids, as well as other physiologically active substances. This makes for a lot of possible drug interactions. Drugs.com lists 129 major and 483 moderate interactions that cannabis can have with medications such as acetaminophen, codeine, fentanyl, hydrocodone, pregabalin and oxycodone.

Moreover, cannabis has been found to reduce thyroid stimulating hormone (TSH) levels. For people with thyroid disease, artificially suppressed TSH can affect medication decisions. Similarly, cannabis reduces platelet aggregation, a problematic and even risky issue for people with bleeding disorders or low platelet counts.

A new review in Current Opinion in Neurology found that cannabis exacerbates tinnitus (ringing of the ears), a common problem for older people and people with Meniere’s disease or Charcot-Marie-Tooth disease.

Tolerance and Withdrawal

Cannabis tolerance may be a clinically significant issue. A new study on CBD oil for seizure management found that cannabidiol loses its effectiveness in treating epilepsy. About one-third of patients in the study stopped taking CBD because of a lack of benefits or side effects like sleepiness and gastrointestinal trouble.

“CBD is a good option for children and adults with certain kinds of epilepsy, but as with anti-epileptic drugs (AEDs), it can become less effective over time and the dose may need to be increased to manage the seizures,” said lead author Shimrit Uliel-Sibony, MD, head of the pediatric epilepsy service at Tel Aviv Sourasky Medical Center.

Also important is withdrawal. Recent research on cannabis withdrawal in a group of chronic pain patients found that about two-thirds reported at least one moderate or severe withdrawal symptom. Withdrawal symptoms included sleep difficulties, anxiety, irritability and appetite disturbance.

In sum, there are important issues to address when using or considering medical cannabis. Unfortunately, knowledgeable physicians are hard to find and high-quality cannabis is difficult to obtain reliably. It is hoped that this will change soon so that medical cannabis can be used safely and effectively.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

The Other Victims of the Opioid Epidemic

By Katie Burge, Guest Columnist

Imagine the fear, frustration, helplessness and anger you might feel upon learning that your doctor cannot treat you to the best of his or her ability because they’re afraid of being arrested. 

I don't have to imagine that because I am a chronic pain patient with a degenerative spinal condition, plus severe osteoarthritis and fibromyalgia; each of which cause severe chronic pain 24/7. Combined, they can make simple tasks like getting dressed in the morning sheer torture.

Pain patients are the other victims of the so-called opioid epidemic, the ones the media usually don’t mention unless they're blaming us for other people's drug usage. 

Patients are being forced to live in agony and, as a result, increasingly lose their lives due to catastrophic medical events, such as stroke, heart attack and even suicide.

These can all be triggered by the physical, mental and emotional pressures of trying to survive with inadequately treated chronic pain.

Why?  Because politicians and bureaucrats (who refuse to admit the government is completely impotent at controlling the proliferation of illicit drugs) have managed to sell the public on the ridiculous premise that refusing medically necessary medication to one group of people will somehow alter the behavior of another group, and handily end America's drug crisis.

This approach simply does not work. Torturing vulnerable pain patients by refusing them life-giving medication will never make the slightest dent in the illegal drug trade because, sadly, people who want to get high will find something somewhere that will enable them to do so. 

Also, most of the prescription opioids that people abuse DO NOT come from doctors or pain patients. Less than one percent of legally prescribed opioid medication is diverted.  People in true pain are not going to suffer additionally by sharing or selling their medication. And doctors are not as careless with their prescription pads as the powers-that-be would like you to think.  

Nonetheless, the entities that control doctors’ licenses to prescribe opioids have yielded to political pressure by ordering doctors to either cut back on pain medication to the point that it's ineffective or stop opioid treatment altogether, regardless of patient need or outcome.

Inadequately treated chronic pain has stolen a great deal of my independence and quality of life, and though I hate the idea of taking pain medication at all, my greatest desire is to simply be able to fully participate in my own life again.  I will never be pain free, but I long to be able to play with my grandchildren, go to the theater or sit through an entire movie (and still be able to walk back to my car).

The mainstream media is also responsible for the ridiculous narrative that opioids have no legitimate clinical use and are immediately addictive. The result of this bias and hyperbole is that most folks believe outlawing the legitimate medical use of opioids can only be a good thing. Society teaches us that pain is somehow shameful.  We must “suffer in silence” and learn to control our pain without complaint or medical intervention. 

With such an abundance of myth and misinformation, it's no small wonder that actual facts about pain tend to get lost in the mix. Please allow me to share a few:

First, many overdose deaths are made to sound as though they were caused by a single prescription or even a single dose of opioids, when they are actually the result of a mixture of different medications, street drugs and alcohol. 

Second, chronic pain affects more Americans than heart disease, cancer and diabetes combined.  And studies have repeatedly shown that less than 4% of those who take opioid medication for pain become addicted.  They might develop a dependence or tolerance, but that occurs with many medications.

Physical “dependence” simply means that, if a drug or substance is stopped abruptly, the body will react by exhibiting withdrawal symptoms.  “Tolerance” occurs over time, as the dosage of some drugs might need to be adjusted as the body grows tolerant to its effects. Neither of these conditions is unique to opioids, nor are they necessarily indicative of addiction -- which is characterized by compulsive drug seeking behavior and use, despite harmful consequences.

Personally, I believe the question of addiction simply comes down to motive.  If your primary motive in taking opioids is to get high, you might be a drug addict.  If your only motive is pain relief and once that relief is achieved you do not increase the dose, you are not a drug addict.

Drug abuse is a complex social issue that has no easy fixes.  It should not, however, be confused with the medical management of chronic pain.  All life is precious and should be valued and protected, but not at the expense of others.

So, the next time your favorite TV show has a story line about someone going to the hospital and being transformed into a raving drug addict, or you hear yet another biased news story about opioids, do something about it.  You can help save lives by contacting the source of those fallacies and insisting that they tell the whole truth about the opioid crisis. Call them. Write a letter. Send an email.

We desperately need your voice, your prayers, your empathy and your compassion.

Katie Burge lives in south Mississippi, which she calls a “a veritable wasteland” for pain treatment. 

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

How Stem Cells Can Reverse Opioid Tolerance

By A. Rahman Ford, Columnist

On January 10, Pennsylvania Governor Tom Wolf declared a disaster emergency to fight the scourge of heroin and opioid abuse in his state, which has one of the highest overdose rates in the country.

“Pennsylvania’s opioid crisis impacts all areas of the state – including urban, suburban and rural communities and all ages including both young people and older Pennsylvanians – and is unprejudiced in its reach and devastation,” the declaration says. Virginia and other states have issued similar declarations.

Gov. Wolf’s effort comes months after President Trump declared the opioid crisis a national public health emergency and the president’s opioid commission released its final report, recommending more federal funding for addiction treatment, further restrictions on opioid prescribing, and the development of new non-opioid painkillers.

However, the commission’s report spent little time discussing an issue that is key to confronting the problems of opioid addiction and overdose – opioid tolerance.  “Tolerance” is defined as a decrease in effect following repeated or prolonged use of a drug, which can result in the need for higher and higher doses to achieve the same result.  For patients suffering from acute or chronic pain, this means that they need more pills to alleviate their pain. 

Tolerance can lead to a dangerous cascade of consequences. According to researchers at the National Institutes of Health, “the repeated administration of any opioid  almost inevitably results in the development of tolerance and physical dependence.” 

Although not all who become opioid tolerant become addicted, the World Health Organization asserts that people dependent on opioids are the group most likely to suffer an overdose. Given the seriousness of the problem, researchers have been looking for a way to prevent opioid tolerance and keep opioid users in a state of analgesia.  In that quest, some have found an answer in stem cells. 

In a recent study, Dr. Jianguo Cheng and scientists at the Cleveland Clinic and the Affiliated Hospital of Qingdao University in China hypothesized that mesenchymal stem cells (MSCs) could prevent or reverse opioid tolerance and opioid-induced hyperalgesia because of their profound anti-inflammatory properties. 

To prove their hypothesis, they induced opioid tolerance in laboratory mice and rats by injecting them with morphine for four weeks.  Astoundingly, after administering MSC therapy to the opioid-tolerant rodents, tolerance was reversed within as little as 2 days. The injections appeared to be completely safe.  All of the rodents showed normal movement, food and fluid intake, and body weight gain.  Their livers, kidneys and other major organs continued to function normally.

The authors concluded that MSCs have “enormous potential to profoundly impact clinical practice and improve opioid efficacy and safety.”  Their study builds on previous research that found MSC therapy “does not produce unwanted side effects and is well tolerated and safe.”  Rejection of the stem cells was not an issue because MSCs are immune-privileged.

America’s opioid problem is as destructive as ever.  If the states and the president’s commission truly seek novel, innovative and readily-implementable solutions to the opioid crisis, tolerance is a critical target and stem cell therapy may be a viable solution.  Patients in pain need solutions now.

A. Rahman Ford, PhD, is a lawyer and research professional. He is a graduate of Rutgers University and the Howard University School of Law, where he served as Editor-in-Chief of the Howard Law Journal. He earned his PhD at the University of Pennsylvania.

Rahman lives with chronic inflammation in his digestive tract and is unable to eat solid food. He has received stem cell treatment in China.  

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.