Use of Kratom in the Substance Abuse Community – How Barriers Impede Quality Outcomes that Would Reduce Suffering and Save Lives
John Shinholser
President/Co-Founder The McShin Foundation
BACKGROUND
The traditional approach to substance abuse disorders and the common co-occurring disorders (COD) has relied heavily on observational research on patient outcomes associated with treatment in both outpatient and residential settings. The complexities of patient abuse behaviors have led to multiple treatment models, from treatment intensive outpatient settings to therapeutic community residential stays of between 6 and 12 months.
The common denominator in these treatment models involves an initial detoxification in which the acute and potentially dangerous physiological effects of stopping drug use are managed, and that typically is followed by referral to a drug addiction treatment program. The detoxification often involves unpleasant and potentially fatal side effects associated with withdrawal that are managed by a physician (in either an outpatient or inpatient setting). Medications assist in the withdrawal from opioids, benzodiazepines, alcohol, nicotine, barbiturates, and other sedatives.
It is common in the recovery population for patients to substitute one form of treatment, or the medications they are prescribed, for another in the course of their treatment and recovery. In many cases these substances produce changes in brain structure and function that both promote and sustain addiction and are often linked to relapses. The fact is, substance use disorders are chronic illnesses that produce clinically significant impairments in health, social function, and the capacity to control substance use. Affected individuals often have difficulty in complying with prescribed treatments, and MAT providers often facilitate changes in approaches and medications to match the needs and adherence behaviors of patients.
Medicated-Assisted Treatment (MAT) programs have become a substantial business involving the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide what is known as a “whole patient” approach to the treatment of substance use disorders, including opioids, alcohol, and smoking. MAT for opioid addiction is subject to an array of federal legislative mandates and regulations with robust government funding allocations to combat the scourge of addiction and its societal costs. According to the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) there are more than 2 million people in the United States who suffer from an opioid use disorderi that includes heroin and prescription opioids, such as oxycodone and hydrocodone.
The costs of these programs are staggering, with 2019 State Opioid Response (SOR) grants alone totaling $1.4 billionii with the bulk of those funds allocated to MAT programs. This funding focuses on using three FDA-approved medications for opioid use disorder (OUD) programs, which are characterized as the “gold-standard” for treatments. It is not surprising that the addiction community resists any alternative treatment, particularly any non-drug product being used to wean off of opioids or replace them entirely without the associated withdrawal programs and costs.
ANALYSIS
I have personally observed the evolution of the treatment modalities for substance abuse disorders as an addiction professional for the past 38 years and personally experienced the process as an addict currently in recovery, clean and sober. I have observed firsthand the biases embedded in the addiction treatment community on any potential new options for patients and was a skeptic myself when initial reports were made on the natural plant kratom being effective in reducing drug cravings and in pain mitigation.
Over the past 7 years, I have personally observed over a thousand kratom consumers reporting routine recreational use (similar to using coffee for an energy boost or to increase focus), as a home remedy for pain-related symptoms and as a diversion product from drugs with dangerous safety profiles with known dangerous side effects. Among those using kratom as a diversion from illicit or prescribed pain medications, a large percentage of those addiction cases involved the use of mood-altering prescription medications.
I have personally witnessed hundreds of substance abuse patients use kratom responsibly as a supplement to ease craving symptoms, both physical and psychological, to reduce reliance on more highly addictive and potentially deadly medications. Among those I have personally observed, dozens of individuals used kratom for chronic pain symptoms to successfully reduce use of more dangerous drugs or eliminate reliance on those drugs altogether. My observations mirror the conclusions of the study conducted by Johns Hopkins researcher Albert Garcia-Romeu and his colleagues, which was published in January 2020 in Drug and Alcohol Dependence. They reported that 41% of their study respondents have used kratom to stop or reduce prescription or illicit opioid use, that 87% of those reported relief from withdrawal symptoms, and that 35% reported they had a >1-year abstinence from opioids attributed to kratom use.iii
A survey of 30 kratom users seeking to relieve pain associated with opiate withdrawal resulted in 29 participants who were pain free within 5 days and had stopped using opiates entirely (the lone non-completion participant left the study prior to its end date). This kind of data should have been the catalyst for MAT providers to reexamine their treatment protocols, but a variety of federal regulations and guidelines literally prevent MAT providers from using any substances that are not on the list of FDA-approved drugs authorized for reimbursement in these treatment programs.
In addition, numerous individuals suffering from acute and chronic pain have reported that kratom effectively mitigates their pain and allows them to reduce or stop using medications with a much higher safety profile. It has been my experience in recovery programs that many individuals who are in early recovery from substance use disorders have found kratom to facilitate an easier recovery process than those who are being treated with prescribed medications.
It is a common practice for those in the recovery population to substitute one product for another in an attempt to mitigate withdrawal symptoms, and a growing number of this population report they have responsibly used kratom and experienced a far easier recovery process than those using the approved prescribed medications in the MAT programs. It is counter- intuitive that federal mandates on MAT programs would be restricted from using kratom when it could reduce patient reliance on dangerous prescription medications, shorten recovery periods, potentially eliminate use of more harmful medications, and even save lives of those who die in the currently approved treatment regimen.
CONCLUSIONS
The FDA has unfairly demonized and stigmatized kratom so that it is not currently approved for use in federally regulated MAT programs, and that impacts the treatment approaches of private providers. These barriers to access and those regulatory limitations prevent substance abuse programs from providing the optimal treatment to those individuals who would benefit from access to kratom use. Kratom should be added as a supplement option to first line addiction recovery treatment regimens to allow patient access to a safer option to prescription medications and to reduce the withdrawal effects and time required to successfully treat addictions in traditional treatment programs.
Our first duty as substance abuse and treatment professionals should be to provide access to treatment programs that best serve the interests of patients, including reducing the use of more dangerous drugs and therapies when appropriate. Research funded by the National Institutes on Drug Abuse (NIDA) showing that kratom is not dangerously addictive and the safety data showing that adverse events and deaths associated with kratom use are actually the result of polydrug use or ingesting adulterated kratom with fentanyl, heroin, or morphine all persuasively argue for a new approach by SAMHSA to include kratom as an approved treatment option supervised in MAT programs. The number of individuals who were trapped in opioid addictions and found kratom to be the pathway to reduce or eliminate opioid use is powerful evidence that kratom is part of the solution, and not the problem. If kratom saved only one life, that would be enough. But based on the reports of kratom users who have successfully used kratom to escape addictions, it clearly has saved many lives.
Kratom needs to be freed from the bias of the FDA against all non-drug substances used to manage acute and chronic pain and from the special interest anti-kratom hysteria driven in part by fears of financial losses. Kratom should be allowed to take its place as a legitimate player in the substance abuse treatment community.
John Shinholser currently serves as President of The McShin Foundation, which was founded in 2004 and named for its two recovering co-founders, John Shinholser and Carol McDaid, Virginia’s largest Authentic Recovery Community Organization. In 2005, Shinholser received the prestigious national America Honors Recovery Award from the Johnson Institute -- one of six recognized (nationally) in 2005. In 2005, he also received, along with his wife Carol McDaid, the Caron Foundation's Outstanding Alumni Award. In 2006, Shinholser received the coveted OSAS (Virginia state office of substance abuse services) Award of Virginia for Significant Contributions to the Field of Substance Use Disorder Recovery. This award is typically given to professionals in the field. Mr. Shinholser was the first recovering community member to receive this award.
Under John’s leadership, McShin won the Recovery Community Organization of the year Award for the United States, The Joel Hernandez Award presented by Faces and Voices of Recovery in a Washington D.C. ceremony in June of 2011. Also, under John’s guidance McShin won the national SAMHSA (Substance Abuse and Mental Health Service Administration) Recovery Month 2011 Flicker Award. McShin also won the SAMHSA special event of the year award in 2014. McShin Foundation is one of only 19 nationally CAPRSS accredited RCO’s.
John Shinholser served as President of the SAARA (substance abuse and addiction recovery alliance) of Central Virginia Affiliate and is a former board member of SAARA of Virginia (2001-2005). Shinholser also served on the board of directors of Rubicon, Inc. for fourteen years, the last two as Chairman of the board (1999-2013), Virginia's most comprehensive substance abuse treatment facility (230 beds).
i https://www.samhsa.gov/data/sites/default/files/cbhsq reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf
ii https://www.hhs.gov/about/news/2019/03/20/hhs-releases-additional-487-million-to-states-territories-to-expand-access-to-effective- opioid-treatment.html
iii Albert Garcia-Romeu, et al., Drug and Alcohol Dependence, https://doi.org/10.1016/j.drugalcdep.2020.107849
