ACMT Toxicology Visual Pearls: Case of a Toxic Tea
The plant pictured is used as a tea, powder, or capsule by individuals looking to self-treat pain or opioid use disorder. Patients may develop nausea, vomiting, hallucinations, or other serious clinical effects after ingestion. What compound is contained in this plant?
- Arecoline from Areca catechu
- Kava lactone from Piper methysticum
- Mitragynine from Mitragyna speciosa
- Salvinorin from Salvia divinorum
Answer
3 – Mitragynine from Mitragyna speciosa also known as Kratom
What is Kratom? [1-6]
- Kratom is an herbal product that derives from the tree Mitragyna speciosa, native to Southeast Asia, where it has been historically used as a stimulant.
- Recently it has grown in popularity in western countries for its opioid activity, primarily used to self-treat opioid withdrawal and chronic pain.
- It is sold in several forms including leaves, powder, capsules, gum, and extract.
- The active compound, mitragynine, may cause nausea, vomiting, hallucinations, and opioid-like Deaths have been reported.
- There are currently no FDA-approved uses for kratom and its legal status is evolving, most recently classified by the DEA as a Drug and Chemical of Concern. The FDA continues to warn consumers not to use any products labeled as containing the botanical substance kratom or its psychoactive compounds, mitragynine, and 7-hydroxymitragynine.
What is the clinical presentation of kratom toxicity? [1,3,5,7]
- Kratom contains over 40 alkaloids, including mitragynine. Mitragynine is primarily a mu-opioid receptor agonist but also has activity at postsynaptic α-2, serotonin, dopamine, adenosine, and additional opioid receptors.
- Kratom’s neuropsychiatric effects occur rapidly after ingestion and may last 4-6 hours after the exposure.
- At lower ingestions (approximately 2-6 grams) kratom acts as a stimulant, while larger ingestions predominantly result in sedation and other opioid effects.
- The dose-dependent effects of kratom are thought to be due to the dual binding of α adrenergic receptors leading to stimulation and μ opioid receptors causing sedation.
- Gastrointestinal symptoms including nausea, vomiting, and constipation
- Cardiovascular symptoms such as tachycardia and hypertension
- Neurologic symptoms including seizures, hallucinations, agitation, psychosis, and coma
- Respiratory depression can occur
- Substance use disorder and withdrawal are reported with symptoms similar to other opioids.
How do you manage kratom toxicity? [1, 3]
- Minor symptoms generally require only supportive care
- Naloxone can reverse opioid effects
- Benzodiazepines can be used to treat patients with seizures, tachycardia, hypertension, and agitation.
- Withdrawal and substance use disorder may be managed similarly to other opioids.
Bedside pearls
- Kratom use is increasingly popular in the United States, often for self-treatment of chronic pain or opioid use disorder.
- Kratom acts on many different receptors, including the μ, κ, and δ opioid receptors, which contributes to potential withdrawal symptoms and substance use disorders
- Toxicity can lead to life-threatening symptoms such as respiratory depression, seizure, and coma
- Withdrawal presents similarly to opioid withdrawal and should be managed similarly
This post has been peer-reviewed on behalf of ACMT by William Eggleston, Bryan Judge, and Louise Kao
References
- Rech MA, Donahey E, Cappiello Dziedzic JM, Oh L, Greenhalgh E. New drugs of abuse. Pharmacotherapy. 2015;35(2):189-197. doi:10.1002/phar.1522 PMID: 25471045
- Stolt AC, Schröder H, Neurath H, et al. Behavioral and neurochemical characterization of kratom (Mitragyna speciosa) extract. Psychopharmacology (Berl). 2014;231(1):13-25. doi:10.1007/s00213-013-3201-y PMID: 23846544
- Fox LM. Plant- and Animal-Derived Dietary Supplements. In: Goldfrank’s Toxicologic Emergencies. Nelson LW Howland MA Lewin NA eds; 11th edition 2019; McGraw Hill,
- Boyer EW, Babu KM, Adkins JE, McCurdy CR, Halpern JH. Self-treatment of opioid withdrawal using kratom (Mitragynia speciosa korth). Addiction. 2008;103(6):1048-1050. doi:10.1111/j.1360-0443.2008.02209.x PMID: 18482427
- Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom Use and Toxicities in the United States. Pharmacotherapy. 2019;39(7):775-777. doi:10.1002/phar.2280 PMID: 31099038
- Department of Justice/Drug Enforcement Administration Drug Fact Sheet: Kratom. Available at: https://www.dea.gov/factsheets/kratom, accessed August 24, 2020
- Swogger MT, Walsh Z. Kratom use and mental health: A systematic review. Drug Alcohol Depend. 2018;183:134-140. doi:10.1016/j.drugalcdep.2017.10.012 PMID: 29248691