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Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

ORIGINAL ARTICLE

Socio-demographic Characteristics, Kratom Use and Quality of Life (QoL) of Regular Kratom ( speciosa Korth.) Users Mohammad Farris Iman Leong Bin Abdullah1, Darshan Singh2, Suresh Narayanan3, Azlan Abdul Rahim2, Balasingam Vicknasingam2

1 Lifestyle Science Cluster, Advanced Medical and Dental Institute, Universiti Sains , SAINS@BERTAM, 13200 Kepala Batas, Penang. Malaysia. 2 Centre for Research, Universiti Sains Malaysia. 11800 Minden, Penang. Malaysia. 3 School of Social Sciences, Universiti Sains Malaysia. 11800 Minden, Penang.

ABSTRACT

Introduction: Kratom which is a tropical use as traditional remedy in rural areas of Malaysia and has recently been a research focus worldwide due to its potential as substitution therapy for . However, data on its effect on the quality of life of kratom users is scarce. This study aimed to describe the socio-demographic and history of kratom use as well as assessing the quality of life and its associated factors in Malaysian kratom users. Methods: This cross-sectional survey recruited 150 kratom users and they were administered with socio-demograph- ic and substance history questionnaires, the World Health Organization Quality of Life- BREF (WHOQOL-BREF) to assess quality of life and the Kratom Dependence Scale (KDS) to assess severity of kratom dependence. Results: Respondents were all males with mean age of 34.4 years old (SD= 11.2). Sixty-percent of respondents use kratom > 6 years (mean duration = 8.5 years, SD= 5.3) while 55% (n=83/150) used >3 glasses of kratom daily. Duration of kratom use, quantity of kratom use and severity of kratom dependence were not associated with all the domains of quality of life except severe kratom dependence users had significant lower physical quality of life score when compared to that of users with mild to moderately severe kratom dependence. Conclusion: Based on our study, kra- tom consumption does not cause impairment in quality of life of kratom users except for severe kratom dependence which may cause deterioration in physical well-being of users.

Keywords: Quality of life, Duration of kratom use, Quantity of kratom use, Severity of kratom dependence, Malay- sian kratom users

Corresponding Author: for treatment of opioid addiction due to its opioid-like Mohammad Farris Iman Leong Bin Abdullah, Dr Psych properties and its ability to reduce and suppress opioid Email: [email protected] withdrawal symptoms, and as treatment of chronic . Tel: +604-5622482 However kratom has fewer life-threatening side effects (even at high dose, kratom does not cause respiratory INTRODUCTION ) and resulting in milder withdrawal despite regular use (5-7). Mitragyna speciosa Korth (M.speciosa) is a naturally occurring tropical plant found mainly in Southeast Although kratom may be associated with several Asia which belongs to a plant family of . It is beneficial effects, it was reported to exhibit concerning known as Ketum in Malaysia and Kratom in Thailand, addictive properties include withdrawal symptoms in which its use both as and as an upon abstinence from kratom use (such as frequent energy source are quite widespread (1-3). There are yawning, muscle pain, running nose, lacrimation, several benefits of kratom which has been highlighted , depression, irritability, insomnia, restlessness in previous literatures such as kratom has long been and aggression), craving, tolerance and cross-tolerance used as traditional remedies for treatment of coughing, to (8, 9). Long-term kratom users have also diarrhea, intestinal infection, muscle pain and to reported difficulty to give up kratom use and kratom enhance tolerance working under the scorching sun users have described kratom withdrawal symptoms as for those who work as farmers, fisherman and machine distracting and annoying (9). In addition, other side operators (1, 3, 4). Recently, researchers began to pay effects which have been reported by long-term kratom more attention to the clinical implications of kratom users are , fatigue, headache, dehydration, in which there are several literatures reported the weight loss and hyperpigmentation over the cheek (9, potential of kratom to be used as substitution therapy 10).

Mal J Med Health Sci 15(3): 4-9, Oct 2019 4 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

Since, kratom produces both beneficial effects and Malaysia to screen for morphine, , side effects, it would be vital to assess how kratom , , , , consumption affects the quality of life of chronic kratom and . Questionnaires administration users. Quality of life is the perception of one’s position and interview of respondents by the research team’s in life in the context of the culture and values of the psychiatrist and psychologist were carried out in the community one lives in and in relation to standard, community halls of the targeted locations. Those who goals, concern and expectations (11). Quality of life is found to have severe kratom dependence were referred an outcome measure and by assessing quality of life, to the nearest psychiatric service for further treatment we will be able to gauge how much is the impact of the and follow up. effect of kratom consumption on the users, particularly in those who use kratom on regular basis and prolonged Measures duration. Assessment of quality of life involved The respondents were administered with a semi- evaluation in many aspects of living such as physical structured questionnaire which collects information health, psychological well-being, social relationship and on socio-demographic characteristics (such as age, the relationship with salient features of their surrounding marital status, employment, education level, and environment (12). Hence, this study utilized the World accommodation status) and substance history (history Health Organization Quality of Life-BREF (WHOQOL- of drug use, duration, quantity and frequency of kratom BREF) to assess quality of life of kratom users as this use). Respondents were also administered the Kratom instrument covers all four aspects of living. To date, Dependence Scale (KDS) to assess severity of kratom there is no study conducted to assess the quality of life dependence and the WHOQOL-BREF to assess quality of kratom users. Hence, this study aimed to describe of life. the socio-demographic and history of kratom use, and determine the quality of life and its associated factors Kratom Dependence Scale (KDS) among Malaysian kratom users. KDS is a self-administered questionnaire which was developed based on DSM and ICD diagnostic criteria MATERIALS AND METHODS to measure the severity of kratom dependence in regular kratom users. It consists of 16 items which are grouped Study design and respondents into a single domain. It is scored in a Likert scale ranged This study received approval from the Human Ethics from 0-3 (0 = never to 3 = almost always/always). Committee of Universiti Sains Malaysia (code: USM/ The total score ranged from 0-48 with score of 0-13 JEPeM/16050174). This cross-sectional survey recruited designates mild severity, 14-34 designates moderate 150 regular kratom users for a duration of 1 year by severity and 35-48 designates severe dependence. It has snowball and purposive sampling. This study was excellent internal consistency (Cronbach’s α) of 0.97 conducted in three locations in the Malaysian state (2). The Malay version of the KDS also demonstrated of Penang which has high prevalence of kratom use. excellent internal consistency (Cronbach’s α) of 0.94 Initially, key informants who were ex-drug users and and exhibit a best fit one factor-model (13). kratom users were identified and recruited in three targeted locations and explained about the objectives World Health Organization Quality of Life- BREF of the study prior to data collection. Then, they were (WHOQOL-BREF) asked to refer potential kratom users for the study. WHOQOL-BREF is a self-administered questionnaire Kratom users who fulfilled all inclusion criteria and and was used in this study to assess the quality of life of without any exclusion criteria were enrolled in the the kratom users. It comprised of 26 items in which items study if they voluntarily agreed to participate and signed 1 and 2 are general questions on quality of life while the written informed consent. The inclusion criteria for the rest of the items are grouped into 4 domains. Each item study includes: (a) 18 years and above, (b) self-reported is scored in a Likert scale ranged from 1-5. WHOQOL- as a regular kratom user (used kratom ≥2 times daily), BREF has good psychometric properties and found to be (c) must have more than 1 year kratom use history, and a valid and reliable alternative to WHOQOL-100 for (d) able to read and write in the Malay language. We measuring quality of life (14). The WHOQOL-BREF was excluded respondents who: (a) tested positive for other also used in studies determining quality of life in opioid drug use besides kratom, (b) had past and/or present users (11, 15). The Malay version of the WHOQOL-BREF history of psychiatric and medical diseases (users were also demonstrated excellent psychometric properties screened with Diagnostic and Statistical Manual for with internal consistency (Cronbach’s α) of 0.89 (16). Mental Disorders 5th Edition (DSM V) criteria to exclude those with past and/or present history of psychiatric content diseases), and (c) history of and illicit drug use We measured the mitragynine content of kratom juice other than kratom within the past 1 year. In fact none which we purchased from each targeted locations where of the respondent had past history of alcohol intake. the subjects were recruited using gas chromatography- Urine drug screening was performed using rapid urine- mass spectrometry (GC-MS). Mitragynine is the most test-kits acquired from Reszon Diagnostic International, abundant psychoactive constituent in kratom

5 Mal J Med Health Sci 15(3): 4-9, Oct 2019 . We found that the mitragynine content in each Table I: Socio-demographic characteristics and history of kratom use glass of kratom from the three targeted locations of of respondents subject recruitment had no significant difference. The Number of respondents (N) % range of mitragynine level in one glass of kratom juice Gender was 24.06 to 28.93mg. Male 150 100 Ethnicity Data analysis Malay 148 99 All data were analysed with Statistical Package for Non-Malay 2 1 Social Sciences (SPSS) version 23. First, descriptive Mean age 34.4 years (SD=11.2) statistics were computed to describe the samples socio- Mean age of first kratom use 25.8 years (SD=10.7) demographic characteristics and history of drug use. Then, the WHOQOL-BREF scores between short term (≤ Age 6 years) and long term users (> 6 years), users with mild 18-32 years 77 51 to moderate kratom dependence (KDS score < 35) and ≥33 years 73 49 severe kratom dependence (KDS score ≥ 35), and users Education who consumed ≤ 3 glasses of kratom daily and those Primary 14 9 who consumed > 3 glasses daily were compared with Secondary 136 91 independent t-test. All the statistical significance was set Employment at level (p<0.05). Employed 138 92 Unemployed 12 8 RESULTS Monthly income ≤RM1,000 49 33 Socio-demographic characteristics and history of kratom use >RM1,000 101 67 The samples demographic characteristics and substance Kratom use history history are shown in Table I. The proportion of young Mean duration of kratom use 8.5 years (SD=5.3) adults (18-32 years old) was almost equal to the Mean quantity of daily kratom use 4.1 glasses (SD=2.5) proportion of older adults (33 years old and older) Duration of kratom use which were 51% and 49% respectively. Mean age of the ≤6 years 60 40 respondents were in the adult age group (mean age: 34.4 >6 years 90 60 years,SD= 11.2). All the respondents were males while Daily quantity of kratom use almost all the respondents were Malays (99%). Most of ≤3 glasses 67 45 the respondents had some amount of education as 91% >3 glasses 83 55 had up to secondary education and majority of them were employed (92%). Almost seven tenth (67%) earned Daily frequency of kratom use more than Ringgit Malaysia 1000 per month. Those who ≤4 times 104 69 used kratom for more than 6 years comprised of 60% of ≥5 times 46 31 total respondents with mean duration of kratom use of SD= standard deviation 8.5 years. All respondents used kratom daily with more of life in kratom users were summarized in Tables than half of respondents (55%) consumed more than 3 II, III and IV. Regarding the quality of life of users in glasses daily (mean daily kratom consumption was 4.1 relation to duration of kratom use, there were no glasses). However, seven tenth of the respondents (69%) significant differences in the scores of all domains of the consumed kratom at not more than 4 times a day while WHOQOL- BREF (physical health, psychological, social the rest of the respondents (31%) consumed kratom at relationships and environment domains) between those five times a day or more. who used kratom for not more than 6 years and users who used kratom more than 6 years. The association of duration of kratom use, kratom dependence and quantity of kratom use with quality of On the contrary, when we looked into the quality of life life of kratom users of users in relation to kratom dependence, those with The associations of the above variables with quality mild to moderate kratom dependence had significantly Table II. QOL and duration of kratom use QOL domains ≤ 6 years (N=60) Transformed score > 6 years (N=90) Transformed score t-test P- Mean raw score ± Mean raw score ± value 4-20 0-100 4-20 0-100 (SD) (SD) Physical health 26.33 (4.32) 15 69 25.52 (5.20) 15 63 0.867 0.320 Psychological 22.52 (3.47) 13 69 21.83 (4.54) 15 69 0.817 0.324 Social relationship 11.28 (2.58) 15 69 11.49 (2.85) 15 69 0.561 0.654 Environment 28.97 (4.07) 15 69 28.37 (5.98) 14 63 0.617 0.498 QOL= Quality of Life, SD= standard deviation

Mal J Med Health Sci 15(3): 4-9, Oct 2019 6 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)

Table III. QOL and Kratom Dependence Scale score QOL domains KDS <35# Transformed score KDS >35# Transformed score t-test P-value (N=107) (N=43) 4-20 0-100 4-20 0-100 Mean raw Mean raw score score ± ± (SD) (SD) Physical health 26.42 (4.70) 15 69 24.42 (5.05) 14 63 -2.387 0.022* Psychological 22.47 (4.00) 15 69 21.21 (4.41) 14 63 -1.453 0.093 Social relationship 11.65 (2.63) 16 75 10.79 (2.93) 15 69 -1.532 0.081 Environment 29.04 (5.19) 15 69 27.53 (5.46) 14 63 -1.087 0.116 QOL= Quality of Life, SD= standard deviation, *significant at p < 0.05, # KDS score < 35= mild and moderately severe kratom dependence, KDS score ≥ 35= severe kratom dependence

Table IV. QOL and daily quantity of kratom use QOL domains ≤ 3 Glass- Transformed score > 3 Glasses Transformed score t-test P-value es (N=67) (N=83) 4-20 0-100 4-20 0-100 Mean raw Mean raw score ± score ± (SD) (SD) Physical health 25.97 (4.95) 15 69 25.75 (4.84) 15 69 -0.342 0.781 Psychological 22.48 (4.03) 15 69 21.81 (4.24) 15 69 -0.802 0.326 Social relationship 11.49 (2.85) 15 69 11.34 (2.67) 15 69 -0.382 0.731 Environment 28.76 (5.13) 15 69 28.48 (5.45) 14 63 -0.350 0.749 QOL= Quality of Life, SD= standard deviation higher score in physical health domain of the employed, completed their secondary education and WHOQOL-BREF when compared to those with severe had regular monthly income. This was similar to the kratom dependence (Mean physical health score [mild socio-demographic status reported in the neighbouring to moderate KDS score] = 26.42 (±4.70), mean physical country of Thailand pointing towards the evidence that health score [severe KDS score] = 24.42 (±5.05), p the functioning of kratom users were not impaired and = 0.022). However, there were no difference in the they can cope well in their daily living in the community scores of three other domains of the WHOQOL- BREF (4, 5, 18). Our study also reported kratom users need to (psychological, social relationships and environment consume kratom on daily basis with mean consumption domains) between those with mild to moderate kratom of 4 glasses per day, chronic and prolonged consumption dependence and severe kratom dependence. were also demonstrated (mean duration of kratom use was 8.5 years). This finding supported the notion that Again, when assessing the quality of life of users in regular and long term use of kratom leads to kratom relation to quantity of daily kratom use, there were no addiction and difficulty to abstain from kratom use as significant differences in the scores of all domains of the a result of uncomfortable withdrawal experienced by WHOQOL-BREF between those who consumed kratom kratom users (4, 7, 10). not more than 3 glasses daily and those with consumed more than 3 glasses daily. When we compared the domains of quality of life of kratom users in our study to a study involving 112 DISCUSSION opioid-dependent users who had undergone nucleus accumbens ablative neurosurgery and 150 opioid- This study aimed to describe the socio-demographic dependent users who had undergone detoxification characteristics and history of kratom use, and evaluate (19), the scores of all four domains of quality of life were the association between duration of kratom use, quantity higher than that of the scores in opioid users (transformed of kratom use, kratom dependence and quality of life score (0-100): 63-75 [kratom users] compared to 34- among Malaysian kratom users. None of the female 62 [opioid users]) (Tables II to IV). Similarly, when users came forward to participate in this study although we compared the scores of all the domains of quality we did not exclude female users from the study. This of life of kratom users in our study with that of a study can be explained by the non-acceptability of female involving 47 Indian -dependent users (20), the kratom users in the society in Southeast Asian countries scores of all the domains of quality of life of kratom like Malaysia and Thailand, unlike male users who are users were higher than that of the heroin-dependent less stigmatized by the society. Hence, although females users. In addition, when the scores of all the domains in Malaysia do use kratom for treatment of mild medical of quality of life in this study is compared with a study illnesses like pain, fever and diarrhea, they usually do involving 60 illicit drug users with history of polydrug not revealed their kratom using behaviour due to fear of use (alcohol, , cannabis, inhalant, being stigmatized by the community (4, 17). Our study and ) (21), the scores of kratom users in this also reported that the age group which used kratom was study were also higher than the scores of polydrug adult age group and majority of the kratom users were users (transformed score (0-100): 63-75 [kratom users]

7 Mal J Med Health Sci 15(3): 4-9, Oct 2019 compared to 47-56 [polydrug users]) (Tables II to IV). association were statistically insignificant. These findings were not surprising as beneficial effects of kratom has been reported in a few literatures which CONCLUSION includes increasing focus, decreasing pain, increasing energy, elevation of mood, reducing posttraumatic This cross sectional study was the first study to assess stress disorder symptoms, produce and quality of life and its associated factors in kratom users. anxiolytic effects, allow reduction and cessation of Our findings indicated that quality of life was not opioid use, and treating opioid addiction (22, significantly affected by regular and prolonged kratom 23). Hence, these beneficial effects of kratom use may use. However, physical well-being was reduced in severe increase the physical health, psychological, social and kratom dependence. Our study provided preliminary environmental quality of life of the users. In addition, findings regarding the possible potential of kratom use kratom’s negative mental health concern which is for medicinal purposes but future prospective study with mainly withdrawal symptoms is relatively milder when control group studying the effect of kratom on quality of compared to that of opioid (7). life of users is warranted to validate our findings. Future study should also investigate the reason why kratom Our study also demonstrated that longer duration of use is associated with impaired physical well-being of kratom use, higher quantity of kratom use and greater users. Safety profile of kratom use should be thoroughly severity of kratom dependence were not associated investigated before we can conclude the potential of with worsening of quality of life of users in all domains kratom use for medicinal purpose. except physical health-related quality of life which was significantly lower in severe kratom dependence when ACKNOWLEDGEMENTS compared to mild to moderate kratom dependence. This important information indicates that kratom consumption This work was supported by the Research University Grant may not cause any significant impact onto the physical of Universiti Sains Malaysia (1001CDADAH/816306) health, psychological well-being, social relationship and and (1001/PSOSIAL/8016015), and Higher the management of environmental activities of the users Institution’s Centre of Excellence (HICoE) Grant even if there was prolonged and heavy use of kratom. (311CDADAH/4401009). We thank Muhammad Eshal However, severe kratom dependence may worsen Bin Dzulkapli for his assistance in the data collection physical well-being of users which may be due to more process. severe withdrawal symptoms affecting pain, sleep and work capacity. REFERENCES

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