Regarding the Recent Florida "Kratom Death" Story

1st of all, my sincere & heartfelt condolences to all those who died directly or indirectly from kratom as well as their loved ones.  May their memory be a blessing.  In a humane & sane society with universal healthcare & science-based drug laws, these kinds of preventable tragedies would be much less common.  Supplements of ALL kinds would be FDA-regulated and not overseen by the same people who profit directly from their sale (thanks, DSHEA).  Mind-altering drugs like kratom & all opioids weaker than fentanyl would be regulated & available at designated locations for adult users to consume safely & privately.  No fentanyl or tranq dope in the drug supply, no doctor-shopping, no pill mills, no prison or job loss for private non-violent drug use.  No DC lobbyists needed to keep any drug legal.  Just addiction being treated like the disorder it is instead of a moral failing.

But we don't live in a sane or loving society, we live in America:  where both drugs and drug education are tainted thanks to the 80+ year Drug War.  Substances like kratom, Spice & bath salts--all powerful drugs with real health risks--are ironically the only "safe" option for consumers due to their legality, purity & affordability;  they're also dangerously over-available due to the refusal of health regulators to do the work of regulating recreational substances in any capacity on moral grounds.  Because in this prohibitionist society, drugs are either seen as a miracle or a threat, black-and-white.... Good or evil.  There is no middle ground between 100% illegal & legal but totally unregulated, and neither black market profiteers nor our gov't leaders give a damn about the human cost of their actions (or inaction).  It doesn't have to be this way.  

Let's take a quick trip down these two divergent yet equally dangerous paths, shall we?  

Path 1:  Prohibition (Schedule 1):  In this scenario, the drug in question is emergency scheduled for about 30-60 days & then chucked into CI permanently, where it's deemed to have no medicinal use and an unacceptable risk of addiction or death. All scientific research is halted & anyone caught in possession or with "distribution" amounts is fined or jailed, and anyone suspected of possession may have their home/property raided, their assets seized & their reputation destroyed.  Testing positive at work can get you fired on the spot.

Of course prohibition only addresses the supply, not the demand.  Legal vendors try to dump their supply ASAP & very quickly the black market (dealers, gangs, cartels, smugglers & other shady characters) pick up where they left off.  This is when things get hairy. Because unlike legal or even grey-market vendors, black market dealers have NO incentive to maintain honest practices--they just want $$$.  They're already breaking the law--what do they care if a customer dies, gets sick, a kid gets hold of their product, etc?  Violence, police & government corruption, drug adulteration & straight-up poison make its way into the scene & it suddenly doesn't resemble the substance you knew & trusted for years.  Prices are jacked up to triple/quadruple (or more) the old going rate to account for the risk inherent in handling illegal drugs and bingo-bango:  kratom's the new Paraquat pot or China white.

Path #2:  Unscheduled & unregulated.  Our current path with kratom, though it may not be for long.  And methinks that's part of the plan:  Let a critical mass of the public die until an outcry happens & the DEA/FDA have the public support to ban it.  In this scenario a total lack of gov't oversight allows anyone to manufacture & sell any form or strength of a drug in any public setting to ANYONE.  No federal age requirements, no standardized package warnings, no upper limits on dosage in products, no oversight at manufacturing facilities.  Nobody knows for certain what the LD-50 is.  This is just as insane as Path #1 and everyone knows it but we keep our mouths shut because, hey, at least it's legal! (for now).   Deaths are inevitable due to a lack of harm reduction education in the public sphere (television, schools, billboards, online, etc).  This path puts short-term kratom industry profits & convenience before public safety & fails to consider the big picture of keeping kratom legal in the long run, therefore it's just as bad as Path 1 because it ultimately leads to Path 1.  

(The 3rd path that the FDA's clamoring for is a CII or CIII designation so the whole plant is banned but its individual alkaloids can be studied & patented by pharma companies & sold back to us at ridiculous prices.  This path is borne of pure greed: history has shown repeatedly that single-ingredient & synthetic versions of plants like the opium poppy (morphine, codeine), cannabis (Marinol, Nabilone) & coca (cocaine) are almost always more addictive/toxic than the whole plant, not to mention nobody wants doctors & insurance companies deciding who's worthy of accessing this medicine.  They have no right to have that kind of monopoly on our health, especially when so many Americans can't even afford medical care or health insurance.  They tried to ban CBD supplements around the time Epidiolex, at a repulsive $32,500 per year, was approved & the public pushback was too overwhelming.  We can't let 'em do it with kratom.  If they want to be taken seriously about important things like vaccines, the FDA needs to get off Big Pharma's dick & be objective). 

The Florida Deaths

"Kratom injury lawyers."  This is bad, guys.

And this brings us to the Florida kratom deaths at the center of this controversy.  Twitter headlines loudly proclaim:  "533 kratom deaths in Florida!  Legal drug sold in gas stations touted as "safe" is killing our kids."  I must admit, this even alarmed me as that's a LOT of deaths.  Was there a tainted or ultra-potent batch going around?  What's going ON? 

Turns out, no.  There isn't.   It's just another case of overblown fear-mongering headlines telling half-truths to a public with the collective attention span of a gnat.  Most folks don't even digest a whole tweet before scrolling onto the next digital dopamine hit, let alone read & comprehend a 2,000+-word article.

To The Tampa Bay Times's credit, they did break down the death stats & include the info we all want to know:  that the vast, vast majority of these unfortunate souls were taking at least one other substance (96%  of the 533 total) or had other contributing health conditions (19 of 46 kratom-only deaths) at the time of death.  That's a lot more than the majority of kratom hitpieces disclose so hats off to the journalists on this story. It actually provides some useful data. 

 Here are the numbers, per the Tampa Bay Times:

White males w/ other opioids in their systems made up the vast majority of "kratom" deaths

At a glance, a couple things jump out at me:  as stated, the overwhelming majority had other drugs (83% had opioids like fentanyl, heroin or Rx pain pills that DO cause respiratory depression) in their system when they died, which makes it impossible to tell what role kratom may have played.  The huge preponderance of males raises questions:  are males just that much more likely to use kratom to begin with, or is it more dangerous in males for reasons we don't yet understand?  Or perhaps men are more likely to take risks like ingesting high doses or mixing kratom with other substances.  These questions & others need further clarification.  

Now, for the part that all kratom users are most concerned with:  the 46 "kratom-only" deaths.  While the article doesn't link to the autopsy or toxicology reports, they do state that 14 kratom-only OD victims had at least one other health condition listed on the autopsy as a contributing factor, which means kratom may have played a huge role or very little role--probably somewhere in between.  But we don't know.  And 5 of those 14 had heart disease--a serious condition on its own.  Regardless, ALL of their illnesses were severe enough to be considered a "contributing factor" in their deaths & not just a separate but unrelated condition. 

This leaves 32 Floridians in a decade who died exclusively of kratom toxicity/overdose with no other drugs in their system and no pre-existing health conditions listed as contributing factors.  Compare that to 380 deaths per DAY from excessive alcohol use nationwide totaling a staggering 140,000 alcohol-related deaths per year in the U.S.  (Source: CDC).

Still tragic but quite different from the headlines, yeah?  (Actually that's an impressively low number of fatalities in a decade for a totally unregulated drug sold OTC in extremely high doses to kids & anyone w/ $5 in their pocket).

Same questions apply in those kratom decedents who DID have contributing diseases:  what role specifically did kratom play in causing these deaths?  How extensive was the disease, how heavy was the dose & how exactly did they expire?  (The article states that kratom users who OD on the drug may die like stimulant users--from sudden cardiac death--or like opioid users, with swollen brains, fluid in the lungs & aspirated vomit.  This sort of makes sense when you consider the differing effects of white/green-vein vs. red-vein strains.  Also, plants harvested at different times of year can contain varying amounts of mitragynine, the active alkaloid in kratom.  7-hydroxymitragynine is the secondary alkaloid that binds to mu-receptors but strangely, neither it nor mitragynine content varied much between the 3 main vein colors in studies.  It was a 3rd, seemingly inactive compound called speciophylline that varied wildly between the stimulating and sedating subtypes, raising more questions than answers).  But it's impossible to tell if these variations in the kratom plant itself were responsible for the different ways these people expired or if it came down to personal physiology or other factors.  We desperately need more research on kratom's pharmacology, LD-50 & mechanisms of action to answer these questions.

It would be helpful if toxicology & autopsy reports were available to the public or, better yet, linked in the Times article. I empathize with the families' desire for privacy, but that horse left the barn when they filed lawsuits against kratom companies & other parties or gave autopsy access to reporters.  When in doubt, always cite & share your sources.  Aside from the sensational headlines, that's the only place the Tampa Bay Times article falls short.

Again, the authors of the Times article did a great job laying out the various ways the victims succumbed & doing actual investigative journalism instead of writing some 2-paragraph nothingburger that leaves 10,000 unanswered questions.  I also credit kratom advocates for holding irresponsible journalists/bloggers' feet to the fire over the years:  they probably know we're not the crowd to mess with.  Let this be proof that our voices DO matter & that coordinated, respectful pushback makes a difference. 

Kratom Myths That Kill

Since you're already here, let's bust some dangerous myths, shall we?  IT IS POSSIBLE TO DIE FROM KRATOM ALONE.  Or oxygen alone, or water, or salt.  Every substance no matter how "natural" or benign has a fatal overdose threshold/LD-50.  Even cannabis.  Just because kratom doesn't slow your breathing doesn't mean you can't overdose on it.  It raises heart rate & blood pressure & can cause seizures even in people who've never had them. Other mechanisms aren't as clear, but sudden cardiovascular events have been involved in some "kratom-only" deaths (see: Tampa Bay Times article).  

Understanding a drug's basic pharmacology is vital for safe use.  Kratom is something of a dirty drug akin to tramadol or clozapine in that it acts on multiple neurotransmitter systems including the mu-opioid & adrenergic receptors, the latter of which are also activated by caffeine & phentermine.  This makes it both an "upper" and a "downer" in a sense.  It's also thought to act on the serotonin & dopamine systems, though more research is needed in this area.  What IS mentioned in almost every kratom study is that it has a significant inhibitory effect on multiple enzymes that metabolize other drugs, which makes it potentially dangerous to combine with any substance that's also metabolized by these enzymes, as it can increase amounts of these drugs in the blood to dangerous levels.  

Additionally, a handful of cases of Serotonin Syndrome have occurred which can be fatal in severe instances.  See my recent article for a whole menagerie of kratom risks, myths & facts.  Common myths are that it's not addictive or the withdrawals are less severe than other opioids (they're about on par with hydro/oxycodone or high-dose codeine withdrawals); that it's "natural" & thus safer than synthetic or semi-synthetic opiates/oids (it's not necessarily "safer" than equipotent drugs, it just comes w/ unique risks that don't include respiratory depression) & that its legal status has anything whatsoever to do with its relative safety or risk--it doesn't, as the legal status of cancerous tobacco & the also-cancerous, toxic-at-any-dose booze should attest to.

Proposed Safety Regulations to #KeepKratomLegal

Example of potent kratom extract sold in stores & online

((The following are my opinions only so take them or leave them, just remember that failure of the industry & kratom advocates to act could very well result in a nationwide ban, if not now then sometime down the line.  We're on borrowed time IMHO.  The media + parents of deceased young people have historically been a very powerful combo, and the general public is always hungry for the next "demon drug" to project their anguish onto.  If you agree please share this article!)).

To begin with, kratom products MUST carry standardized warnings about dosage & drug interactions on the label (if sold in a container) or at the point of sale (in kratom/kava bars, etc).  Its effects on cytochrome enzymes that metabolize so many other substances makes it potentially deadly in this setting, as does its affinity for so many diverse neurotransmitter systems.  Kratom advocates should be leading the charge for these changes if we want to avoid a nationwide ban.

And in what universe are we banning the sale of booze/weed/vapes to kids while selling them an opioid agonist over the counter?  Kids too young to vote or buy explicit rap albums who could be prosecuted under "child porn" laws for sending racy selfies to each other in 3rd period can saunter into any truck stop or corner store & buy as much kratom as their hearts desire.  The way the drug is marketed as a natural benign supplement & its legality do give the false appearance of total safety, especially to kids with developing brains who already feel invincible.  In reality, many of these products are ultra-potent extracts or 'enhanced blends' with no health warnings on the package, plus teens are more likely to do risky things like combining kratom with other drugs, driving intoxicated, etc. Even in a best-case scenario, kratom is potentially addictive due to its opioid-binding effects & can cause nasty physical withdrawals.  No child can truly consent to that kind of life-ruining decision.  This can't be left up to states--children should not have legal access to recreational drugs, period.  Some things are for adults & kratom is one of them.  I'm all for parental responsibility but this one is on legislators.  We need federal age requirements yesterday.  Moving kratom products behind the counter like tobacco to prevent theft & send a message that these are actual drugs meant for adults wouldn't hurt either.

Finally, dosage clearly matters when it comes to kratom safety.  I know some may take issue with this but I would strongly suggest banning the commercial sale of kratom extracts & putting upper limits on alkaloid content in enhanced leaf products.  According to the Tampa Bay Times article, around half of the "kratom-only" decedents had upwards of 1,000 nanograms of mitragynine per ml of blood at autopsy, which is an absurd amount.  It would be very, very hard to ingest that much plain leaf fast enough to keel over.  These extracts have historically been responsible for many other kratom deaths due to adulteration & sheer potency as well.  If individuals want to make their own extracts at home, fine.  But no commercial extracts should be sold in businesses.  Americans turn everything into its most ridiculously potent form, from liquid fire kratom shots to crack-like cannabis "dabs" & shatter to actual crack cocaine.  We're never satisfied, always seeking stronger, harder, faster & bigger everything.  As we see here, that level of gluttony is not always good.  Our obesity epidemic, fentanyl crisis, housing crash & plenty of other societal plagues were caused by this same endless quest for MORE.  And it's killing us. 

So that's my recommendation as a lowly drug blogger and long-term kratom user:  1.)  standardized dosage/interaction warning labels on all packages, 2.)  federal minimum age requirements to purchase kratom (18 or 21), 2.5.)  move kratom products behind the counter like tobacco (optional), 3.)  ban the commercial sale of kratom extracts & 4.) enact (liberal/reasonable) upper limits for mitragynine on any enhanced leaf sold in public establishments. 

It's not perfect & will require cooperation between federal regulators, the AKA & kratom industry leaders but it will go a long way to put minds at ease & show that these entities care about consumers & not just kratom industry profits (or in the FDA's case, pharma profits).  More importantly, it will prevent or delay the dreaded scheduling/outright ban our gov't has been pushing for since damn near antiquity.  And MOST importantly, it will save lives--something we should all care about.  If they all can't be adopted right away, do what you can.  Something is better than nothing.  Change takes time but these seem like doable changes that don't place an unreasonable burden on vendors or growers like, say, testing every batch of leaf for alkaloid content or requiring expensive government licenses to grow/sell kratom. 

You can't very well claim that #kratomsaveslives when people are out here dying horrible deaths from it, and I say that as a long-term user & advocate who has watched many beloved legal substances get the banhammer in my lifetime.  Victim-blaming is easy but it helps nothing & is a bad look.  As stated in my previous article: common sense isn't so common.  Not everyone is informed about harm reduction due to the abstinence-only drug "education" (read: propaganda) of the Drug War, & many other factors like age, stress & trauma, income & general mental health/IQ can all influence a person's choices & lead to deadly outcomes.  It's on US to make kratom as safe as possible for everybody since our elected leaders refuse to lift a finger.  

The alternative is far worse.

Resources:  

The Tampa Bay Times -  Deadly Dose: Part 1

Centers for Disease Control: Deaths From Excessive Alcohol Use in the United States