Lower back pain is arguably the most burdensome public health problem on a global scale, COVID-19 aside. In terms of years lived with disability and prevalence among adult populations, lower back pain is a perennial top contender in almost any study of global burdens of disease.

Opioid use, abuse, and the damage done to individuals, families, and the societal ramifications of these medications are likewise well documented.

So it is welcome to see that chiropractic care, and other conservative treatments for lower back pain, are associated with less reliance on opioid medications, which do not have a particularly great track record in resolving spinal pain complaints and are not recommended as first-line interventions for acute or chronic lower back pain.

From Reuters Health in 2019:

Patients with spinal pain who visit a chiropractor may receive treatments such as spinal manipulation, massage, acupuncture, exercises and education as appropriate,” said lead author Kelsey Corcoran of Yale School of Medicine in New Haven, Connecticut. These therapies may lead to decreased pain, improved range of motion and increased function, Corcoran said by email. If a patient’s pain is well controlled by the treatment they received from a chiropractor, they may subsequently need less pain medications or even none at all.

Addressing Biases

Of course, you might say, “You’re a chiropractor so obviously you’re going to tout these studies” and you’d be correct. Also, there is selection bias involved, people who self-select conservative care like chiropractic or physical therapy over medical care may be doing so with the explicit intention of avoiding the use of medications.

However, these studies were not just done by chiropractors, and they haven’t only been published in niche journals catering to the chiropractic or manual therapy professions. It is true that these types of studies tend to be retrospective and observational, and cannot imply causation, but evidence will continue to accumulate and it will be interesting to see what future work on this topic elucidates.

Final Thoughts

I’ve written on this subject several times before, but when it comes to addressing your pain, you have options. One of those options is to see a chiropractor. Unfortunately, chiropractic care is a mixed bag ranging from evidence-based multimodal care to, ugh, pretty much any of the trash you will see if you type chiropractic into YouTube.

In my personal opinion, and knowing the majority of lower back pain has a favorable natural history, I’m inclined to recommend conservative treatments such as yoga, walking, chiropractic care, PT, or a general exercise program over medical care and definitely before considering opioids, advanced imaging, injections, or surgery.

Thank you for reading and let me know what you think or share your experiences in the comments.

Works Consulted:

Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020;8(6):299. doi:10.21037/atm.2020.02.175

Whedon, James M et al. “Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain.” Pain medicine (Malden, Mass.) vol. 21,12 (2020): 3567–3573. doi:10.1093/pm/pnaa014

Whedon, James M et al. “Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids.” Journal of alternative and complementary medicine (New York, N.Y.) vol. 24,6 (2018): 552–556. doi:10.1089/acm.2017.0131

Kazis, Lewis E et al. “Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use.” BMJ open vol. 9,9 e028633. 20 Sep. 2019, doi:10.1136/bmjopen-2018–028633

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Many of those people first received an opioid drug, not from a drug dealer, but from a doctor, prescribing it in good faith to treat pain. The question is: are opiates good for treating pain that is not from cancer. The latest research says, “No.” 

Researchers from Australia randomized two groups of patients who had 1 or more bone fractures that required surgery to receive either oxycodone — what they called a “strong” opioid — or acetaminophen and codeine (aka “Tylenol #3) to treat pain after they were discharged to the hospital. 

They found no significant difference in pain between each group, despite the fact that the oxycodone group had a 6-fold higher opioid dose. The study authors concluded, “These findings suggest that ongoing first-line strong opioid use after discharge from the hospital should not be supported” in those patients who had a surgically managed bone fracture. 

This is an important study. It further strengthens the recommendation that strong opioids such as oxycodone should not be used for noncancer-related pain. In fact, when thinking about a bone fracture, the mechanism of the pain after surgery has nothing to do with the opioid receptors in the body, and they are more likely due to the inflammation after the fracture and the surgery to fix it. 

In fact, the absolute best pain medicine I’ve used to treat the surgical pain of patients recovering from heart surgery — and this was confirmed to me by a physician colleague who had the surgery himself — has been ketorolac, which is an NSAID like ibuprofen. The only thing is, NSAIDs such as ketorolac can cause serious complications like bleeding and kidney failure (which I’ve seen in my practice). 

Still, even though opioids are ubiquitously used for post surgery pain, they really are not good drugs for the pain. This also goes for pain after dental surgery and procedures. As clinicians, we need to use less of them. 

Of course, it is not our fault if we prescribe an opioid for pain in good faith and our patients abuse the medication. At the same time, we need to heed the science about opioids for noncancer pain. The literature increasingly suggests that opioids are not effective and can lead to abuse and complications. Thus, we should prescribe less of these medications as much as possible. 

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I suffered from a chronic pain issue, but I hid my problem. I feared doctors, and nurses only saw a drug seeker. It was so hard to admit when things got out of hand; that I needed help. I was a drug seeker. But what if, God forbid, my addiction went one step too far? What if it was too late to get help?

My story starts innocently enough but takes a dark turn. Things all started with a typical female gynecologic issue, debilitating menstrual cramps. Every month I suffered the misery of terrible periods. I missed school and work. I tossed and turned in bed, trying to find a comfortable position. I used heating pads, Tylenol, and Ibuprofen.

I would use anything to alleviate the pain.

One day, a friend’s mom recommended a doctor. The office was quite far away, but the doctor had a reputation for being a good listener with a genuine concern for women in pain.

This doctor gave me hope. She suggested birth control pills for cycle suppression but also prescribed something “new” to make me more comfortable. The hope was the new birth control would reduce menstrual cramping while I took the other medication “as needed” for pain.

This new medication was Hydrocodone-Acetaminophen 10/325 mg, a potent opiate.

I went for a follow-up appointment with my regular doctor. The doctor was highly concerned with this new prescription. I was young, healthy, and on a strong dose of opiates for a long period of time.

Honestly, I hadn’t realized this medication came with dangerous addiction potential. The prescribing doctor never mentioned it. My menstrual pain was gone, but now I was facing a new problem.

Pain pill addiction.

Good-bye magic pill

Getting off pain medication triggers horrific withdrawal symptoms. My menstrual cramps paled in comparison to withdrawal pains. These abdominal pains were the worst thing I have ever gone through in my life.

It was agony.

I needed something to make it stop.

Addicts will do anything to get a fix. In our minds, the sky is the limit. We play out every scenario in our minds to get relief. I called everyone I knew who had ever taken this medication. Sadly, finding pain pills was simple. Many people had extra pain medication leftover from surgeries and other medical problems.

Finding more and more pain medication was easy. I learned all the tricks. I spent many hours going to various doctors and emergency rooms to fill the continuous gap in my life.

Hydrocodone made the pain go away.

I continued this pattern for eight years.

I also have a history of depression. Depression is a common compounding problem for addicts, often not correctly diagnosed. Getting high off pain pills filled an emotional hole, as well as the physical one.

A doctor asked the hard questions

I got pregnant with my first pregnancy. My doctor looked at my prescription history and asked if I was taking opiates. No other doctor had ever confronted me with my actual prescription history. They just took me at my word, and I was good at lying.

I wanted to be honest, but I didn’t have the courage to my doctor the truth. I was not ready yet.

I denied narcotic use.

I honestly didn’t have faith in myself to be done with pills after my son was born. I was worried about going through labor and not having good pain relief.

I had many excuses that all made perfect sense at the time.

My doctor saw through my denials. He enrolled me in a pain management program, and I started Suboxone. The pregnancy was a success but soon after I relapsed. After I had my baby, I went through a few more years in and out of the recovery and relapse phase.

After my second child, I finally got tired of prescription chasing. Calling people for pain pills got old. Finding medication was exhausting.

I always had an excuse or a lie. Eventually, the lies catch up to you.

While I had legitimate pain from some nerve damage after my second pregnancy, it was nothing major. I was uncomfortable at times, but I used the MRI showing a small bulge in my spine to get my pain medication.

I no longer had the energy to take care of my boys without a dose of pills. This life was embarrassing and frustrating.

My depression was growing.

A day came when I had enough. A Suboxone clinic opened near my house. I drove by it a few times before I actually made a call.

The clinic’s fees were not sky-high. Finding affordable help is another barrier to addicts. Without health insurance, it is cheaper to buy pills off the street or go to an ER. Cost is also a convenient excuse to avoid the terrifying decision to go get help.

Now it makes sense to me when people say no one can help you until you are ready to help yourself.

The day I called, I made sure to get an appointment for the same day. If I did not go right away, I would make up an excuse to cancel.

I was fighting an intense internal battle. A war between good and evil waged inside my head. Walking into the clinic was the right decision for myself and for my family.

But I tried talking myself out of it.

I did not want to go inside the door. Entry meant something was really going to change in my life. I don’t care for change even though I really needed it. Addiction’s tight grip on your brain is powerful. No matter how much pain it causes, you just can’t pull away.

I held my head up and tried to keep calm. My heart was pounding. My palms were sweating.

I walked through the door, and I have never looked back.

I started appropriate anti-depressant medication. We also began non-narcotic medicines to help with nerve pain.

I am now 3 years sober. I am also happy.

I take the process one day at a time. I am human. Healing takes time. Everyone has baggage. We are all a little damaged. Our scars are part of our unique story.

My faith in God and my family are sources of inspiration to keep walking the right path.

I thank the doctors who confronted me with the truth of my addiction.

You called my bluff. I needed it.

Doctors who express legitimate, sincere interest can help people who are struggling. Addicts will lie and deceive, but they need the trusted help a doctor can give.

If you are a patient struggling with any addiction problems, please know you can reach out. You can get help without being scrutinized. It may not feel like it, but there are people who know what you are going through and want to help.

It is my genuine hope to bring good out of this dark time in my life. For anyone struggling, I hope they see the light shining from my story.

Ask for help.

Come out of the darkness and join the sunshine.

This article was contributed by an anonymous patient at MacArthur Medical Center and edited by Dr. Jeff Livingston. We respect her privacy and value her strength and courage to share her experience.

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Death is relative unless of course, it affects someone close to you. How we measure deaths and over what period of time matters in how the public perceives these deaths. Here a few figures about deaths related to opioids, and we’ve changed the way they’re presented. Rather than spreading them out over time, we’ve aggregated them. They make for pretty shocking figures.

Opioid-related data demonstrated an almost fourfold increase in overdose deaths from 1999 to 2008, according to a 2018 review published in NCBI.

By 2016, deaths had risen to over 42,000 for that calendar year. Keep in mind these are deaths directly caused by overdose or abuse of the drug. Many deaths aren’t shown as such, so this figure is conservative. People die in drug-related crimes, violence, and suicide, directly linked to their addiction lifestyle. Opioids pulled the trigger, but arent recorded as the primary cause of death.

Opioid overdoses related to illegally manufactured fentanyl (the most powerful of the opioids) represented the greatest contribution to the increasing numbers, accounting for 20,000 of the 42,000 deaths. As a result, on October 16, 2017, the US Government declared the opioid epidemic a public health emergency.

The medical community, and particularly pain medicine practitioners, had been active participants and fully aware of the development of the current state. Prescription drug monitoring programs (PDMPs) and the National All Schedules Prescription Electronic Reporting Act (NASPER) have effectively contributed to the reduction in opioid prescriptions by 8%, but on the ground, these initiatives have not translated into saved lives. In fact, quite the opposite.

Fast forward to 2021. From emerging figures, it becomes evident that we are losing this battle, and spectacularly so. In 2019, nearly 50,000 people in the United States died from opioid-involved overdoses.

From 1999 to 2019, nearly 841,000 Americans died from a drug overdose.³ Over 70% of overdose deaths involved an opioid-like prescription, opioids, heroin, or synthetic opioids (like fentanyl). If you add in figures from 2019 to now, 2021 you can safely assume we are over a million deaths, of which more than 700 000 are related to opioid addiction.

How did we get here?

Opioids and cocaine were widely prescribed in the late 19th century for anything from toothache to diarrhea. No regulation existed and only when street addition became evident was regulation enforced. The Harrison Narcotic Control Act of 1914, passed in response to the sudden emergence of street heroin abuse as well as iatrogenic morphine dependence, influenced both physicians and patients alike to avoid opiates.

It would take nearly eighty years for opioids to come back into vogue as one of the most effective treatments we have to manage pain, particularly extreme and chronic pain. The concept was a simple one. If cancer patients could benefit from opioid use to manage pain, why not extend the benefit to chronic pain sufferers too? The flaw in this concept, evident even to a layman, lies in the fact that the two types of pain differ significantly, cancer pain and chronic, non-cancer pain, and ignores the etiologies of malignant and non-malignant pain

This dangerous conflation disregarded the complex biopsychosocial phenomena that is chronic pain, and despite many cautions to this effect, opioids grew into the primary modality of chronic non-cancer pain treatment we know today in the USA¹.

It can therefore be argued that pressure from within Pharma and the decision to widely ignore the cautionary voices raised across the industry are directly responsible for the opioid scourge that now blights American Healthcare. This is worth noting as we look to assign responsibility for the opioid pandemic.

To explain the depth of complicity, consider this. In 2000 the Federation of State Medical Boards and the Drug Enforcement Agency issued statements promising less regulatory scrutiny over opioid prescribers, thereby assuaging physician reluctance to prescribe more liberal amounts of opioid analgesics.²

Provider abetted addiction in modern-day American Healthcare had just been given the official green light.

How opioids work

All opioids are chemically related and interact with opioid receptors on nerve cells in the body and brain. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use — even as prescribed by a doctor — can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose incidents, and deaths.

Exactly how addictive are opioids? That depends on a number of factors and varies from patient to patient. It should take a couple of weeks to become physically dependent on an opioid, but that varies. If you take an opioid for a day or two, it should not be a problem and, generally, you will not become addicted. However, some studies show even the first dose of an opioid can have physiological effects.

There is no exact data and by ingesting an opioid, you are in effect playing a pharmacological version of Russian roulette. If you suffer from cancer-related pain, then you are in a category where the risk is justified by the pain you are experiencing. It is important to understand that you can be physically dependent on a substance but you don’t necessarily have problematic use. A cancer patient with chronic pain may be physically dependent but not addicted.

Opioids are one of the most addictive medications prescribed. Even doctors can become caught up in this dependency cycle, popping a few pills over the course of a few days for sorting out a nagging pain. Ingesting an opioid exposes you to the risk of addiction.

Examining the types of opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.

Brand names (generic names)

• Abstral (fentanyl),
• Actiq (fentanyl),
• Avinza (morphine sulfate extended-release capsules),
• Butrans (buprenorphine transdermal system),
• Demerol (meperidine [also known as isonipecaine or pethidine]),
• Dilaudid (hydromorphone [also known as dihydromorphinone])
• Dolophine (methadone hydrochloride tablets)
• Duragesic (fentanyl transdermal system)
• Fentora (fentanyl)
• Hysingla (hydrocodone)
• Methadose (methadone)
• Morphabond (morphine)
• Nucynta ER (tapentadol extended-release oral tablets)
• Onsolis (fentanyl)
• Oramorph (morphine)
• Oxaydo (oxycodone)
• Roxanol-T (morphine)
• Sublimaze (fentanyl)
• Xtampza ER (oxycodone)
• Zohydro ER (hydrocodone)

Street Names

Captain Cody, Cody, Schoolboy, Doors & Fours, Pancakes & Syrup, Loads, M, Miss Emma, Monkey, White Stuff, Demmies, Pain killer, Apache, China girl, Dance fever, Goodfella, Murder 8, Tango and Cash, China white, Friend, Jackpot, TNT, Oxy 80, Oxycat, Hillbilly heroin, Percs, Perks, Juice, Dillies.

Opioids listed by strength

Opioids are not all created equally and are available in varying strengths, with carfentanil and fentanyl widely recognized as the most potent. This list, provided with thanks by the Dana Point Rehab Campus lists the typical opioids by strength.

1. Carfentanil — Carfentanil is an extremely dangerous opioid that is 10,000 times more potent than morphine and 100 times more potent than fentanyl. Carfentanil is used to tranquilize elephants and other large animals and is not intended for use in humans. Drug dealers may mix carfentanil into their drug supplies to provide their customers with a more potent, addictive high.

2. Fentanyl — Fentanyl is 50 to 100 times more potent than morphine and has been the main contributor to the rise in overdose deaths in recent years. The majority of fentanyl-related deaths involve synthetic fentanyl that is manufactured overseas and mixed with other illicit drugs including heroin, cocaine, and methamphetamine.

It is sold under brand names including Sublimaze, Duragesic, and Actiq. It also has many street names including China Death, TNT, Murder 8, Jackpot, Goodfella, Dance Fever, Apache, and China Girl.

3. Buprenorphine (Butrans) — Buprenorphine is an FDA-approved medication for the treatment of opioid use disorder. It is about 25 to 100 times more potent than morphine, but it does not provide a euphoric high like other opioids. Buprenorphine is used in drug detox to relieve and reduce opioid withdrawal symptoms.

4. Oxymorphone — Oxymorphone is sold under brand names such as Opana and Numorphone. It is an extended-release opioid that has many street names including O Bomb, Stop Signs, Biscuits, and Blues. Oxymorphone is used to relieve moderate to severe pain in patients who are unable to reduce or control pain with other medications. Oxymorphone is 3 times stronger than morphine when taken in tablet form, and 10 times stronger than morphine when received as an intravenous injection.

5. Hydromorphone — Hydromorphone is used to relieve moderate to severe pain and is about two to eight times more potent than morphine, reports the DEA. It is available as an injection, tablet, liquid, and rectal suppository.

6. Heroin — Heroin is an illicit drug classified as a Schedule I substance with a high potential for abuse. Heroin is usually two to five times stronger than morphine and commonly mixed with other potent substances such as fentanyl or carfentanil. In 2018, heroin was involved in 14,996 overdose deaths in the U.S.

7. Methadone (Dolophine, Methadose) — Methadone is another FDA-approved medication for the treatment of opioid addiction and is about three times stronger than morphine. Methadone is often used for long-term maintenance in people in recovery from opioid addiction, and can only be dispensed at an outpatient clinic under direct medical supervision.

8. OxyContin — OxyContin is a brand name for Oxycodone, a well-known extended-release opioid. Oxycodone is prescribed to treat moderate to severe pain and is about 50% stronger than morphine. The CDC reports that oxycodone is one of the most common drugs involved in prescription opioid overdose deaths. In 2018, prescription opioids like oxycodone contributed to 14,975 overdose deaths in the U.S.

It is usually sold as a tablet that is meant to last an entire day, which is often bypassed by drug abusers to quicken the release time. Street names include O.C., Oxy, Oxycet, Oxycotton, and Hillbilly Heroin.

9. Percocet — This drug is a combination of oxycodone and acetaminophen. It comes in tablet, liquid oral solution, and capsule form. Some of the street names for the drug include Percs and Hillbilly Heroin since it also contains oxycodone.

10. Hydrocodone — The next in the list of opioids strongest to weakest is hydrocodone, which is sold under many different brand names such as Norco, Vicodin, and Zohydro. It is usually sold as a way to manage pain after surgery, chronic pain, or pain from an injury. It comes in both syrup and tablet form. Street names for hydrocodone include names such as Watson-387 and Vike.

Hydrocodone has about the same strength as morphine and is commonly combined with other pain relievers such as ibuprofen and acetaminophen.

11. Morphine — The drug that was known as the “soldier’s disease” due to addictions it caused during war times, is the next in our list of opiates. Brand names include MS Contin and Duramorph among others. It is often used as a pain-management solution for cancer patients. It is available in tablet, capsule, suppository, and injectable form. It has street names such as White Stuff, Monkey, and Miss Emma.

12. Tramadol (Ultram) — Tramadol is used to relieve moderate to moderately severe pain and has about one-tenth the potency of morphine. This drug is the only opioid categorized as a Schedule IV substance on the Controlled Substances Act.

13. Demerol (Meperidine) — The brand name opioid, Demerol, is most frequently used to treat moderate to severe pain, and is about 7 to 10 times less potent than morphine. It may also be used as anesthesia due to its potency. The drug comes in a variety of forms including an injectable solution, tablet, and liquid oral solution. Common street names include Pain Killer and Demmies.

Though meperidine is less potent than many other opioids, it is classified as a Schedule II narcotic along with oxycodone and fentanyl.

14. Codeine — This opioid is a relatively short-acting opiate. It is commonly prescribed along with aspirin and acetaminophen. Tablet, capsule, and liquid forms of the drug are sold. Some of the names that Codeine goes by when sold illegally include Purple Drank, Lean, Cody, and Sizzurp.

Overcoming opioid addiction

It will probably come as no surprise that pharma has been beavering away to create treatments it can sell you to counter opioid addition. Ironic and possibly the most glaring indictment of an industry bereft of ethics or patient-focused motives. Weaning a patient off opioids is a lengthy, expensive and demanding process, for both provider and patient and is often met with failure.

Methadone, when administered properly, is included in treatment with counseling and is always provided in a clinical setting. It helps to block the effects of opioids and to reduce cravings.

The medicine buprenorphine also helps opioid cravings without giving the same high as other opioid drugs. Prescribed by many physicians, this is typically a daily dose placed under the tongue and can also be delivered as a once-a-month injection or through thin tubes placed under the skin every six months.

These medicines both activate opioid receptors in the body that suppress cravings, and are effective and similar in safety and side effects, and typically used for maintenance treatment. They can be used as a taper agent as well but some patients relapse. Patients who are highly motivated and have good social support have a tendency to do better.

Naltrexone

This medicine is very different and doesn’t activate the opioid receptor the way that buprenorphine and methadone do, but instead blocks the euphoric/sedative effects of opioids. Your system must be completely free of all opioids before beginning naltrexone. It can be taken orally or as a once-a-month injection.

References

1. Opioid treatment of chronic nonmalignant pain. Stein C Anesth Analg. 1997 Apr; 84(4):912–4. [PubMed] [Ref list]
2. Pain management, controlled substances, and state medical board policy: a decade of change. Joranson DE, Gilson AM, Dahl JL, Haddox JD J Pain Symptom Manage. 2002 Feb; 23(2):138–47. [PubMed] [Ref list]
3. America’s Drug Overdose Epidemic. [CDC]

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It hasn’t been tested, at least not in meaningful ways that would allow traditional medicine to give it the green light. Additionally, current pressure in the public sphere from groups of Kratom supporters reeks of ulterior motives and their strategies look remarkably similar to those used by the anti-vaccination campaigners. 

So what is the truth? Is the drug a godsend, as users would have you believe? Is it a dangerous narcotic that needs to be banned, or is it perhaps something more important? A medicine, waiting to be formally recognized. I asked a few users from within the Kratom community to share their stories. I’ve received many but wanted to share the two below as they highlight the two different benefits of the drug claimed by its supporters, namely pain relief and release from opioid addiction. 

To be clear, I am not an advocate for Kratom, not as it currently distributed. I do however believe the drug offers a real window of hope to many suffering from chronic pain and it is my firm belief that action needs to be taken to both protect users and to ensure. availability of a clean and safe, clinically trialed product. I’ll discuss the routes to this below. 

Let’s hear from Keith first, a Kratom fan and potentially, a life long devotee. He has been using the product for a while and his story is reflective of many Kratom users. Here. unedited, is his response to my request for information. 

Hi Robert. I am a 48 year old Catholic School Teacher in NYC the last 24 years. Had terrible DDD and didn’t want to use any Rx drugs. Found Kratom in 2011. Got my pain down so much I put a full gym in my house. Down 120lbs. Healthiest I’ve ever been. Kratom has been a God send. I saw what opioids did to my dad and swore never to take them. Found it in a simple Google search and now I’ve been on network news 3x (NBC, CBS, PIX11) and have contributed to many interviews and podcasts. I have to say, your statement that it’s deadly is misleading. Sure, theres some bad apples out there, but I am getting pure, lab tested, cGMP Kratom. Never abused it. I drink 2 cups of tea a day with a few grams of it in each. My entire family (wife is a Doctor. Mom an RN) support Kratom after seeing the amazing results. Energy, focus, motivation…All fantastic. Zero side effects. Zero WD. Have to have a good honest source with labs. I look forward to a productive conversation\debate.

Next up is Kendell. Kendell was addicted to opioids and experienced life threatening symptoms from Tramadol use. This is his experience with Kratom, verbatim from his response. 

I’m responding to your request for kratom input. I can’t speak to other advocates, but me personally, I use kratom for 3 things. TO manage chronic pain from scoliosis, to keep me away from medications of the opioid class, specifically tramadol, and to manage the mild depression that goes along with my tramadol withdrawal. I’ve been using it for a total of a year this december, so I’m new compared to most other kratom users. One of your reporters wrote a very negative article on kratom claiming it to be a legal narcotic that people can buy at gas statations, he’s right, it can be bought at gas stations, but it’s no more a narcotic than coffee is. Others will probably send you good scientific proof of this, so all I can do is share my own personal kratom story. Read here at kratomherald.com/real-life-kr…. We don’t ordinarily respond so passionate to reporters but this article was particularly unpleasant, with a host of assumptions, mainly that all kratom users are drug addicts looking for a legal high or to get around the regulations on opioid pain meds. Kratom is a partial bias gProtein agonist at the mu opioid receptor, so yes it does bind at the same site as opioids, but it binds differently. Most opioids are full agonists, and cause a huge release of dopamine into the nucleus acumbuns, leading to addiction. Kratom’s alkaloids don’t affect this area of the brain, and one of them, mitragynine, reverses the downregulation of opioid receptors caused by chronic opioid use, and also reduces the upregulation of cAmp, cyclic adenasine monophosphate, which happens when you use opioids for a long time. We fight for kratom’s legality because we don’t see any other choice, but we aren’t ordinarily so harsh with reporters unless they treat kratom advocates rather badly, as this one did.

In case you’re wondering about that nasty reporter, guilty as charged. You can read the article he is referring to here. 

That feedback was not what I had expected, given the drug’s bad reputation and FDA advice. It wasn’t the end of it though. My DM’s on Twitter soon filled with similar stories and this has led me to a few conclusions I will share below. First off though, let’s have a closer look at some of those ingredients Kendell was referring to. It’s important, as these alkaloids are at the very heart of the Kratom controversy.

The two primary alkaloids of Kratom that are in contention are Mitragynine and 7-Hydroxymitragynine. We’ll start by examining each of these ingredients individually.

Mitragynine

According to a ScienceDirect article (reproduced in part below), Kratom is a psychoactive compound (drug) found in the leaves of M. speciosa. It can be consumed in fresh, dried (leaf or powder), or concentrated liquid extract form. The use of M. speciosa as a narcotic is not new; however, the extraction and refinement of the alkaloids from the plant into Kratom is relatively neoteric (new).

This is an important point and lies at the heart of regulation. There is a world of difference between chewing on a leaf and extracting and refining the active ingredients. It is very likely that this practice has led directly to regulation and bans imposed globally (see countries listed below).

A common route of administration is by chewing the fresh leaves at a dosage of normally 10 to 30 leaves per day. Kratom can be ingested as crushed dried leaves by taking the powder, drinking as a tea, or by smoking the leaves or the extract. Mitragynine is the major alkaloid (up to 66% in the extract) in kratom and is the principal compound responsible for analgesic activity due to its potent opioid agonist property

Recently, 7-hydroxymitragynine, a minor constituent (2%) of M. speciosa, was isolated and demonstrated potent antinociceptive activity in mice. It is now considered to be a major contributory factor for the analgesic properties of M. speciosa due to its selectivity for μ- and κ-opioid receptors. The presence of an hydroxyl group at C-7 increases the potency of 7-hydroxymitragynine to be 13- and 46-fold higher than morphine and mitragynine, respectively. This clearly indicates that this is one of the main pharmacological markers of kratom products’ quality and potency.

In addition to analgesic activity, mitragynine is also a key component for the anti-inflammatory properties of kratom by suppressing prostaglandin E2 (PGE-2) production in the cyclooxygenase 2 (COX-2) pathway [73].

This all sounds very promising but is there a downside, According to the research documents, yes.

Mitragynine has been shown to demonstrate a wide range of adverse effects. Opioid-like adverse effects have been observed and include constipation, dry mouth, and loss of appetite. There have also been reports of patients suffering from intrahepatic cholestasis after two weeks of kratom use and seizure and coma which might result from opioid agonist action of the major components in kratom.

Studies in mice showing serious conditions after administration, for example, elevated blood pressure and hepatic enzymes after a single dose, impaired cognition and behavior from long-term use, and acute lethally hepatotoxic and mild nephrotoxic effects after high dose administration. Kratom extracts and mitragynine have also been shown to possess cytotoxicity to some human cancer cell lines namely SH-SY5Y cells (neuronal cells).

In conclusion, the author cites the following;

A study looking at ‘kratom dependence syndrome’ has suggested that as it is a short-acting μ-opioid receptor agonist, therapeutic agents such as dihydrocodeine and lofexidine are effective in aiding detoxification. Further studies on kratom toxicology and other natural NPS are crucial to understanding the harms associated with this material due to their increasing popularity.

7-Hydroxymitragynine

7-Hydroxymitragynine is a potent opioid analgesic alkaloid isolated from the Thai medicinal herb Mitragyna speciosa. The following is again courtesy of ScienceDirect and the link will take you to the article, parts of which I have highlighted below.

In clinical studies conducted on mice, Subcutaneous (s.c.) administration of 7-hydroxymitragynine produced a potent antinociceptive effect mainly through activation of μ-opioid receptors. Tolerance to the antinociceptive effect of 7-hydroxymitragynine developed as occurs to morphine. Cross-tolerance to morphine was evident in mice rendered tolerant to 7-hydroxymitragynine and vice versa. Naloxone-induced withdrawal signs were elicited equally in mice chronically treated with 7-hydroxymitragynine or morphine.

7-Hydroxymitragynine exhibited a potent antinociceptive effect based on activation of μ-opioid receptors and its morphine-like pharmacological character, but 7-hydroxymitragynine is structurally different from morphine. These interesting characters of 7-hydroxymitragynine promote further investigation of it as a novel lead compound for opioid studies.

Important research by a mouse does not a man maketh. How these ingredients react in humans still needs to be established and clinical trials are already underway, but are very limited and have no doubt been affected by the Covid pandemic. 

The Alkaloid Takeaway

Clearly, we are dealing with two very promising and potentially lethal (If abused) compounds here, a fact which has no doubt prompted the countries listed below to act against Kratom. Remember the extract comment earlier. We aren’t simply dealing with a leaf you chew anymore. We’ve now extracted the useful bits in concentrations that are untried and untested. These are potent concentrates in quantities previously not available through simply chewing a leaf. 

Further study is definitely warranted, given the initial research and user feedback, but this raises a particularly interesting question, one which should be at the forefront of most people’s minds.

Where is big pharma? Why do they apparently express very little interest in the plant or its compounds? Make no mistake, combatting pain is big money. The only market more lucrative, and arguably one they have created themselves, is dealing with opioid addiction, one of the biggest challenges American healthcare faces in the coming decade. There are two possible answers to this question.

The first is simply this. They may have already evaluated the compounds and not seen the financial viability in further development, given the clinical risk profile associated with (perhaps unfairly so) both ingredients. The second is that they may simply view any opioid-related products as tainted, given their current market saturation and the associated negative press surrounding opioids. Simply put, if the drug works, pharma is all over it.

The conspiratorialist that lives on my shoulder would also like to raise a third possible scenario. Existing treatments for opioid addiction, developed at huge cost and generating massive income for big Pharma may have seriously affected decisions to explore a cheaper alternative. Pharmaceutical companies don’t down-sell. It is simply not in their makeup. 

Next, let’s examine global regulation and then look at the nutrition and health sectors’ role in Kratom distribution in the US.

Global Regulation and Bans

This is a definitive list of countries across the globe that have either ruled Kratom to be a regulated medicinal drug (available from your doctor on prescription) or classified it along with other illegal substances, such as heroin and cocaine, meaning possession of the drug is illegal. The information below was sourced from this webpage.

European countries

Belarus, Bulgaria, Croatia, Denmark, Estonia, Finland, France, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Moldova, Norway, Poland, Portugal, Romania, Russia, Slovenia, Switzerland, Turkey, United Kingdom,

Worldwide

Ironically, Indonesia. It is the world’s largest producer of Kratom but use and possession are illegal. Shipping it off to users globally is however encouraged. China and Hong Kong, Japan, Malaysia, Myanmar, Singapore, South Korea, Taiwan, Thailand, Vietnam, Middle East (all countries), Israel, Australia, New Zealand, Egypt, and Argentina all regulate Kratom. 

USA (States)

Alabama, Arkansas, Indiana, Mississippi, Vermont, and Wisconsin have called for a ban on sales. It’s is freely available in most other States or can be ordered online. 

That makes a total of 45 countries (excluding American states) globally that either ban or regulate Kratom as medicine or a controlled substance. Many of these countries have only recently (within the last decade) applied bans or stricter regulation, indicating a growing awareness globally of the dangers of Kratom’s two psychotropic substances in unregulated use. The fact the plant is now sold as an extract has undoubtedly also impacted this decision-making process. 

The Business Side of Kratom

In 2016, Kratom exports from the region of West Kalimantan, Indonesia conservatively reached $130 million in annual profits. Most of these exports were to the USA and in the subsequent years till 2020, profits and volumes have risen annually, but not for much longer. 

A law was passed in late 2019 in Indonesia banning the further production of Kratom. Farmers have been given a five-year “window of grace” to switch over to another crop, but you can be sure production will be ramped up in that period. Make hay will the sun shines. 

The world will soon be facing a Kratom supply problem. This is great news for countries with the right climate and lax legislation. As shrinking demand drives up Kratom prices, the supply chain will be rubbing its hands in glee, in anticipation of the financial windfall to follow. To sell your product though, you require a legal marketplace to peddle your wares, and America’s lax regulatory system allows the perfect climate for exploitation.

To clarify, Kratom is currently sold and marketed by the natural products sector. A sector Medika views as a real danger to public health. These are the same companies and individuals that encourage the sale of Covid cures, bleach-based treatments and that make a plethora of ridiculous claims about the products they sell. 

They are unscrupulous, driven by profit, and a complete lack of ethical responsibility to the users who buy their snake oils. They are also largely unregulated. 

If anything, every effort should be made to ensure Kratom distances itself from this market. The accompanying reputation of dishonesty and deception the natural products market brings with it will do nothing to further Kratoms case to be recognized as a real medicine with legitimate benefits. 

Enter the AKA (American Kratom Association). This not for profit is essentially a group of lobbyists petitioning anyone and everyone for the right to legally choose to use Kratom. Their pitch is essentially this. Fund us and we will ensure that you retain the right to have access to your drug. 

Again I take issue with the tactics being employed by the AKA. Confusing freedom of choice and the safety of the patient is misleading and a clear effort at diversion. Diversion from what though? Could the AKA simply be a tool of the natural products industry to secure future sales? This is simply my suspicious nature at this point smelling smoke, but further investigation is, in my opinion, warranted. If I am wrong, I’ll be the first to hold up my hands.

There are supposedly over 25 million Americans who currently use Kratom if the figures the AKA give out are to be seen as reliable. This figure is an indicator of the size of the market in America and any product with this potential reach is worth its weight in gold to the retailers selling it. 

The looming issue around supply will only serve to drive up prices and poses a further potential risk. The development of synthetic versions of the two key ingredients to ensure availability and dilution of existing formulations to stretch existing stock. 

As there is currently a lack of regulation there is little to stop manufacturers from lacing or watering down formulations with a myriad of potentially life-threatening cocktails. That’s 25 million potential fatalities waiting for us, not so far down the road. 

The AKA’s efforts to ensure self-regulation and quality control, impossible and unenforceable within the natural health sector, in my opinion, may simply be an attempt to avoid regulation from a higher authority. Yeah, I know. Cynical, but sadly a very real possibility. 

I intend to reach out to the AKA to discuss these issues in more depth in a later article. 

What’s the Value of the Kratom Industry in the US 

Great question, but I am not certain anyone has reliable figures. How could they? Product quality differs wildly as does presentation. Kratom takes the form of anything from vapes to powders, teas, and tablets, and with a user who requires the product on a daily basis in varying strengths, the numbers are huge. 

The actual active ingredients or alkaloids in the product are often not measured or represented correctly and as there is no testing of products made available to the public, it’s pretty much a question of going on what the label says. Labels sadly are often misleading. Particularly when you’re dealing with the unregulated natural products industry. Fancy packaging isn’t an indicator of quality or content. No matter what the marketing blurb says. 

Protecting current users

If there are in fact 25 million Americans using Kratom then the issue truly is pressing. Finding a way forward that protects both the users and assures them continued access to Kratom matters. Particularly to those individuals that rely on Kratom to combat chronic pain. 

Banning the drug is short-sighted and counterproductive to its acceptance as medicine if that is where it truly belongs and mounting evidence suggests that to be the case. 

Make a claim, substantiated or not, relating to the use of Kratom and its ability to relieve pain or assist users to kick an opioid addiction and you’ve just moved the product into the realm of medicine. Let’s be completely clear about this point. There is no getting around it. Kratom is a medicine that hasn’t as yet been labeled as such. 

You can dress it up any way you like, it will always come back to this one simple fact. What Kratom purports to do and what you claim as users, makes Kratom a medical drug, a medicine. 

If it’s to be sold OTC or under the supervision of licensed doctors remains to be seen. My gut feel tells me that it is going to require medical supervision, particularly for patients looking to escape the vicious cycle of opioid addiction. 

Dosing and safe levels need to be established. Interactions with other medications need to be listed and monitored. Long-term usage brings its own risks and with it, the need to monitor for symptoms that would indicate problems. For all of the above, you require the hand of a trained medical professional. Not an online Quack with a degree in bullshit and shelves of herbal products waiting to be sold.. 

These individuals are neither properly trained nor do they have the best interests of the patient at heart. Admittedly, neither does every doctor, and it is the duty of the patient to recognize poor care and seek an alternate care provider. 

How do we get Kratom reclassified?

Human trials are an essential part of any medication’s journey to acceptance by the FDA. There aren’t any short cuts. Not unless your name is Covid and you’re threatening the globe. Kratom may be controversial but it’s definitely not in that league so it’s going to be subject to lengthy scrutiny. 

What may very well benefit the drug is its widespread usage in the US. We have, in effect, got real live clinical trials underway and some of these subjects have years of exposure to the product in varying degrees. 

The whole scope of usage is covered. From the occasional mild dose to daily cocktails that would send an elephant into a coma, we have data at our fingertips. Data that could easily be harvested and would reveal the drug’s true risk profile. 

Additionally, testing of users for blood toxicity and related safety concerns centered around the liver and high blood pressure would be easy to determine. As would dependency. 

It is our intention, through our MOBILIZE Health platform to enable a start to the collection of this data. We will, over the coming days, reach out to research groups involved currently in assessing Kratom’s alkaloids. 

Hopefully, harvesting data, data which current users are all too keen to share, will help this novel drug find a safe path onto the shelves of pharmacies across the country. 

In doing so, this will also ensure the safety of current and future generations of Kratom users. Feel free to register a free account and add your comments below to join in the conversation. We value your opinions.

The post Kratom, the Undiluted Truth. Is it a Dangerous Drug or a Godsend? appeared first on Medika Life.

If you would like your local retailers to stop selling this drug to your children and other vulnerable members of the community, there is a link at the end of this article to report the drug and actions you can take to have the product removed from shelves.

What is Kratom?

According to a very detailed analysis of the plant on Wikipedia, Mitragyna speciosa (commonly known as kratom) is a tropical evergreen tree in the coffee family native to Southeast Asia. It is indigenous to Thailand, Indonesia, Malaysia, Myanmar, and Papua New Guinea, where it has been used in herbal medicine since at least the nineteenth century. Kratom has opioid properties and some stimulant-like effects.

As of 2018, the efficacy and safety of kratom are unclear, and the drug was unapproved as a therapeutic agent due to the poor quality of the research. FDA and other investigations suggest that any applications for licensing would fail, based on the drug’s current safety profile and reported interactions with other medications and substances, reactions that are often fatal.

In 2019, the Food and Drug Administration (FDA) stated that there is no evidence that kratom is safe or effective for treating any condition. Some people take it for managing chronic pain, for treating opioid withdrawal symptoms (no shred of clinical evidence exists to support this), as a herbal cure-all sold on various websites as a treatment for pretty much everything, from the common cold to cancers, or for recreational purposes.

The onset of effects typically begins within five to ten minutes and lasts for two to five hours. It’s worth noting that most opioid users end up taking both opioids and Kratom (or cycling), clear evidence that Kratom is useless as a treatment against opioid addiction.

Common and more serious side effects include;

• nausea
• itching
• sweating
• dry mouth
• constipation
• increased urination
• loss of appetite
• seizures
• hallucinations
• respiratory depression (decreased breathing),
• seizure
• addiction
• psychosis

Other serious side effects may include high heart rate and blood pressure, trouble sleeping, and, rarely, liver toxicity. When use is stopped, withdrawal symptoms often occur. Deaths have occurred with kratom both by itself and mixed with other substances. Serious toxicity is relatively rare and generally appears at high doses or when kratom is used with other substances.

Kratom is a controlled substance in 16 countries and, in 2014, the FDA banned importing and manufacturing of kratom as a dietary supplement. As of 2018, there is growing international concern about a possible threat to public health from kratom use. In some jurisdictions, its sale and importation have been restricted, and several public health authorities have raised alerts.

The real danger posed by Kratom

Availability is a key problem. Your child can stop in to shop at a gas station and buy the product off the shelf. A fact verified today by my colleague in Texas. It also doesn’t show up on regular drug tests, so many deaths associated with Kratom go unlisted.

If in some weird alternate universe Kratom is shown to possess any real medical benefits (none have been discovered or scientifically validated as yet) it would still require a lengthy regulation process for certification by the FDA. This process exists to protect consumers against products exactly like Kratom. In 2013, the US Drug Enforcement Agency (DEA) issued a warning about Kratom, stating that there was no proven medical use for the drug.

To be 100% clear on this. Kratom is considered highly dangerous by the FDA and many other countries’ drug licensing authorities. It can lead to death, dependency, and a host of other nasty conditions. It is a psychedelic, so please don’t feed me bullshit about pain management. Get stoned enough and your pain tends to magically evaporate for the duration of the high. The effects reduce with each usage, leading to increased dosages and almost guaranteed addition.

Kratom also won’t cure any diseases or conditions, no matter what the quacks and con-artists selling Kratom promise you.

New drugs often enjoy a honeymoon period with the public, a window where they can be freely distributed simply because legislation has not yet been enforced to protect the public. Cocaine was legally sold across the counter not so many years ago. The system isn’t perfect and it is slow to react. Sadly, death and addition are an all too common byproduct of this window.

There is a reason doctors don’t (or shouldn’t) keep their patients permanently stoned up the yazoo and there is a reason America has a MASSIVE problem with opioid addiction. Psychotropic and psychedelic drugs aren’t the answer for management of chronic pain. In fact, they aren’t a medical solution for just about anything.

If you’re a late-stage cancer patient or other, bedridden and on death’s door, that is a different issue. Don’t confuse chronic pain with end of life scenarios.

On overdose and related interactions

There have been multiple reports of deaths in people who had ingested kratom, but most have involved other substances. A 2019 paper analyzing data from the National Poison Data System found that between 2011–2017 there were 11 deaths associated with kratom exposure. Nine of the 11 deaths reported in this study involved kratom plus other drugs and medicines, such as diphenhydramine (an antihistamine), alcohol, caffeine, benzodiazepines, fentanyl, and cocaine. Two deaths were reported following exposure from kratom alone with no other reported substances.

In 2017, the FDA identified at least 44 deaths related to kratom, with at least one case investigated as possible use of pure kratom. The FDA reports note that many of the kratom-associated deaths appeared to have resulted from adulterated products or taking kratom with other potent substances, including illicit drugs, opioids, benzodiazepines, alcohol, gabapentin, and over-the-counter medications, such as cough syrup.

Also, there have been some reports of kratom packaged as dietary supplements or dietary ingredients that were laced with other compounds that caused deaths. The FDA also seized various Kratom products that were contaminated with Salmonella. Still think your local retailer should be selling this?

Figures above provided by the National Institute on Drug Abuse

The FDA and Kratom in the US

According to a 2019 statement on the FDA website the FDA stated the following regarding Kratom.

The U.S. Food and Drug Administration is warning consumers not to use Mitragyna speciosa, commonly known as kratom, a plant which grows naturally in Thailand, Malaysia, Indonesia, and Papua New Guinea. FDA is concerned that kratom, which affects the same opioid brain receptors as morphine, appears to have properties that expose users to the risks of addiction, abuse, and dependence.

There are no FDA-approved uses for kratom, and the agency has received concerning reports about the safety of kratom. FDA is actively evaluating all available scientific information on this issue and continues to warn consumers not to use any products labeled as containing the botanical substance kratom or its psychoactive compounds, mitragynine and 7-hydroxymitragynine. FDA encourages more research to better understand kratom’s safety profile, including the use of kratom combined with other drugs.

To date, they have taken the following actions against the product’s import into the US.

• In September 2014, U.S. Marshals, at the FDA’s request, seized more than 25,000 pounds of raw kratom material worth more than $5 million from Rosefield Management, Inc. in Van Nuys, California.
• In January 2016, U.S. Marshals, at the FDA’s request, seized nearly 90,000 bottles of dietary supplements labeled as containing kratom and worth more than $400,000. The product, manufactured for and held by Dordoniz Natural Products LLC, located in South Beloit, Illinois, is marketed under the brand name RelaKzpro.
• In August 2016, U.S. Marshals, at the FDA’s request, seized more than 100 cases of products labeled as containing kratom and worth more than $150,000. The products are distributed by Nature Therapeutics LLC, which does business as Kratom Therapy and is located in Grover Beach, California. The seized products are marketed under the brand name Kratom Therapy.

The FDA has issued warnings to companies. The companies receiving warning letters use websites and social media to illegally market kratom products, making unproven claims about the ability of the kratom drug products they distribute to cure, treat, or prevent disease. Examples of claims being made by these companies include:

• “Kratom acts as a μ-opioid receptor-like morphine.”
• “In fact many people use kratom to overcome opiate addiction.”
• “Of course, people who are using kratom to overcome a preexisting opiate addiction may need to use kratom daily to avoid opiate withdrawal.”
• “Usage: It is for the management of chronic pain, as well as recreationally.”
• “Kratom is frequently used as a natural alternative to treat depression, anxiety, addiction, diabetes, chronic pain and fatigue…Kratom has been reported to have taken the place of brand name drugs like Hydrocodone or Oxycodone for individuals, all the way to weaning people off of Heroin.”
• “Some researchers have even claimed that kratom can protect you against cancer!”
• “Kratom is used for energy, to increase attention/focus, to relax, and also to treat pain and addiction. Here is just some of what our customers have used kratom to treat . . . Chronic Pain, Migraines, Opiate Addiction, ADHD/ADD, Anxiety, Depression, Arthritis, Insomnia, and much more!”

Health fraud scams like these can pose serious health risks. These products have not been demonstrated to be safe or effective for any use and may keep some patients from seeking appropriate, FDA-approved therapies. Selling these unapproved products with claims that they can treat opioid addiction and withdrawal and other serious medical conditions is a violation of the Federal Food, Drug, and Cosmetic Act.

There are a lot of advisories issued by the FDA on this drug, you can find an extensive list in the footer of the article linked to above.

Reporting This Drug

You can use this link provided by Medwatch to report the drug and any adverse interactions you, or someone you know, may experience.

MedWatch Online Voluntary Reporting Form

What can you do about retailers making these products freely available in your town or city? If they are large chains, reach out with a formal letter to their head office, notifying them of the dangers of Kratom, and copy in your local government and press. For smaller private retailers, try dropping off or sharing information on the dangers of the product and if they show disregard for your children’s safety and others within their community, consider boycotting the stores.

The post Kratom is an Unregulated Addictive Drug That Kills appeared first on Medika Life.