Nov. 01 2016

Kratom: Health Risk or Harm Reduction?

Silvia Martins looks at how the increasingly popular substance might be regulated in light of potential benefits and risks

On October 13, the Drug Enforcement Agency did something uncharacteristic of the 43-year-old bureaucracy: it changed its mind. Six weeks earlier, the Agency ruled that kratom, an organic substance with opioid-like properties, would be listed as a Schedule I drug, deeming it “an imminent hazard to the public safety,” the like of heroin and cocaine. But after an outcry from kratom users, many who take it to treat pain and addiction, the DEA announced it would postpone its decision until December.

Silvia Martins, an associate professor of Epidemiology at the Mailman School who studies the health risks of drug use, applauds the turnaround. “More research is needed to better understand both the beneficial effects and risks associated with kratom use,” she says.

The DEA classifies upwards of 150 drugs as Schedule I, indicating great potential for abuse and no accepted or safe medical use. In their reversal on kratom, the Agency acknowledged the protests of community of users and called for a scientific assessment from the Food and Drug Administration. But so far, says Martins, there is almost zero science on the substance, and it seems unlikely that any studies could be complete in time for the DEA’s December deadline.

If the DEA decides to put kratom in its highest-risk category, any research into its health benefits would be difficult since research into Schedule I substances are strictly regulated. Such is the case of marijuana, which the DEA decided over the summer to keep listed as a Schedule I drug. There are pros and cons to declassification, says Martins. “On the one hand, it would be easier for researchers to better study its potential medical properties. On the other hand, it might be widely available for recreational use and be misused by those who do not need it for a medical purpose.”

Going to Pot

On November 8, residents of Arizona, California, Maine, Massachusetts, and Nevada will decide whether or not to legalize recreational marijuana; Arkansas, Florida, Montana and North Dakota will vote on medical marijuana. An anti-marijuana television ad by the Campaign for a Safe and Healthy Massachusetts references “drugged driving” research by Guohua Li, professor of Epidemiology. His 2013 study of fatal car crashes showed a marked increase in fatally injured drivers testing positive for marijuana during a period when states started legalizing the drug, although Li cautions that drug use does not necessarily imply impairment.

In the period between 2001 and 2013, when marijuana laws have became more permissive, rates of marijuana dependence more than doubled, according to research by Deborah Hasin, professor of Epidemiology (in Psychiatry). Of particular concern is regular use by adolescents, which is known to increase risk for dropping out of school. However a recent study by Martins found states with medical marijuana laws have not seen an uptick in use by teens.

Another consideration when thinking about the legality of any drug, according to Martins, is the potential criminal justice implications. Legalizing or reclassifying marijuana could reduce the number of possession-related arrests that disproportionally affect communities of color. Between 2001 and 2010, there were more than 8 million pot arrests in the U.S. Compared to whites, African-Americans were nearly four times as likely to be arrested for possession, despite using the drug at roughly the same rate.

Harm Reduction

Kratom has been used for centuries in Southeast Asia where the tree from which the substance is derived is native. In recent years, it has become popular in the U.S. where it can be purchased online. Many users say the substance helps them manage chronic pain and provides a safer alternative to prescription pain medication. Research by Guohua Li presents evidence that medical marijuana could help curb opioid use, suggesting the same could hold true for kratom.

In the context of the heroin epidemic, safer alternatives to prescription pain medications are more important than ever, says Martins. After the federal government tightened regulations around pain medications, oxycodone and similar drugs have been more difficult to obtain, an unintended consequence of which was to drive some of its users to switch to heroin. Making kratom illegal could have a similar effect on its users, she cautions. “I am concerned that outright banning it is not the way to go and could push them to use more dangerous drugs,” she says.

While many kratom users say they rely on its medicinal properties, others may take it recreationally. There is the possibility that some may form a habit, and even graduate on to more powerful opioids. According to Martins, a balanced approach is needed; the DEA could chose to classify the substance as a Schedule II or III drug. Or they might decide it should be regulated like alcohol, a substance with its own risks and benefits. Says Martins, “There is room for middle ground.”