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Kratom Alkaloids

Kratom is a tropical evergreen tree (Mitragyna speciosa) native to Southeast Asia. Its leaves contain compounds that can have psychotropic effects.Two compounds in kratom leaves, mitragynine and 7-α-hydroxymitragynine, interact with opioid receptors in the brain. At low doses, kratom acts as a stimulant, making users feel more energetic. At higher doses, it reduces pain and may bring on euphoria. At very high doses, it acts as a sedative. Kratom takes effect after five to 10 minutes, and its effects last two to five hours. Rarely, chronic use of Kratom is associated with cholestatic liver disease. 

Kratom is not considered to be an illegal substance and is readily available by the following names: Biak, Ketum, Kakuam, Thang and Thom. People who use kratom believe it is safe because it is plant-based and natural. Most people take kratom as a pill, capsule, or extract. Some people chew kratom leaves or brew the dried or powdered leaves as a tea. Sometimes the leaves are smoked or eaten in food.

The Drug Enforcement Administration includes kratom on its Drugs of Concern list, which includes substances that are not currently regulated by the Controlled Substances Act, but that pose risks to persons who abuse them. The number of kratom exposures reported to United States Poison Control centers increased almost 5000% from 2011 to 2017. A high percentage of kratom exposures required admission to a healthcare facility and had serious medical outcomes. In 2017, the FDA identified at least 44 deaths related to kratom, with at least one case attributed to pure kratom. Many of the kratom-associated deaths have resulted from adulterated products or taking kratom with other potent substances such as illicit drugs, opioids, benzodiazepines, alcohol, gabapentin, and over-the-counter medications. Kratom dietary supplements have also been laced with other compounds that caused deaths.

The kratom alkaloid mitragynine and its metabolite 7-hydroxy-mitragynine can be detected in urine. LabCorp performs an initial immunoassay. Specimens that exceed the threshold of 5.0 ng/mL are considered presumptive positives and are confirmed by liquid chromatography/tandem mass spectrometry (LC/MS-MS) . Results higher than the esting threshold of 1.0 ng/mL are considered positive.

Some case studies have suggested an association between kratom use during pregnancy and neonatal abstinence syndrome (NAS). Testing to identify fetal exposure to kratom may be helpful during patient management. 

Umbilical cord tissue can be tested by qualitative liquid chromatography-tandem mass spectrometry for two kratom alkaloids, mitragynine and speciociliatine, as evidence of fetal exposure to kratom during pregnancy. 

Specimen requirement is at least 8 inches of umbilical cord. Testing is available at ARUP Laboratories. 

The cutoff for each alkaloid is 0.08 ng per g of umbilical tissue. 

References

Dorman C, Wong M and Khan A. Cholestatic hepatitis from prolonged Kratom use: a case report. Hepatology 2015; 61:1086

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