Among this sample of individuals who reported kratom use, whether for non-therapeutic/recreational or therapeutic/self-treatment purposes, kratom was rarely initiated prior to alternative treatments/substances. Those endorsing the use of other psychoactive substances typically initiated kratom after discontinuing the other substance(s) or while still using them. Only three respondents (1.9%) reported concurrent kratom use to enhance the effects of another substance, whereas previous research identified 14% using it in this manner. ²⁴ Thus, despite its current non-controlled status and accessibility in the US, these findings do not suggest kratom is a common first psychoactive substance used or a “gateway” to other substance use. Instead, kratom appeared to more commonly be used as an adjunct or alternative to other psychoactive substances.

While some respondents indicated that their kratom use was largely unrelated to their other substance use, managing withdrawal, reducing cravings, cutting down or quitting their use of other substances, or losing access to another substance were all among the most commonly endorsed reasons for using kratom alongside or after discontinuing other substances. This is in line with previous research indicating that people more often use kratom to reduce their frequency of substance use or mitigate dependence and withdrawal from other substances.^20,27 Given the opioid epidemic and opioid agonist effects of kratom, this has most often been studied in relation to opioid use disorder (OUD) and opioid sparing. Previous observational research identified that approximately 10-20% of people who used kratom did so to manage withdrawal or reduce opioid use, though this was observed at higher rates among people seeking SUD treatment. ²⁸ In a study of individuals at a residential treatment facility, 69% of those who had used kratom did so to curtail their non-prescribed opioid use and 64% as a substitute for opioids. ²⁰ While a relatively low number of respondents to this survey endorsed non-prescribed opioid use compared to other substances, 50% of those that endorsed previous opioid use indicated that they used kratom to reduce opioid cravings and 40% endorsed using it to manage opioid withdrawal. This was considerably more commonly reported with non-prescribed opioids than the other substances assessed, with the exception of alcohol which was similar. Previous observational research has also indicated that some individuals use kratom to help reduce alcohol or stimulant use or withdrawal symptoms. ⁶ In this survey, approximately half of those currently or previously using alcohol endorsed using kratom to help reduce/quit alcohol use or manage withdrawal, while approximately 10-20% reported the same for their stimulant use.

Cannabis was the most common substance use reported in this study, which has also been observed in previous kratom research. ²⁵ This is not surprising given cannabis is the most used federally illegal drug in the US. As such, this finding may not necessarily be indicative of a link to kratom use. ²⁹ Respondents who had discontinued cannabis use reported a variety of reasons for initiating kratom. While many reported their use of kratom and cannabis was unrelated or for different purposes, others noted not liking the side effects or the way cannabis made them feel, as well as no longer having access to cannabis or having concerns regarding the legal ramifications of its use. Thus, it seems that for some who have tried cannabis, kratom may be viewed as an alternative psychoactive substance preferred for its different effects, adverse effect profile, or legal status. A lower proportion cited using kratom to reduce cravings or manage withdrawal associated with cannabis than the other substances assessed in this study. Thus, it seems the relationship between kratom and cannabis use may be different than with opioids, stimulants, alcohol, or sedatives.

Similar patterns were observed among those endorsing pertinent medical conditions that kratom might be used to self-treat. Kratom was typically initiated concurrently with or after discontinuing medical treatment for those conditions. Given that this study and previous research have identified that kratom is most commonly used for therapeutic/self-treatment purposes, ¹² these findings may indicate that ensuring people with underlying pain, substance use, and mental health conditions have access to effective treatments may reduce their desire to try kratom. Unfortunately, these conditions are often stigmatized and result in reduced access to care. Many patients with SUD do not receive treatment, despite effective medications available for opioid, alcohol, and tobacco use disorders.^30,31 Perhaps not surprisingly, respondents reported initiating kratom prior to receiving SUD treatment more often than any other diagnosis included in this study. This was followed closely by pain, which is typically among the most cited therapeutic reasons for using kratom and is also a stigmatized condition in which many patients struggle to access effective treatments.^{10,12,24,32,33} In these cases, it is possible that kratom is an appealing option since it is available without a prescription. Kratom may be more affordable/accessible than traditional healthcare for those who are uninsured/underinsured, have other access barriers, or desire to avoid potentially stigmatizing healthcare interactions. Accordingly, lack of insurance, cost, and opinions of others were cited as reasons why some survey respondents stopped receiving treatment for their medical conditions from their HCP. This is in line with previous research assessing the temporal relationship between kratom use and medical care, which has identified that difficulty obtaining adequate treatment for mental health, pain, or SUD, as well as discrimination or stigma experienced within a healthcare setting, influenced individuals’ decision to try kratom.^24,33 Conversely, research has shown that kratom use was less likely among people prescribed buprenorphine for opioid use disorder. ²⁵

While the quality of and access to medical care may influence kratom use patterns, it is likely that some might continue kratom use because of a preference for CAM approaches or kratom specifically. In the present study, more than one-third of respondents indicated that they had previously sought treatment from CAM providers, and more than half noted they preferred natural/holistic treatments and felt kratom was safer than Western medicine. Furthermore, nearly a third of respondents discontinued their medical treatment because they felt it was ineffective and almost half of those initiating kratom in addition to their medical treatment did so because they felt kratom was more effective. Previous research has similarly indicated that people who use kratom generally believe it to be safe and relatively effective for self-treating various ailments. One study asked people who used kratom to rate the safety and effectiveness of kratom on a 100-point scale; respondents rated the perceived average safety as 90/100, while effectiveness ratings as an opioid, stimulant, or alcohol substitute or to manage withdrawal or depressive symptoms ranged from 67-76/100. ²⁴ However, while anecdotal reports from people who use kratom indicate that it may provide some relief for various medical conditions, it is important to recognize that considerably more clinical research is needed to accurately assess its potential benefits and risks before it could be recommended for any medical treatment.^6,12

This is particularly true given the rapidly changing kratom market. While it has been used for centuries in Southeast Asia as an herbal medicine, this use consisted of chewing or drinking tea from fresh kratom leaves. ¹ These natural, whole-leaf kratom formulations contain relatively small amounts of the primary active alkaloid mitragynine, which acts as a weak partial agonist at the mu opioid receptors, and has activity at the adrenergic and serotonergic receptors. As its US popularity has grown, kratom product diversity has greatly expanded. Until recently, kratom has primarily been consumed in the US as dried leaves ingested as tablets, teas or powders, but it is now available as edibles, vapes, tinctures, liquid shots and other novel formulations and may be combined with additional active ingredients like kava.^1,12 More concerningly, a number of semi-synthetic kratom derivatives have entered the market that contain much higher mitragynine levels or alkaloids like 7-hydroxymitragynine or mitragynine pseudoindoxyl, which are not found in detectable amounts in fresh, whole-leaf kratom. Unlike mitragynine, 7-hydroxymitragynine and mitragynine pseudoindoxyl function as potent opioid receptor agonists, thus profoundly changing the pharmacology and relative risk. ¹ However, given that they are typically still marketed as kratom products, many consumers likely do not fully appreciate these differences or the inherent risks associated. In the present study, 38.3% of respondents reported using kratom extract products with higher concentrations of mitragynine and 16.9% reported using kratom products containing isolated mitragynine, 7-hydroxymitragynine, or mitragynine pseudoindoxyl. Not only are these products much more potent opioid receptor agonists, they are also under-regulated and under-studied and likely to confer considerable risks to those using them, particularly if they do not appreciate the differences in pharmacology or dosing. ¹ Unfortunately, previous research has indicated that most people who use kratom do not identify it as an opioid or recognize that there is limited regulation to ensure consistency among products or that kratom products may be adulterated with other substances. ²⁵ Thus, it was concerning that most respondents believed kratom was safer than medications, which have considerably greater research to support their safety and efficacy. This would seem to indicate that consumers likely underappreciate the risks associated with kratom use, particularly with regard to the newer, more potent products being used by more than one-third of the survey respondents.