Written by: Dean Hayes (NUEM ‘27) Edited by: Andrew Long (NUEM ‘25)
Expert Commentary by: Rafael Lima, MD
A mid 20s male presents to the ED after seizure-like activity. Per the patient's partner at bedside, he had a 2-3 minute convulsive episode and the description is consistent with a likely seizure. The patient has never had a seizure before and is A&Ox4 upon arrival to the ED with reassuring examination. Social history is notable for Kratom use. The patient reports smoking 6 grams (much more than he typically uses) of Kratom that evening along with daily use, last smoking Kratom 1-2 hours prior to his seizure-like episode. He denies any other substance or alcohol use. After initial evaluation you leave the room wondering, “What is Kratom?” and “Can Kratom cause seizures?”
Kratom is produced and sold as an herbal supplement in the United States. It is derived from Mitragyna speciosa, a tree native to several countries in southeast asia. While it has been used for hundreds of years in parts of southeast asia, Kratom has recently gained significant popularity in the United States and other western countries. As the production and sale of Kratom in the US is unregulated, the exact number of people using it is unclear. However, recent studies estimate there are 10-16 million active Kratom users. Currently, Kratom is illegal in 6 states and the FDA warns against consumer use of Kratom.
The primary active components in Kratom are mitragynine and 7-hydroxymitragynine, although there are dozens of other active alkaloids. Mitragynine is a mu- and delta-opioid agonist, while 7-hydroxymitragynine has activity at the mu- and kappa-receptors. Interestingly, many people in southeast asia report using Kratom as an at-home remedy for opioid addiction, reporting a decrease in cravings for opioids while using Kratom. In addition, Kratom has been found to have GABAergic, alpha-adrenergic, serotonergic and dopaminergic activity while also modulating the cytochrome p450 pathway. Therefore, Kratom induces a number of clinically significant effects and has the ability to cause significant drug-drug interactions although no major studies are available in this area.
At low levels, users report increased alertness and energy similar to caffeine use. At higher doses Kratom can exert analgesic, depressive, and anxiolytic properties. Unfortunately, data surrounding Kratom toxicity is relatively limited and therefore there is wide variance in estimates of adverse events from kratom use. Currently, available literature describes agitation, tachycardia, drowsiness, vomiting, confusion, and seizure as adverse effects of Kratom toxicity. Additionally, there are some case reports attributing coma and death to Kratom.
As health care providers, it is important to understand why patients are electing to use Kratom in order to most effectively treat them. Common reasons people report using Kratom include, increased energy, improvement in mood, reduction in anxiety, chronic pain, reduced opioid cravings/withdrawal symptoms. Notably, a minority of people actively using Kratom report their motivation is to achieve a high or euphoric state. A smaller minority have reported Kratom as an at home remedy for alcohol abuse. Given the wide range of patient motivations for Kratom use, it is important to spend time during the patient's history uncovering why the individual is motivated to use Kratom, as this can guide what further resources the patient may need. One online survey with over 8000 respondents found that 68% and 66% of Kratom users reported doing so for chronic pain or an emotional/mental condition, respectively.
Given the lack of regulation, differing preparations/concentrations, multiple active alkaloids and high likelihood for drug interactions, Kratom has the potential for significant negative health impacts on patients. In the case of the patient discussed above, his first time seizure workup in the ED was unremarkable. Poison control was consulted for additional workup due to concern for Kratom toxicity. Although no confirmatory testing is available, poison control believed there was a reasonable likelihood Kratom toxicity contributed to the patient’s likely seizure. The patient was ultimately discharged from the Emergency Department with primary care and neurology referrals along with seizure precautions and advised to abstain from Kratom use.
Treating Kratom toxicity varies based upon the clinical presentation as well as severity of symptoms. Over 1100 cases of Kratom only exposure were reported to the National Poison Control Center from 2011-2017. Just over half of these cases required medical intervention. Stimulant-like toxidromes presenting with symptoms such as tachycardia, agitation, and hypertension should be treated with CNS depressants, most commonly benzodiazepines. In contrast, patients presenting with opioid-like toxidromes should be treated with naloxone along with supportive measures.
Key Take Home Points:
Kratom can caused a mixed toxidrome, presenting in some cases like a stimulant or opioid intoxication in other cases
Patients should be advised that the quality/concentration/preparation of Kratom is unregulated and therefore unpredictable
Uncovering the reason why a patient is using Kratom is vital. It may likely reveal a symptom/problem such as mood disorders or opioid dependence that could be further intervened upon
Further study is needed to understand the safety and pharmacokinetics of Kratom in humans.
Further regulations and/or legislation regarding Kratom is possible in the coming years
Expert Commentary
As Dr. Hayes summarized above, kratom use is growing in the United States and the likelihood of a patient presenting to your local emergency department with intoxication or withdrawal is ever increasing. Recognition of kratom intoxication can be challenging because of a differing presentation depending on the dose consumed - in some cases acute ingestion can present with stimulant-like symptoms of agitation, seizures, and tachycardia, but in other cases, respiratory depression and encephalopathy can present similarly to an opioid toxidrome. As with any unregulated substances, there can be numerous adulterants at unknown quantities that can produce other dangerous symptoms.
The current state of legislation around kratom in the United States is that it cannot be lawfully marketed as a drug, dietary supplement, or added to foods. Despite this, the sale of kratom is not outlawed in many states.
References
1. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. (2019). Kratom use and toxicities in the United States. Pharmacotherapy, 39(7), 775-777
2. Grundmann O. Patterns of Kratom use and health impact in the US-Results from an online survey. Drug Alcohol Depend. 2017 Jul 1;176:63-70. doi: 10.1016/j.drugalcdep.2017.03.007. Epub 2017 May 10. PMID: 28521200
3. Henningfield JE, Chawarski MC, Garcia-Romeu A, Grundmann O, Harun N, Hassan Z, Huestis MA. (2023). Kratom withdrawal: Discussions and conclusions of a scientific expert forum. Drug and alcohol dependence reports
4. Hofmeister M. (2022). Kratom consumption can be addictive and have adverse health effects. Novelty in Clinical Medicine. 1(4): 168-172
5. Kerrigan S, Basilier S. (2022). Kratom: A systematic review of toxicological issues. WIREs Forensic Science, 4, e1420
6. Swogger MT, Smith KE, Garcia-Romeu A, Grundmann O, Veltri CA, Henningfield JE, Busch LY. Understanding Kratom Use: A Guide for Healthcare Providers. Front Pharmacol. 2022 Mar 2;13:801855. doi: 10.3389/fphar.2022.801855. PMID: 35308216; PMCID: PMC8924421.
7. Veltri, C., & Grundmann, O. (2019). Current perspectives on the impact of Kratom use. Substance abuse and rehabilitation, 23-31.
Rafael Lima, MD
Medical Toxicology Fellow
Indiana University Health
How To Cite This Post:
[Peer-Reviewed, Web Publication] Hayes D. Long, A. (2025, 2/4/2025). Complications of Kratom Use. [NUEM Blog. Expert Commentary by Lima, R]. Retrieved from http://www.nuemblog.com/blog/complications-of-kratom-use
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