Episode 34
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What is Khat?
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What is Kratom?
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Could Kratom help with opiate addiction?
In this episode we’ll be talking about two different plants: Khat and Kratom. One is a cultural staple in some parts of the world. Another is being proposed as help for opiate addicts, but faces some legal challenges in the United States. Tune in to this week’s episode of All Things Substance.
Helpful Links
Khat DEA
Khat – Alcohol and Drug Foundation
What Is Khat | Why the Herbal Stimulant ‘Khat’ Was Banned | Live Science
Khat To Be Banned In UK, Against Drugs Advisory Body’s Recommendation | HuffPost UK
British Khat Cafes: The Next Battleground In Fight Against Terror? | HuffPost UK
COVID-induced khat shortage adds to health problems in Somalia | Reuters
Khat | Effects of Khat | FRANK
Khat: Myths, Effects, Risks, and How to Get Help
WHO | Khat chewing in Yemen: turning over a new leaf
Khat – is it more coffee or cocaine? – Los Angeles Times
Khat use: lifestyle or addiction? – PubMed
Kratom DrugFacts | National Institute on Drug Abuse (NIDA)
Kratom: Unsafe and ineffective – Mayo Clinic
The good, the bad, and the maybe, about kratom
The DEA Changes Its Mind on Kratom
Kratom: What science is discovering about the risks and benefits of a controversial herb
Case Report: Treatment of Kratom Use Disorder With a Classical Tricyclic Antidepressant
Can Kratom (Mitragyna speciosa) Alleviate COVID-19 Pain? A Case Study
Thousands Say Kratom Cured Their Addiction. The Government Says It’s Just Another Opioid.
Free Treatment Tool https://betsybyler.com/treatment-tool/
Transcript
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance podcast. This is episode 34.
It seems like spring might have actually sprung up here in the North woods. We get about 10 months of winter and that’s only a slight exaggeration. In the last week it was 80 closing in on 90. Then we had snow, not a lot of it, but enough. Today, I think it’s going to be about 50 and raining. So for us, that means spring is here.
The trends I’ve seen in our work tend to be that we have a real busy new year up through March. It gets a little slower for a little while. Then as tempers become high and school is getting to a close, people tend to want to come back to therapy. Of course, we always have the summer slowdown as most of us know that that’s the best time for us to be taking a vacation.
I’m planning on a trip to go see my sister and head to one of our favorite places on the planet. If you’ve never had a chance to go to Mackinac Island in Michigan, it is fabulous. It’s a small island located between the upper and lower peninsula of Michigan and about eight and a half miles around. There are no cars and you walk, you ride a bike or you take a horse-drawn buggy. It is a really cool place and if you’ve never been, I highly suggest it.
I’m hopeful that each of you are planning some time off. If you haven’t, now’s the time to start thinking about it. That burnout comes out really quickly and strongly at times. I find that I am a better therapist when I am more rested and have been doing things that are fun and not necessarily super productive.
In last week’s episode, I mentioned that we would end up talking about the plant khat or as I found out is pronounced khat. K-h-a-t. The reason it came up last week is that the chemical is strikingly similar in structure to the one that’s found in synthetic methamphetamine or bath salts.
If you haven’t heard of it before, that’s not super surprising. But if you’ve spent any time In the Middle East or Eastern Africa, you definitely would have heard of khat. Khat is a slow growing shrub or tree that typically grows in arid environments and has evergreen leaves. Khat is sometimes called the flower of paradise.
The leaves are usually green or green brown. When they’re fresh, they have a glossy appearance. As they dry, they turn leathery yellow brown. It’s sometimes mistaken for marijuana. The leaves of the plant are often packed together in a bundle and wrapped in banana leaves.
People who use khat typically chew fresh leaves because the active components of the plant break down quickly as they dry out. Dried leaves are sometimes used as tea although the effects are less potent. The buds and leaves of the khat plant are chewed for it’s a stimulant and reportedly euphoric effects. It’s traditionally been used for medicinal purposes as well as recreationally.
People tend to chew khat leaves because of the stimulant effects, which are similar to other stimulants. People who chew it over a span of a few hours, state that it produces a feeling of calm. When I’m talking about chewing, I’m not talking about actively chomping on leaves. Think of it like when someone is using chewing tobacco and they stick it inside their lip and they leave it there for quite some time.
They tend to chew the leaves and then push them into kind of a ball into the side of their cheek. If you look up khat online, you’ll see pictures of people with a bulge in their cheek, almost the size of a golf ball or larger at times. Some people might keep that ball of leaves in their cheek from three to four hours.
Khat’s effects are similar to those of other stimulants. People will become talkative, alert. Sometimes elated and euphoric. Sometimes people report higher self-esteem, increased imagination and ideas. It can also act as an appetite suppressant. The effects began to subside about 90 minutes to three hours or so, but it could last up to 24 hours at the end of a khat session. The user may experience a depressed mood, irritability, loss of appetite and difficulty sleeping.
While the drug itself might be considered pretty low risk. There is an increased risk of some medical issues that come along with khat. The most common issues are related to dental disease, weight loss, constipation, impotence, blurred vision, dizziness, and headaches. It’s unclear which compound is causing these kinds of issues. Although I think the tooth decay one is pretty self-explanatory.
There’s some concern about pesticides used on these plants, because most people who are using khat typically aren’t going to wash the leaves because it might reduce some of the potency of it.
There are some risks of serious side effects and there have been some reports of death caused by khat. What we largely see though is a little bit of a different problem.
The main issues seem to be coming from the up and the down of khat and the amount of time and money needed to be spent on it. From the accounts I read and from the literature I looked at, it seems like there is a moment of euphoria or feeling good and calm, followed by a drop and a depressive state.
This can happen multiple times, depending on how often someone’s using it. And it’s to be expected. The cathinone in there is the stimulant. That’s going to be popping that up. Well, that’s not going to last forever, and we’re not talking about seriously large amounts of the compound because this is a naturally occurring plant and not something that was created and therefore pumped full of cathinone.
There are some reports that it can cause depression because of that up and down and that your body isn’t regulating the way it should. There’s also reports of psychosis, which is to be expected when we’re talking about cathinone. There are some people who psychosis seems to stick around regardless of their use of khat.
Khat contains cathinone and cathine which are the chemicals that produce a stimulant effects. You’ll remember that word cathinone from last week’s discussion on synthetic methamphetamine or bath salts. Cathinone is also one of the main active ingredients in that drug.
Khat is illegal in the United States and Canada, but legal in many other parts of the world including Ethiopia, Somalia, Yemen and Kenya. Cathinone that’s in khat is what makes it illegal as that is classified as a schedule one drug. The other compound cathine is considered a schedule four drug. The schedule four drugs are considered to have lower potential for abuse, but still can lead to limited physical or psychological dependence.
There’s a pretty large cultural difference here it seems in how people view it. Some people feel like it’s no more harmful or dangerous than people drinking coffee all day. There are others who would disagree. It seems like khat has become part of the social fabric in a few countries like Somalia and Yemen.
Those places were particularly hard hit during the pandemic, as the khat wasn’t readily able to be brought into the country due to the pandemic restrictions. News reports from Somalia was that there were a number of people who use khat on a regular basis that were going into withdrawal. There were people showing up in emergency rooms in the country having difficulty because of the withdrawal symptoms
Khat is a chewing practice that dates back thousands of years in the horn of Africa and the Arabian peninsula, where the khat plant is widely cultivated and known by a variety of names.
It has become part of a cultural tradition in a number of countries. In Yemen. For instance, there are people quoted as saying that there is not a single event in Yemen that doesn’t include khat. It’s estimated that 90% of the men there chew caught on a daily basis.
Khat is a regular part of life in a number of countries in Northeast Africa and in the middle East. It’s traditionally been a custom associated with older Muslim men. Its use has expanded to include women and younger people. In Eastern Ethiopia, nearly 30% of adolescent girls and over 70% of adolescent boys chew khat.
Those who don’t chew experience a feeling of isolation. The place of cut in society in certain countries has been under scrutiny at times. The president of Yemen had gone on record saying that something needs to change with the country’s focus on khat. There are a number of issues, like the amount of acres of land dedicated to growing it, which takes away land and water resources from other crops that might be grown too.
What they feel like is sometimes that breakdown of a family where men go and chew khat alone, women go and chew khat alone because they’re not able to do that together in that instance. And that the children are being left without parental supervision. There are reports all over of people who say that their spouse or their parents go out to chew caught in the afternoon and evening. And don’t return until late. Certainly this is not everybody, but this is just what’s being talked about, even from people who are part of the culture.
As for the cultural part, it seems to transfer over country lines. Several years ago, there was some suggestion that khat was a link to terrorist organizations. This came because there are certain cafes, so to speak where khat is served and reports all over the UK were saying that these places were hotbeds of recruitment for Somalian and terroristic activities.
I didn’t find any proof of that, but it was definitely in the news for a few years. The UK decided to ban khat as a way to make sure that they weren’t getting shipments of it through the country.
In the United States, there are areas of the country that have large Somalian populations. For instance, San Diego has a large Somali population. In an article by the LA times entitled. Khat:. Is it more coffee or cocaine? It talks about how in San Diego alone, there’s been an eightfold increase in khat seizures over the last few years.
California joined 27 other States and the federal government in banning the most potent substance in khat and the district of Columbia is proposing to do the same. The president of the African resource center in Washington said “It is a touchy subject. Some people see it like a drug. Some people see it like coffee. You have to understand our background and understand the significance of it in our community”. An Ethiopian medical technician is quoted as saying “we grew up this way. You can’t just cut it off.”
In the same article the spokesperson for the DEA made a statement that seemed to be really dramatic. He said “it’s the same drug used by young kids who go out and shoot people in Africa, Iraq, and Afghanistan. It is something that gives you the heightened sense of invincibility. And when you look at those effects, you could take the word khat out and put in heroin or cocaine.”
I’m not sure about that. And that’s what led me to start looking into the suggested connection here between acts of terrorism and the use of this plant. I can say that I didn’t find any research that would show that there is such a link. I think that that statement is indicative of something else.
I’m wondering if the comparison there isn’t the problem in general. Saying, is it like coffee or is it like cocaine? Those are really different things. From what I read in the personal accounts of people using it, it seems a little more like alcohol. Now, I don’t know that the high or the intoxicated effect from khat is quite as all consuming as alcohol can be.
The reports from families do sound like sometimes what I hear that people have gone out drinking, they spend all their money on alcohol. They’re hanging out with friends while drinking, not being home with their kids, those kinds of things. And I wonder if it’s more like that. Whatever the case actually is, it doesn’t appear to be quite as high risk as something like cocaine, which we’re going to cover next week.
Khat is something that is part of the culture in a number of countries. In the United States. It’s definitely illegal. And for those people who use it in our country, they have to find an illegal source for it.
There’s another plant that I want to cover today. That also has a bit of controversy to it. And that is kratom. Spelled k-r-a-t-o-m. Kratom is a tropical tree from the coffee family native to Southeast Asia. The properties of it range from stimulant-like where it’s energizing and uplifting to opiate-like causing drowsiness and euphoria. Kratom has dozens of active components, which makes it difficult to characterize it as one or the other stimulant or depressant.
There are two main chemicals in kratom mitragynine and hydroxymitragynine. They have strong activity on the main opioid receptors called the “mu” receptor. That’s the one stimulated by heroin and oxycodone. That bit of information there will become important in just a few minutes.
Kratom is generally consumed orally with added sweetener to overcome its harsh bitterness. It can be made into a tea or swallowed as a pill. Kratom is not illegal in the United States. It can be found in gas stations, head shops, you can buy it online and it’s not well-regulated. Kratom takes effect after five to 10 minutes and its effects last for about two to five hours. The effects of kratom become stronger as the quantity taken increases. In animal tests kratom appeared to be more potent than morphine.
Kratom causes effects similar to both opioids and stimulants. It kind of depends on how much you use. It’s reported that smaller amounts are more stimulant like effect and a larger amount is more like an opiate effect. Because it interacts with the opioid receptors it can produce sedation pleasure, decreased pain, especially when used in large amounts. When taken in small amounts, it’s reported to cause increased energy, sociability, and alertness instead of sedation.
Some of the health side effects of Kratom have been reported as nausea, itching, sweating, dry mouth constipation, increased urination, loss of appetite, seizures, and hallucinations. Symptoms of psychosis have been reported in some users.
Kratom is something that you can overdose on. However, users say that you’re going to end up throwing up long before you could end up dying from an overdose. Evidence does suggest that there is a tolerance effect to Kratom. That just like most drugs, you build up a tolerance and therefore have to use more of the substance in order to get the kind of high that you’re looking for.
Evidence and reports also suggest that there’s a withdrawal syndrome. The withdrawal syndrome appears to be similar to the withdrawal from opiates, including muscle aches, insomnia, irritability, emotional changes, runny nose, jerky movements, like restless leg syndrome, those sorts of withdrawal effects.
So Kratom is an interesting drug and I use the word drug because we’re talking about a mood and mind altering substance, which this is. When we look at drugs, we’re looking at: how is it used? Is it illegal? Is there a tolerance? Is it dangerous in terms of can it kill you?
So when we look at Kratom it’s typically something that is used orally, whether someone is chewing the leaves, but most likely they end up doing something like brewing it in a tea or end up using it in a capsule in powdered form. Yes. There is a tolerance. Yes. There’s withdrawal. Yes, there are some significant side effects at higher volumes and yeah, it could kill you. It’s not likely, but it is possible.
It has both a stimulant effect and an opiate effect. That’s pretty rare. Especially for something that is naturally grown, as opposed to being created. Ecstasy has both a stimulant and a hallucinogenic effect, but ecstasy is not naturally occurring. There is a lot of controversy around kratom.
It has to do with the receptors that it’s active on. Remember earlier when I said that it was the Mu receptor that it was activating, and that, that was the same one that is activated by hydrocodone and heroin. Well, that’s where the controversy lies. Some people view Kratom as just another opiate and that it is another epidemic waiting to happen.
Other people swear that it saved them from overdosing on heroin and some other people even claim that it’s cured their addiction to opiates. And that’s just the tip of the iceberg of the controversy surrounding it.
Kratom has become more and more popular in the United States. In 2016, the Drug Enforcement Agency, the DEA had put a notice of intent that they were going to use their emergency powers to make it a schedule one drug. As we know, schedule one drugs are listed as having no medical uses and a high potential for abuse.
This would have put a stop to all kratom on a legal market. There was an incredible amount of public outcry. There were people talking to their senators and other representatives. They were talking in Congress and there were petitions and protests. They were able to get the DEA to back off.
Which is kind of a feat in and of itself. It sorta feels like once the government decides to do a thing, like it’s going to do it. But in 2017 they issued a statement saying that they were going to retract that intention and that there needed to be further public conversation. I certainly don’t think that kratom needs to be a schedule one drug.I don’t know that it needs to be illegal. I’m not sure that I know enough to have an opinion about it.
What I noticed as I was reading is that there’s people in different camps. There’s kratom users who feel like it saved their lives. There’s kratom users who feel like it changed their relationship with pain. There’s kratom users who are either current or former kratom users who believe that kratom ruined their life. And then there’s others who feel like it’s not a big deal and they can take it or leave it.
I was reading in some of the forums on Reddit and other places online where kratom users have gotten together and are discussing things. Rather than having you have to go do that, I’ll kind of summarize what I found. I don’t know that anyone is saying that it’s not addictive. It is. When we say addictive, we mean that your body gets dependent on it. The same way it does on heroin, but also the same way it does on caffeine or nicotine; your body does get used to it.
There is a withdrawal syndrome from it. The withdrawal syndrome itself isn’t dangerous. It sounds unpleasant. And it sounds more unpleasant than say the withdrawal from marijuana, but it doesn’t sound quite as bad as a full-blown opiate withdrawal.
I didn’t see people saying, it’s no thing. I did see some people start talking about how they feel like this is the answer kind of life, God, and everything. That it helped their irritable bowel syndrome, that it cured headaches or that it cured their depression or their anxiety or pain or all sorts of things.
That’s where things start to get a little murky. Because if it’s not just nothing and it does have a mood altering effect, then claiming that it’s going to cure all sorts of things without any evidence. That’s the part I have trouble with.
My experience with kratom comes as a treatment center director. We ran a Suboxone program.
That’s a medication assisted treatment program and required that they weren’t using other substances. Well, a lot of opiate addicts tend to use kratom to handle withdrawal, or when they’re not able to find their drug of choice because it does mimic it.
Kratom is something that’s not easily tested. You have to use a specific test to see it. Now, some might wonder if it’s not illegal why wouldn’t we let people use it? Well, when we’re treating opiate addiction, we’re also asking them to be abstinent from alcohol. It’s not that they have to choose this forever. We’re asking them to choose it while they’re doing this treatment so that their brain can fully clear and we can see what’s left.
Opiate usage causes an incredible amount of damage in the body. It rewires the way we experience pain. In the meantime, we’re trying to arrest this addiction and giving them an abstinence is sort of like a med wash. When someone goes in and gets all their meds taken away and they get their body kind of reset to ”normal.”
Keeping in mind that when someone is in an MAT program, they have a lot of support. They’re being seen multiple times a week, if not close to daily. They have Suboxone onboard, which is a powerful opiate that is helping control cravings and as a side effect helps with pain. In a non- treatment setting though, there are people who feel like kratom has been the answer to keeping them free from heroin.
Yes. They’re using a lot of kratom and it is something that they do need in order to get through their day. However, they’re not using heroin, they’re not snorting pills. The risk of overdose is decreased exponentially. I know that there are cases of people who have died from overdoses of kratom. It’s also not super common.
On one hand we have heroin, which absolutely will kill you. And on the other hand, we have kratom that people say helps with their cravings, withdrawal, and that the use is similar. We do know that it’s similar. We know that it acts on the same receptors as heroin.
What to do about it is sort of the question. I was in a forum the other day and a woman was asking about whether or not using kratom could be part of her recovery. She has chronic pain and she’s been in recovery from other drugs and alcohol for a few years, but she’s continued to use kratom to manage her pain.
She was asking the group if anyone else had that experience. She said in there that she didn’t believe that it was nothing. Because it absolutely is addictive. She also said that she would like to cut back her use of kratom. But she felt like it helped her stay away and stay sober. I’m not sure that I have an issue with that.
I know that the abstinence-based part of me has an initial sitting up and going. What’s that? But I also know that recovery is going to be what it is for each person. It is not my job to determine what your recovery is going to be or what someone else’s recovery is going to be, because each of us have to approach that differently.
My concern is always over a message that a drug is no big deal, that you can use it without any caution or without any issues. That’s where I have struggle, because for a lot of addicts and alcoholics, they aren’t going to be able to use any mood altering chemicals, anything that alters reality at all. Because it eventually leads them back to their drug of choice.
I quoted a comedian a few episodes ago where he was telling a friend I’d love to be able to smoke weed, but every time I do, I wake up with a needle in my arm. Clearly he is not saying that marijuana is a direct link to heroin, but for him it leads him back there. He’s figured out he just has to stay away from it.
When it comes to kratom, I think we don’t know enough yet. I don’t see a reason to make it illegal. I don’t see that it’s especially damaging or dangerous. If alcohol right now is the measure for what we have as legal in the United States. I would say that kratom is at the same level if not below.
We need more research. There could be really good medical reasons to be using kratom. There could be some negative health outcomes because people in the creative community do talk about struggles with constipation or nausea or issues with their liver that it’s not neutral.
So there’s something about the culture in the United States that when something like this pops up and people are getting high on it, that the immediate response is to ban it because nobody can get high. But apparently we can get drunk and that’s not a problem.
There are differing opinions about kratom. In the medical community the Mayo clinic has stated that kratom is unsafe and ineffective. There are reports of exposure to kratom in utero causing withdrawal, otherwise known as neonatal abstinence syndrome.
Mayo feels like the research shows little promise. They say that kratom had been reported to cause abnormal brain function when taken with prescription medicines. This can result in severe headache or losing your ability to communicate or becoming confused.
One issue that has come up is contamination. Because this industry isn’t well-regulated, there can be issues with the products that come through. In April, 2018 there were more than 130 people in 38 States that became ill with salmonella after taking kratom. Salmonella poisoning can be fatal and the FDA linked more than 35 deaths to the contaminated kratom.
We know that opiate addiction is killing people all over the place. Having worked at a treatment center, the majority of people using I don’t think they’re getting treatment and I think they’re stuck and don’t know what to do. They’re afraid to go to their doctors, because if they’re getting any prescription medication they’re afraid is going to get taken. They’re afraid to get help for any number of reasons. It could be because of lack of insurance if you’re in the United States. It could be stigma. It could be fear of the withdrawal and they don’t know if they’re going to be okay.
I saw a number of people talking about using kratom. And for me, I try to keep my eye on the prize. If they are alive, if they are breathing, then there is still hope. There is still hope that they can recover. I absolutely believe that medication assisted treatment is recovery. Kratom assisted recovery? I don’t know. Maybe it’s possible.
I know when it comes to doing therapy, I’m going to have the same response as I do with marijuana or anything else: don’t come high. I’m not doing therapy with someone when their mind is altered. I need them to be present physically and emotionally. That’s going to be my response.
I do believe that we need to be asking about kratom. Sometimes people see it as something that they don’t want to bring up and I think it’s something we need to know about because there are mental health side effects that could be there. I’m not suggesting that we need to go after it and get rid of it.
I’m saying that the person should be able to evaluate their use of it and you need to watch for if it’s causing a problem and try to help them sort through if it is or isn’t. If it is causing a problem. Well, then what do they want to do about that? Do they want to cut back? Why are they using it? I know for myself, one of the things I want clients to do is be able to cope without using substances.
Even if they do drink alcohol or smoke weed socially. I don’t want them doing it in response to being sad or in response to emotional pain. I want them to use skills and I want them to be able to process through the information as best they can. I think it’s dangerous to use a substance each time you feel something that you don’t want to feel. That is a slippery slope.
I wanted us to be aware of kratom. Of the fact that opiate addicts may also be using kratom , that there are people using kratom and using it legally that may not consider it much of a drug. It’s part of our evaluation and our assessment to see what the full picture is of what someone’s use is like and how it impacts their world.
There are a lot of calls for research and my guess is that the research will probably continue. The government wants to make a decision about kratom and figure out what it wants to do regarding its legality. There are some people saying that the only reason that the government wants to ban it is so that they can keep the control in big pharma. That if this was an effective pain medication and you could buy it over the counter that that would take too much money away from all the big pharma companies. I don’t really have a comment on that. We’ll just have to see how this goes as the research comes out.
Earlier in the podcast. I mentioned cocaine and the fact that that’s going to be the topic of our next podcast. As I was going through my list of all the podcasts I have planned, I realized that cocaine and crack weren’t on the list. Which is totally bizarre and not at all a reflection on whether or not cocaine and crack are a big deal.
Cocaine is actually making quite a comeback, at least where I live. So next week, we’re going to talk about cocaine and crack. I hope you’ll join me for that podcast until then have a great week.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.
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