Kratom in Crisis: Realities, Risks, and Community Challenges

Muhamad Aly Rifai, MD

Welcome back to The Virtual Psychiatrist. I’m your host Dr. Muhamad Aly Rifai, and I’m joined by my co-host, Dr. Norman Clement. Today, we’re diving into a topic that’s been popping up more and more in both clinical practice and the news—kratom. Norman, I feel like every time I turn around, someone’s asking about it, whether it’s a patient, a colleague, or even just folks in the community. So, let’s start with the basics. Kratom, or Mitragyna speciosa, is a tropical tree native to Southeast Asia, right? Traditionally, it’s been used by farmers in places like Thailand and Malaysia to combat fatigue and boost productivity. But now, it’s showing up in the U.S. in all sorts of forms—teas, capsules, powders, you name it.

57effe3a

Yeah, and you know, Dr. Rifai , what’s wild is how quickly it’s spread here. I mean, you can walk into a smoke shop or even order it online, no questions asked. The main active compounds are mitragynine and 7-hydroxymitragynine. These alkaloids interact with opioid receptors, but they also hit serotonin, dopamine, and adrenergic systems. That’s why you get this weird mix of stimulant effects at low doses and opioid-like sedation at higher doses. It’s not your typical opioid, but it’s not just a caffeine buzz either.

Muhamad Aly Rifai, MD

Exactly. And the demographic trends are interesting. Surveys show that most U.S. users are middle-aged, often men, and a lot of them have private insurance and a decent income. But what really stands out is why people are using it—chronic pain, mood issues, and especially to manage withdrawal from prescription or illicit opioids. I mean, we’re talking about folks who might not have access to traditional healthcare, or who are wary of the system for all sorts of reasons.

57effe3a

That’s right. In my own advocacy work, I’ve seen kratom pop up in communities that have been hit hard by the opioid crisis and by barriers to care. People are desperate for alternatives, and kratom’s legal status and easy access make it appealing. But, you know, there’s this perception that because it’s “natural,” it’s safe. And that’s where things get complicated real fast.

Muhamad Aly Rifai, MD

Yeah, and I think that’s a good segue into the risks, because the pharmacology is only half the story. But before we go there, Norman, anything else you want to add about how you’ve seen kratom used in the community?

57effe3a

Just that it’s everywhere now—kava bars, head shops, even some gas stations. And the forms keep multiplying. I’ve seen people mix it into smoothies, take capsules, or just brew it up like tea. The bottom line is, it’s accessible, and for a lot of folks, it feels like a lifeline. But that lifeline comes with some real strings attached.

Muhamad Aly Rifai, MD

So let’s talk about those strings. Kratom’s effects are dose-dependent. At low doses—say, 1 to 5 grams—you get stimulant-like effects: more energy, alertness, maybe even a little euphoria. But once you get into higher doses, 5 to 15 grams, it starts acting more like an opioid—sedation, pain relief, and, for some, a sense of calm. But with that comes the risk of dependence and withdrawal, especially with regular high-dose use.

57effe3a

And the adverse events are no joke. We’re talking liver toxicity, seizures, withdrawal syndromes, and even some deaths. Now, the deaths are usually in the context of polysubstance use—so kratom plus opioids, benzos, or other drugs. But the risk is real, especially since kratom products aren’t regulated. You don’t always know what you’re getting. Some products have been found contaminated with salmonella or even adulterated with other substances.

Muhamad Aly Rifai, MD

Yeah, and I’ve seen this firsthand in my addiction medicine practice. I had a patient who came in with classic opioid withdrawal symptoms—restlessness, anxiety, sweats, diarrhea—but their tox screen was negative for opioids. Turns out, they’d been using kratom heavily to manage pain and opioid cravings, and when they stopped, the withdrawal was just as real. We had to manage it much like we would for opioid withdrawal, but there’s no standardized protocol for kratom detox. It’s a gray area, and that makes it tough for both patients and providers.

57effe3a

And let’s not forget, the FDA and DEA don’t recognize any legitimate medical use for kratom. There’s no clinical evidence for its safety or efficacy, and yet it’s being used as a self-treatment tool all over the country. That disconnect is dangerous, especially when you factor in the risk of organ injury and the lack of quality control.

Muhamad Aly Rifai, MD

Right. And even though some folks say the withdrawal is milder than with classical opioids, it can still be pretty miserable—nausea, chills, irritability, insomnia. And the risk of toxicity goes up when people are using high doses or mixing kratom with other substances. So, it’s not the harmless herbal remedy some people think it is.

Muhamad Aly Rifai, MD

Now, let’s shift gears to the mental health side. There’s growing evidence that kratom can actually worsen psychiatric conditions, especially in people who are already vulnerable. I’m talking about psychosis, mania, even full-blown mood episodes. And the tricky part is, kratom’s metabolites don’t show up on routine tox screens, so it can be a real diagnostic challenge.

57effe3a

Yeah, and I read a case recently—actually, it was in one of the journals we both follow—about a patient with bipolar disorder who was stable for a while, then started using kratom to manage anxiety and opioid cravings. He ramped up his dose, and next thing you know, he’s in the ER with mania and psychosis. The team couldn’t figure out what was going on until they dug into his supplement use. Turns out, he’d been taking massive amounts of kratom capsules, and that was the trigger.

Muhamad Aly Rifai, MD

Exactly. And the literature backs this up. Kratom’s active compounds hit not just opioid receptors, but also serotonin and dopamine systems—so it’s not surprising that it can destabilize mood, especially in people with underlying vulnerabilities. And because it’s not detected on standard screens, clinicians might miss it entirely unless they specifically ask.

57effe3a

And that’s a big problem, especially in communities where access to mental health care is already limited. People might turn to kratom thinking it’ll help with anxiety or depression, but for some, it can actually make things worse. And if you’re not looking for it, you might just chalk up the symptoms to a primary psychiatric disorder and miss the real driver.

Muhamad Aly Rifai, MD

Right. So, for anyone listening—whether you’re a provider or someone who’s using kratom—just know that it’s not a benign substance, especially if you have a history of mental health issues. The risks are real, and the diagnostic challenges are significant.

57effe3a

Let’s talk about how the pandemic changed the landscape. There’s some really interesting data from surveys done during COVID-19. Some people increased their kratom use—to self-medicate for pain, anxiety, or opioid withdrawal—while others actually cut back, maybe because of supply issues or financial stress. It’s a mixed bag.

Muhamad Aly Rifai, MD

I agree COVID 19 screwed everything in our world

57effe3a

Yeah, and what’s fascinating is that, statistically, increases in kratom use during the pandemic were less likely to be reported as “for the worse” compared to alcohol or tobacco. A lot of people described their increased use as neutral or even positive, especially compared to how they felt about drinking or smoking more. But, of course, that doesn’t mean there aren’t risks—it just means people perceive kratom differently.

Muhamad Aly Rifai, MD

Right. And the open-ended responses in those surveys really highlight the complexity. Some folks said kratom helped them cope with stress or manage withdrawal when they couldn’t access other supports. Others mentioned cutting back because they couldn’t get it, or because they started noticing side effects. It’s not a one-size-fits-all story.

57effe3a

And in the communities I work with, the pandemic just amplified existing barriers. People lost access to clinics, lost jobs, lost insurance. For some, kratom became a stopgap—something to fill the void when other options disappeared. But again, that comes with its own set of risks, especially when you’re flying blind without medical guidance.

Muhamad Aly Rifai, MD

Yeah, and I think it’s important to remember that while kratom might feel like a lifeline for some, it’s not a substitute for evidence-based care. The pandemic just made the cracks in the system more visible, and kratom use is one way people are trying to patch those cracks themselves.

57effe3a

So, where does that leave us? Legally, kratom is in a weird spot. It’s banned in a handful of states—Alabama, Arkansas, Indiana, Vermont, Wisconsin—but legal in most others. The FDA hasn’t approved it for any medical use, and the DEA has it on their “drugs of concern” list. There’s ongoing scrutiny, but no federal ban yet. And the products on the market? Totally unregulated. You don’t know what you’re getting, and that’s a huge problem.

Muhamad Aly Rifai, MD

Yeah, and the debate is fierce. Some argue kratom could be a harm reduction tool, especially for people trying to get off opioids. Others see it as an emerging public health threat, given the risks of toxicity, dependence, and psychiatric complications. The reality is, we just don’t have enough data. There are no large-scale, well-designed clinical trials on kratom’s safety or efficacy. The FDA is starting to support some research, but we’re a long way from having clear answers.

57effe3a

And in the meantime, people are using it—sometimes out of desperation, sometimes out of curiosity, sometimes because they just don’t trust the system. We need better labeling, quality control, and public awareness. And honestly, we need to educate health care providers, too. Most docs I talk to don’t know the first thing about kratom, and that’s a problem when patients are coming in with complications.

Muhamad Aly Rifai, MD

Absolutely. And I’ll just say, as someone who’s navigated regulatory gray zones myself, it’s critical that we don’t let fear or stigma shut down research. We need rigorous trials, ongoing education, and a willingness to meet patients where they are—even if that means having some uncomfortable conversations. The lessons I’ve learned from my own legal battles are that transparency and advocacy matter. We can’t just criminalize our way out of this.

57effe3a

Couldn’t agree more. And as we wrap up, I just want to say—if you’re a provider, get educated. If you’re a patient, ask questions. And if you’re a policymaker, listen to the people on the ground. This isn’t going away anytime soon.

Muhamad Aly Rifai, MD

That’s a good note to end on. Thanks for joining us for this episode of The Virtual Psychiatrist. We’ll be back soon with more stories from the front lines of psychiatry, health, law, and politics. Norm, always a pleasure.

57effe3a

Always, Dr. Rifai. Take care, everyone—and keep questioning, keep learning. and remember folks you are within the norms Goodbye!