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Kratom (Mitragyna speciosa) is a plant indigenous to Southeast Asia, typically consumed by tea or powder, with physiologic effects similar to opioids, as well as stimulants. There is an increasing prevalence of kratom use, raising concern for possible dependence, addiction, and toxicity. Given the increasing popularity and the potential harm this substance could cause, it is essential to understand how it works, its physiologic side effects, and any possible treatment options for symptoms related to a toxic overdose. This activity reviews the etiology, presentation, evaluation, and management/prevention of kratom toxicity and also reviews the role of the interprofessional team with management. Objectives: Summarize the pathophysiology/toxicokinetics of kratom toxicity. Outline the signs, symptoms, and examination findings for patients with kratom toxicity. Describe management strategies for kratom toxicity. Review the interprofessional team approach to identifying and improving care for managing patients suffering from kratom toxicity. Access free multiple choice questions on this topic.

As many patients with kratom toxicity will primarily be seen in the emergency department, performing a primary survey and assessing the patient's airway, breathing, and circulation is crucial. Developing a broad differential in these patients is imperative as initial presenting symptoms may vary based on the dose of kratom ingested. Also, screening for kratom misuse is primarily based on patient disclosure, as kratom is not detected on regular drug screens. There are no formal, evidence-based guidelines for the treatment of kratom toxicity. Presentations for kratom toxicity can differ as symptoms vary based on the dose ingested and whether the substance has been altered. The physiologic effects of kratom ingestion vary dose-dependently, where stimulant-like effects are seen at lower doses, and opioid-like effects are seen at higher doses.[16][17] Toxicities typically occur when the ingested dose exceeds 8 grams.[22] Multiple organ systems are at risk for injuries related to kratom use, with hepatotoxicity, seizure and coma, lung injury, kidney injury, and cardiotoxicity being reported. For pregnant patients who use kratom, there is also the risk of neonates developing neonatal abstinence syndrome.[33][25][26] Evaluation should be tailored toward the patient's presenting symptoms. Also, it is likely beneficial for providers to contact their local poison control center to help for guidance and assistance if kratom ingestion is suspected or known. At higher doses, kratom toxicity can mimic an opioid toxidrome. While there are reversal agents, like naloxone, for opioid overdoses, the efficacy of reversal agents has not been well established with kratom toxicity. However, there are cases that have reported potential benefits, and some studies have recommended their use.[34][35] There have also been cases of kratom toxicity causing acute drug-induced hepatitis, in which treatment with N-acetylcysteine has been used, as in other cases of drug-induced hepatitis.[36] Standard seizure management with anti-epileptics is warranted for patients who develop seizures after kratom ingestion.[33]

Kratom ingestion and toxicity require an interprofessional approach. Depending on the severity of presenting symptoms, critical care, nursing, pharmacy, social work, and addiction services may be required. Nursing and pharmacy are essential for the initial resuscitation and delivery of medications. Pharmacists, in particular, need to be knowledgeable about the effects of this substance so they can inform patients and other interprofessional healthcare team members regarding kratom use. Critical care teams and psychiatry involvement is crucial for critically ill patients with possible co-ingestions and those with suicidal intent. Social work and addiction services are necessary for those motivated to control their drug addiction. Overall, kratom use, toxicity, and withdrawal require further research to develop definitive management practices.