Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole, and joining me today to discuss the growing concerns around Kratom use and recent overdoses in Los Angeles and to offer valuable insights into the risks, health effects, and what patients should know about this substance, is fan favorite, Dr. Anirudh Rai. He's a primary care physician on the medical staff at Henry Mayo Newhall Hospital. Dr. Rai, thank you so much for joining us today. As we get into this topic, you and I were talking just a little bit off the air. It's not something I knew about, so I love to learn from you because you are such a great educator.

Can you start for people who may not be familiar as I was, what exactly is Kratom and why do some people use it?

Anirudh Rai, MD: Absolutely. It's always a pleasure to be on the show here and just let everyone know. Kratom itself is a pretty old plant that is native more to the South Asian side. And it's been known for quite some time. The best way to describe it is the same way we discovered morphine in a similar sense.

It's an alkaloid type of chemical. We discovered that plants make it, and we found out that ingesting it, whether in teas or as topicals, we could find their therapeutic effect. And thankfully, due to technology, we found out particularly recently, or I would, for a while actually, what chemicals are in Kratom and how they reach this effect.

Similar to how morphine is a opioid blocker, a partial blocker, Kratom is a similar sense of opioid in the sense that it blocks pain, gives what we call analgesia, meaning more pain relief. And we found out that the cultures in the Southeast Asian side have been using it in teas as medicinal qualities.

And then we and the western side took more of a scientific approach and found out the chemicals that were in it. And we could go more into that about the specific chemicals because they have some similarities to morphine, and that's why it's become more of a topic because people are getting overdosed on it.

Host: Okay, so explain a little bit about how it's used here scientifically and by you doctors, and then we'll get it into how people are suffering from overdose and how they're using it out on the street.

Anirudh Rai, MD: Absolutely. So the basic way to start off is to tell you a little bit about the chemical, a little bit about the plant. So in the Asian side, people tend to chew the plant, particularly the Kratom plant. And it's a particular species of these plant that have it. The plant itself produces a variable type of chemicals.

 One of the chemicals known as 7-mitragynine is a very known chemical. About 60% of the plant has this chemical readily there. But there's a process that occurs in the plant, I believe it's hydrolysis, and where a hydroxy group, an OH group gets attached to this chemical and becomes 7-hydroxymitragynine.

And that's where it becomes very potent because it has a very similar reaction to how morphine has to our system. It reacts to the opioid receptor, a partial agonist, what they call it, a reacts to it very mildly, but it has a very strong attachment to these receptors. And because of these receptors are activated, we get these reliefs of pain reliefs.

We get these euphoric sort of highs and we found out from further studies that about one to five grams, a very low dose of 7-hydroxymitragynine, we tend to have basically uh, euphoric notions. We tend to feel okay about it. No signs of overdose when it comes to these low amounts, but when it goes above five grams, we tend to have these opioid sort of effects, the same as morphine.

That's why this chemical is very potent. The interesting thing about it is usually the plant itself has about less than, I would say, less than 7% of the chemical the plant produces is 7-hydroxymitragynine. Majority of it is about the 7-mitragynine, which is not as potent. In fact, people could chew on it and not have this effects essentially of morphine where they feel the pain is gone, extremely euphoric.

So it has a relaxing effect on it, but you need to chew a, a large quantity of this plant to have that effect when it comes to overdosing. So that's why we in the West have found ways to honestly synthesize it. Same way that morphine got it initiation. We have in a similar extent, there's some mirroring when we're starting to see the chemicals and we found a way to synthesize it and make this more potent chemical, more pronounced, and that's where it becomes more of an issue.

Host: So people here, and what we're talking about today are not chewing the plant itself. They're using a more of a synthesized version, brought down so that we're getting just to the chemicals and not dealing with the plant itself. Right?

Anirudh Rai, MD: In a sense. To give you a little bit of the history around, I believe in 2011, is when we actually found out about the properties of this plant and the FDA was actually known about it. But the American Kratom Association actually went against it saying, Hey, this is a safe plant. People are using it for years.

And so far because of that, the FDA, put out his warning saying, it's not going to be controlled by us. It's no longer considered a controlled substance. Because of that, people have been able to get some way to either overseas or even here, honestly, get some form of the plant here. The synthetic component, typically we're not allowed to make synthetic components of that plant here because of this implication. The FDA currently has not classified this as a controlled substance but by its nature, it is, I would say, 10 to 20 times more potent than even morphine. So this is something very potent, but it's hard to say.

I, I don't know if it's politics, but the fact that we don't know much about it. But this plant has been known for many centuries. And since we synthesized it and known about the chemical, people have been actually using it without knowing too much about its potency. They think it helps them, they feel great on it, they feel euphoric on it, and they take more and more of it.

But the interesting thing about these overdoses is they sometimes mix it with the chemicals we prescribe, like pain medicines we prescribe and, they don't tell the doctor they're taking Kratom as well and they have inadvertently overdose on essentially pain meds because the Kratom behaves in that similar manner.

Sometimes even alcohol itself could propagate that effect. So the overdose is in a sense accidental, but at the same time it's something that could have been prevented or it can be prevented if you just tell your doctor, Hey, I'm taking Kratom as well. And sometimes they can educate you more about what to watch out for.

Host: So we've seen those reports about overdoses in Los Angeles, Dr. Rai, how are people getting Kratom? Is it available on the street? Is it a street sold drug? How are they even getting this?

Anirudh Rai, MD: That's a really good question. More often than not, we aren't really allowed to sell Kratom here in California, per se, even though if the FDA has not classified as a controlled substance, I personally believe, I'm not too sure entirely, but I do believe it is sold in the street where people get it somehow from dealers who get it, their sources from overseas and they get it and they chew on it. Sometimes even it's people who are overseas that they get this from. So it is something that, it is hard to say where they get it from, but it's not in a illegal sense. I would say best way to describe it.

Host: Yeah, that's pretty much what I was asking. Is it, has it gotten illegally? So can it cause dependence? And then if they're not using it, withdrawal, speak a little bit about how, you've mentioned morphine a few times, and we know how addictive that can be. So speak about the addictive capabilities of Kratom.

Anirudh Rai, MD: Absolutely. So Kratom itself is similar to morphine in the sense it acts on the same receptor. The interesting thing about, it's actually, it's, I'll say 13 times more potent than morphine. So if you were going to take a little bit of it, if the same grams of morphine versus the Kratom, especially with the 7-Hydroxymitragynine, it's about 13 times more potent.

So this is a very potent chemical nonetheless, and it works in a similar sense. That the opioid causes pain relief, and at the same time, your body will crave it more and start depending on it more. And it's the same behavior we see with patients who are on these opioids. They have these medications, they take them, they get a dependence on them, and they have similar withdrawal symptoms as morphine, the sweating, the feeling, nervous, the palpitations, the dry mouth.

All these symptoms are essentially opioid withdrawals. And there have been cases where people have been having these symptoms. In fact, back in the day, actually even centuries ago, people would use these for these kind of symptoms when they have withdrawals from pain meds and it actually can help with that.

But nonetheless, it is a chemical that's extremely potent and if taken without the knowledge of the doctor, it could actually cause these overdoses. And even taken with other chemicals, it can cause these overdoses. Withdrawal is very common with Kratom, especially in the higher doses. And it's something that typically doctors should be aware of when the symptoms arise, they can't see these symptoms visually and actually ask the patient more information about it.

Host: So are there any FDA warnings? Have they thrown up their hands, are they out of this completely? Is there anything patients should know?

Anirudh Rai, MD: So after that whole back and forth between the Kratom Association of America and the FDA, typically the FDA says that, okay, they will not classify this as a controlled substance, but they do classify it as an opioid, meaning it is similar to morphine. So they do have that warning on it.

But it, it's hard to say politics and medicine is not a good mix. And this is a clear example of that. I'll be honest.

Host: Yeah, you're right about that. Now if somebody's currently using it, you mentioned they should let their doctor know that they are, because there could be interactions with other medications and or alcohol. What should they look for Dr. Rai that might indicate that it's harming their health or that it's a problem or that it's not doing what they are hoping it will do?

Anirudh Rai, MD: I did have a couple of patients on Kratom and actually a family member as well more often than not, at least in these scenarios, the family member lets the doctor know and saying, Hey, the patient's been using this and behaving in a certain way, as in they're craving more, they're more antsy.

 They're not behaving their normal self. Usually it's more of an observation we see from family members and even from us as physicians. When we see these certain symptoms, we ask, Hey, are you on any medications that could do it? And then more often than not, we're not asking it as much, but we should be asking, are you on any sort of supplements?

And sometimes they would mention Kratom because patients do think of it as more of a supplement rather than an actual medication that's this potent. It's hard to say just because the knowledge of this patients don't know too much about when someone who's selling it to them saying, Hey, this will help in X, Y, and Z sort of symptoms.

So this hearsay back and forth between patients and whoever's selling them or giving them this information is a bit hard to even track. I'll be honest. But it's always important to let your doctor know if you're taking Kratom and you think it's a supplement, let them know. Doctors should be aware that you're taking it just because, as you mentioned, there's interactions with other medications and there's a high risk of dependence, particularly in the higher doses.

Host: Then what if someone does recognize or recognized by a loved one, and you and I have spoken about addiction before, if they are struggling with Kratom use dependence, what should they do? Are we going to go through addiction psychiatry, in that case of what happens?

Anirudh Rai, MD: Yes, so, addiction psychiatry is a good place to start. Going to an addiction center is a great place to start. There are medications we can prescribe, naltrexone or Naloxone, which is very common medication to battle some of the overdose effects of morphine have been used. Can be used in this regard for Kratom as well.

So there are things that we as physicians can prescribe to decrease the chance of death. But ultimately it's going to be up to the patient, up to the family to get them to a center where they could get the proper care, where the withdrawals can be monitored and once they get off of it, to have that sort of back and forth with the center to make sure that they avoid it if they can.

Host: So Narcan works on Kratom?

Anirudh Rai, MD: Yes, so the reason for that is because how it works for morphine on what they call the mu receptors, which is the opioid receptors. It works similar to Kratom as well, and Naltrexone itself works in that receptor. So it does help essentially take the overdose effects of Kratom and reduce them and even mitigate them completely.

Host: Dr. Rai, you're so educational. You just teach us so much every time. I have two final questions here for you. I'm putting them together. I'd like you to summarize what you really want us to know about Kratom and its uses, and do you see in the future if you were to look in your crystal ball, a use for it within the medical community, since it's been around for centuries, sometimes these ebb and flow, right?

We learn about certain things and supplements and things like folic acid that come in and, all of a sudden really they are something very important. Do you see a use in the opioid or pain management world for Kratom? And if so, what would that be?

Anirudh Rai, MD: Yeah, sure. So Kratom in summary is an herb that we've known for quite some time. We've known historically for centuries, people have been using it, they've been chewing on the leaves, have been finding this effect. Thanks to technology, we found out the actual chemicals that are causing it and we know the potency of these nowadays.

Kratom itself is quite dangerous, I would say. If anyone is taking this herb or the supplement, let your physician know so that they're aware of it. The risk of overuse and abuse is quite high, especially with Kratom. So it is something that we as physicians should be aware of and as patients, definitely let your doctor know because they can help you, guide you through that process.

Kratom has a similar history to how morphine got its sort of origin. So I do believe in the future, once we get more of a handle on this chemical, we may come out with a new type of medication similar to morphine, where we could actually give to patients more safely and have more control over it.

Thankfully, with the FDA if something goes under the FDA, they have guidelines specific for how much of a certain medications that there meaning they have rules and regulations to say you will get this amount of drug per pill. Right now Kratom doesn't have that. So even any Kratom that you would get, we can't guarantee you how much you're going to get, and that does increase the risk of overdose. I do believe that FDA will eventually get on top of it. They'll get a better regulatory sort of mechanism around it and eventually we'll get another medication to supplement or to even compliment morphine so that we get better pain relief for our patients.

Host: Thank you so much, Dr. Rai, for joining us today and once again sharing your incredible expertise. And to book an appointment with Dr. Rai, please visit our website at HenryMayoprimarycare.com. Thanks so much for joining us on this edition of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole.