bc centre for disease control

Has kratom come to BC? Calls to the BC Drug and Poison Information Centre, 2013–2017

ratom () is a plant indigenous to 6 K Southeast Asia known for 5 dual therapeutic and toxic proper- 4 ties: at low doses it acts as a stimulant 3 while at higher doses it activates opi- 2 oid receptors.1 The use of kratom in 1 North America has been documented 0 2013 2014 2015 2016 2017 only in recent decades.2,3 In Canada, kratom is a relatively new psychoac- Physician Exposed person tive substance, which has not been licensed for human consumption and Figure 1. Kratom exposure calls 2013–2017 by caller type (n = 15). b1: (see the Figure ). has been seized from outlets that were b1: ( Figure 1 ). selling it as such.4 We performed a descriptive an- 7 6 alysis of kratom exposure calls re- 5 ceived from 2013–2017 at the BC 4 Drug and Poison Information Centre 3 2 (DPIC), extracting data from manda- 1 tory coded fields and case histories in 0 DPIC’s call database. Pain Dystonia We identified 15 calls involving Palpitations omitting/nausea exposure to kratom. Six were received V Agitation/ Diaphoresis/chills Dizziness/blurred vision from the Interior Health Authority, Abdominal pain with fever Depression/suicidal ideation none from Northern Health, and three Altered mental status/Confusion each from Vancouver Coastal, Fraser, and Island Health. Kratom-related Kratom only Kratom and coexposure Kratom withdrawal calls increased in number from 2014– 2017 ( Figure 1 ). Physicians made up Figure 2. Symptoms documented in kratom-only exposures, kratom with coexposures, and kratom withdrawal (n = 14). 80% of callers, unusual as the propor- tion of calls to DPIC from physicians about exposure to other psychoactive and liquid extract. One-third of calls of kratom withdrawal, and one patient substances is much lower. All call reported coexposures including sup- was sedated and intubated due to ex- subjects were adults, with a median plements such as phenibut, 5-HTP, treme agitation. age of 25 years; 60% were men. L-tyrosine, all used for anxiety and Of eight calls describing long- The Internet, friends, and local insomnia, other natural products term exposure, three relayed with- distributors were mentioned as pro- (Maca root), tea, alco- drawal symptoms. Eleven cases had curement sources. Kratom was used hol, marijuana, amphetamines, and symptoms associated with recent for various reasons, including recrea- anxiolytics. kratom exposure ( Figure 2 ). Clinical tional (for its psychoactive effects), Call subjects were considered to findings included tachycardia (n = 2), pain relief, and withdrawal. have had minor or moderate clinical hypertension (n = 1), and elevated liv- Kratom was ingested as powder, outcomes. Supportive treatments fol- er function tests (n = 1). root, leaf, tea, capsule, supplement, lowing kratom exposure included The increase in kratom-related ex- adenosine for tachycardia, benzodi- posure calls to DPIC, as with rising This article is the opinion of the BC Centre azepines for anxiety/agitation, and numbers of US calls,2 likely reflects for Disease Control and has not been peer antipsychotics for psychosis. Benzo- an increase in kratom availability. reviewed by the BCMJ Editorial Board. diazepines were used in the treatment Currently, kratom products are sold

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In Canada, kratom is a relatively new psychoactive Divisions Dispatch. Bimonthly substance, which has not been licensed for human news from the Divisions of consumption and has been seized from outlets that Family Practice initiative. www.divisionsbc.ca/provincial/ were selling it as such. dispatch Newsletters from local divisions of family practice. www.divisionsbc .ca/provincial/divisionnewsletters as “not for human consumption” and, venience stores in the Greater Toronto GP Update. Quarterly GPSC therefore, do not have any dosing rec- Area may pose serious health risks. Ac- newsletter. www.gpscbc.ca/ ommendations, making individuals cessed 4 June 2018. http://healthycana news/publications vulnerable to overdose/misuse. This dians.gc.ca/recall-alert-rappel-avis/ The Link. Updates from the is concerning given that members of hc-sc/2018/65822a-eng.php. Shared Care Committee. the public consume kratom believ- 5. Ulbricht C, Costa D, Dao J, et al. An evi- www.sharedcarebc.ca/news ing it to be efficacious for analgesia, dence-based systematic review of kra- -and-events/newsletters mood elevation, anxiety reduction, tom (Mitragyna speciosa) by the Natural SSC Focus. Quarterly newsletter and opioid withdrawal.5 In the con- Standard Research Collaboration. J Diet from Specialist Services text of the current North American Suppl 2013;10:152-170. Committee. www.sscbc.ca/ opioid crisis, kratom exposures are 6. Swogger MT, Hart E, Erowid F, et al. Ex- news/ssc-focus-e-news likely to increase.3 While there is not periences of kratom users: A qualitative Pathways Update. Latest news sufficient evidence of its effective- analysis. J Psychoactive Drugs 2015; and user tips from Pathways. ness in facilitating opioid withdrawal, 47:360-367. pathwaysbc.ca/newsletters there is growing research demonstrat- (login required) ing the potential harms of kratom withdrawal.1,6 —Grazia Salvo, MD —Dennis Leong, DPIC —Victoria Wan —Tom Kosatsky, MD, BCCDC

References 1. Cinosi E, Martinotti G, Simonato P, et al. Following “the Roots” of Kratom (Mitrag- yna speciosa): The evolution of an enhanc- er from a traditional use to increase work and productivity in Southeast Asia to a recreational psychoactive drug in western countries. BioMed research int 2015; Article ID 968786. 2. Anwar M, Law R, Schier J. Notes from the Field: Kratom (Mitragyna speciosa) expo- sures reported to poison centers—United States, 2010–2015. Morb Mortal Wkly Rep 2016;65;748-749. 3. Cumpston KL, Carter M, Wills BK. Clinical www.johnson.ca/doctorsofbc outcomes after Kratom exposures: A poi- son center case series. Am J Emerg Med 2018;36:166-168. 4. Government of Canada. Unauthorized kratom and sexual enhancement prod- ucts seized from multiple George’s Con-

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