Kratom, controversy and harm reduction (Part 2: Federal Ban-aloo)
December 22, 2016 2:03 AM Subscribe
Kratom is a name for the product of the tree Mitragyna speciosa, which is native to Southeast Asia. The leaves of the tree are made into a tea or chewed by users. Initially it was scheduled to be banned on the 30th of September however significant public response prompted an extension. The Washington Post, Wired, Scientific American, and many other outlets have commented on the situation.
Joe Rogan interviews documentary filmmaker Chris Bell who was in the middle of filming a documentary on Kratom when the ban was announced.
Previously on metafilter
Joe Rogan interviews documentary filmmaker Chris Bell who was in the middle of filming a documentary on Kratom when the ban was announced.
Previously on metafilter
DEA: useless group of fear mongering imbeciles trying to remain relevant any way they can
posted by james33 at 3:15 AM on December 22, 2016 [8 favorites]
posted by james33 at 3:15 AM on December 22, 2016 [8 favorites]
Hmm, I feel like many of these articles are one-sided. Kratom can be highly addictive and is actually a real problem in Thailand.
Here is another piece by a highly cited researcher.
Interesting potential, yes. A drug that's currently abused by people in the community? Also yes. I'm not saying it should be banned, but the DEAs decision making is not inexplicable, here, and there may be a sound public health rationale behind it.
We don't want to throw the baby out with the bathwater, but also it's worth taking some time to look at what exactly is in the bath water.
posted by smoke at 3:30 AM on December 22, 2016 [19 favorites]
Here is another piece by a highly cited researcher.
Interesting potential, yes. A drug that's currently abused by people in the community? Also yes. I'm not saying it should be banned, but the DEAs decision making is not inexplicable, here, and there may be a sound public health rationale behind it.
We don't want to throw the baby out with the bathwater, but also it's worth taking some time to look at what exactly is in the bath water.
posted by smoke at 3:30 AM on December 22, 2016 [19 favorites]
@smoke, thanks for posting some more critical stuff. One of the interesting stories about Thailand is that the government there made Kratom illegal because it was cutting into the markets opium sales:
Justice Minister Chaikasem Nitsiri is pushing senior officials to end a 70-year-old ban on kratom enacted under a dubious pretense: kratom once helped opium users kick addiction in an era when the government raked in lucrative opium taxes. source
Really I just think there needs to be a lot more nuance than the outright bans DEA does on things that clearly have some medical value despite not being researched by "the right folks" who determine what has value but take forever to do so and at great cost.
posted by whorl at 4:00 AM on December 22, 2016 [4 favorites]
Justice Minister Chaikasem Nitsiri is pushing senior officials to end a 70-year-old ban on kratom enacted under a dubious pretense: kratom once helped opium users kick addiction in an era when the government raked in lucrative opium taxes. source
Really I just think there needs to be a lot more nuance than the outright bans DEA does on things that clearly have some medical value despite not being researched by "the right folks" who determine what has value but take forever to do so and at great cost.
posted by whorl at 4:00 AM on December 22, 2016 [4 favorites]
Kratom gets a second chance, yet CBD gets kicked to Schedule 1 with nary a thought, despite actual studies to support its use. Fuck the DEA.
posted by Thorzdad at 5:09 AM on December 22, 2016 [21 favorites]
posted by Thorzdad at 5:09 AM on December 22, 2016 [21 favorites]
I've been following the stories around kratom and CBD for awhile now, and I feel like a big part of the demand for kratom is driven by the fact that marijuana is itself Schedule 1. While there may be some incremental benefits offered by kratom, I suspect de-scheduling marijuana would cause the demand for kratom to dry up substantially.
With respect to CBD, this is just a mess. The DEA takes the position that CBD has always fallen into Schedule 1, despite not being explicitly identified. The DEA also ignores case law and the express statutory authorization to grow industrial hemp, from which most non-THC-bearing CBD is derived. The DEA issued the new rule regarding CBD without public comment, essentially treating it as an emergency rule relying on treaty obligations. It's not clear what impact this will have on sellers--some have stopped shipping outside states where marijuana has been legalized, while others continue to ship at least for now.
Good thing the new administration will probably institute a nationwide coherent marijuana policy and solve this mess. /s
posted by monju_bosatsu at 5:51 AM on December 22, 2016 [11 favorites]
With respect to CBD, this is just a mess. The DEA takes the position that CBD has always fallen into Schedule 1, despite not being explicitly identified. The DEA also ignores case law and the express statutory authorization to grow industrial hemp, from which most non-THC-bearing CBD is derived. The DEA issued the new rule regarding CBD without public comment, essentially treating it as an emergency rule relying on treaty obligations. It's not clear what impact this will have on sellers--some have stopped shipping outside states where marijuana has been legalized, while others continue to ship at least for now.
Good thing the new administration will probably institute a nationwide coherent marijuana policy and solve this mess. /s
posted by monju_bosatsu at 5:51 AM on December 22, 2016 [11 favorites]
It's not clear what impact this will have on sellers--some have stopped shipping outside states where marijuana has been legalized, while others continue to ship at least for now.
I traded emails with one of the larger CBD suppliers and they said they will continue to ship until forced to do otherwise. They also said that, as far as their lawyers are concerned, they are in the clear under the auspices of the 2014 federal farm bill that allows their products. It should be...interesting.
posted by Thorzdad at 6:06 AM on December 22, 2016 [4 favorites]
I traded emails with one of the larger CBD suppliers and they said they will continue to ship until forced to do otherwise. They also said that, as far as their lawyers are concerned, they are in the clear under the auspices of the 2014 federal farm bill that allows their products. It should be...interesting.
posted by Thorzdad at 6:06 AM on December 22, 2016 [4 favorites]
Cannabidiol (CBD) (INN)[5] is one of at least 113 active cannabinoids identified in cannabis.
Ya, I was wondering too.
posted by Mitheral at 8:26 AM on December 22, 2016
Ya, I was wondering too.
posted by Mitheral at 8:26 AM on December 22, 2016
CBD can be used for pain relief without the confusing or euphoric effects of THC.
posted by poe at 8:34 AM on December 22, 2016 [1 favorite]
posted by poe at 8:34 AM on December 22, 2016 [1 favorite]
This has me thinking about how to handle substances that have benefit but also the potential for addiction.
Not leaving people utterly alone for the majority of their days seems like an important part of a solution.
At the same time, not forcing people to be in the company of others when they don't want to be is important too.
posted by amtho at 9:00 AM on December 22, 2016 [1 favorite]
Not leaving people utterly alone for the majority of their days seems like an important part of a solution.
At the same time, not forcing people to be in the company of others when they don't want to be is important too.
posted by amtho at 9:00 AM on December 22, 2016 [1 favorite]
> worth taking some time to look at what exactly is in the bath water.
Unfortunately given the economics of pharmaceutical research in the US, scheduling Kratom, or any other substance, as schedule I amounts to throwing out the baby, the bathwater, the bath itself, any towels or soaps used, and effectively ban any conversations about maybe having children. Getting a new drug to market takes lots and lots of time and an enormous pile of money, so drugs that are older than 20 years don't get developed. Unpatentable drugs classified by the DEA as schedule I, II, or III; doubly so.
Given the number of states that have already legalized medical marijuana use, I have the very slimmest sliver of a hope that the incoming federal government will legalize marijuana - not only because the DEA is ignoring their own definition of Schedule I (meaning no accepted medical use despite many states recognizing medical use) or nor because we're in the midst of a opioid epidemic, so non-opioid pain killers might possibly be something we should allow, but because it means the new president will be able to fire a large number of government employees. No DEA, no kratom ban.
posted by fragmede at 9:12 AM on December 22, 2016 [7 favorites]
Unfortunately given the economics of pharmaceutical research in the US, scheduling Kratom, or any other substance, as schedule I amounts to throwing out the baby, the bathwater, the bath itself, any towels or soaps used, and effectively ban any conversations about maybe having children. Getting a new drug to market takes lots and lots of time and an enormous pile of money, so drugs that are older than 20 years don't get developed. Unpatentable drugs classified by the DEA as schedule I, II, or III; doubly so.
Given the number of states that have already legalized medical marijuana use, I have the very slimmest sliver of a hope that the incoming federal government will legalize marijuana - not only because the DEA is ignoring their own definition of Schedule I (meaning no accepted medical use despite many states recognizing medical use) or nor because we're in the midst of a opioid epidemic, so non-opioid pain killers might possibly be something we should allow, but because it means the new president will be able to fire a large number of government employees. No DEA, no kratom ban.
posted by fragmede at 9:12 AM on December 22, 2016 [7 favorites]
I also have been following the Kratom news, as my day gig centers around pharma research. It's another sad story for the pile of sad stories in US biopharma pain relief research.
fragmede gets it right. Except also, we burn down the building containing the bath, fund a study in Texas about the second-hand dangers of bathing in people exposed to shampoo in their teen years, and then salt the earth in a five mile radius around the former location of the bathing location.
Next week's Newsweek headline: KRATOM: Pedophile Tea, or Satanist Salad? YOU DECIDE!
posted by mrdaneri at 9:41 AM on December 22, 2016 [9 favorites]
fragmede gets it right. Except also, we burn down the building containing the bath, fund a study in Texas about the second-hand dangers of bathing in people exposed to shampoo in their teen years, and then salt the earth in a five mile radius around the former location of the bathing location.
Next week's Newsweek headline: KRATOM: Pedophile Tea, or Satanist Salad? YOU DECIDE!
posted by mrdaneri at 9:41 AM on December 22, 2016 [9 favorites]
Given the number of states that have already legalized medical marijuana use, I have the very slimmest sliver of a hope that the incoming federal government will legalize marijuana...
Jeff Sessions is Trump's pick as AG and has always been one of the staunchest anti-legalization voices anywhere. I fear your slim sliver is going to be crushed under the boot of a DEA marching into and raiding legalized states, if ole' Jefferson has anything to say about such things.
posted by Thorzdad at 11:07 AM on December 22, 2016 [6 favorites]
Jeff Sessions is Trump's pick as AG and has always been one of the staunchest anti-legalization voices anywhere. I fear your slim sliver is going to be crushed under the boot of a DEA marching into and raiding legalized states, if ole' Jefferson has anything to say about such things.
posted by Thorzdad at 11:07 AM on December 22, 2016 [6 favorites]
2016: The year it was my grandchildren's turn to mistakenly believe the headlamp of an oncoming train was the light at the end of the tunnel.
posted by mule98J at 11:15 AM on December 22, 2016 [4 favorites]
posted by mule98J at 11:15 AM on December 22, 2016 [4 favorites]
Hmm, I feel like many of these articles are one-sided. Kratom can be highly addictive and is actually a real problem in Thailand.
In fairness that article says kratom as used traditionally does not have I'll effects on health but it becomes addictive when mixed with cough syrup and methamphetamine.
Kratom and cannabinoids (the non thc kind) are not harmless, I think it's foolish to say they are, but they are better alternatives for managing chronic pain than many pharmaceutical opiods, particularly when you factor in the costs and insurance needs, that's for sure. I personally hate kratom, it makes me itch and also feel loopy and I'm not a fan of weed at all but I can see that they help people.
I did drink some kava a friend made recently and it was remarkably relaxing. To the point I took a cab home. Now I'm a lightweight but just because something is legal doesn't absolve your of responsibility for your actions..
posted by fshgrl at 11:30 AM on December 22, 2016 [2 favorites]
In fairness that article says kratom as used traditionally does not have I'll effects on health but it becomes addictive when mixed with cough syrup and methamphetamine.
Kratom and cannabinoids (the non thc kind) are not harmless, I think it's foolish to say they are, but they are better alternatives for managing chronic pain than many pharmaceutical opiods, particularly when you factor in the costs and insurance needs, that's for sure. I personally hate kratom, it makes me itch and also feel loopy and I'm not a fan of weed at all but I can see that they help people.
I did drink some kava a friend made recently and it was remarkably relaxing. To the point I took a cab home. Now I'm a lightweight but just because something is legal doesn't absolve your of responsibility for your actions..
posted by fshgrl at 11:30 AM on December 22, 2016 [2 favorites]
The bad stuff in the bath water according to Smoke's links:
1) recovering opiate addicts find themselves more likely to relapse with continued kratom use than sobriety
2) kratom can be dangerous when combined with certain other drugs
3) stopping habitual use results in mild withdrawal
4) some users end up spending huge amounts of money to support their habit (which seems like a failure to shop around - it's about ten times as expensive in head shops as online, where a typical dose costs less than $1)
5) there are some unknowns about how it works due to lack of studies
No doubt these are public health concerns, but I think the DEA's initial decision to make kratom a Schedule 1 drug isn't credibly explained by the public health issues the drug presents. It makes more sense when you consider their pattern of harshly criminalizing drugs associated with "drug using types." I get why the sometimes over-the-top rhetoric of kratom proponents would make someone want to throw a wet blanket on them, but the DEA really doesn't have a public health leg to stand on in proposing such harsh regulation.
posted by vathek at 11:32 AM on December 22, 2016 [5 favorites]
1) recovering opiate addicts find themselves more likely to relapse with continued kratom use than sobriety
2) kratom can be dangerous when combined with certain other drugs
3) stopping habitual use results in mild withdrawal
4) some users end up spending huge amounts of money to support their habit (which seems like a failure to shop around - it's about ten times as expensive in head shops as online, where a typical dose costs less than $1)
5) there are some unknowns about how it works due to lack of studies
No doubt these are public health concerns, but I think the DEA's initial decision to make kratom a Schedule 1 drug isn't credibly explained by the public health issues the drug presents. It makes more sense when you consider their pattern of harshly criminalizing drugs associated with "drug using types." I get why the sometimes over-the-top rhetoric of kratom proponents would make someone want to throw a wet blanket on them, but the DEA really doesn't have a public health leg to stand on in proposing such harsh regulation.
posted by vathek at 11:32 AM on December 22, 2016 [5 favorites]
This has me thinking about how to handle substances that have benefit but also the potential for addiction.
Not leaving people utterly alone for the majority of their days seems like an important part of a solution.
At the same time, not forcing people to be in the company of others when they don't want to be is important too.
Where opioids are concerned, and that's the number one thing matching your description to be concerned with, I still think the idea of cracking down on supply (which seems to be somewhat resurgent?) is ultimately misguided. Look what we're getting now instead - not even heroin but ultrapotent fentanyl analogues! So I say dramatically increase the availability of naloxone and buprenorphine, maybe go after sales of some of the sketchier synthetics, allow some legitimate or semi-legitimate distribution channel to exist for the well-studied opioids - this last part I admittedly have no idea exactly how to do. And yeah, improving living conditions and giving people other shit to do will help.
(biases: some personal experience)
posted by atoxyl at 11:36 AM on December 22, 2016 [4 favorites]
Not leaving people utterly alone for the majority of their days seems like an important part of a solution.
At the same time, not forcing people to be in the company of others when they don't want to be is important too.
Where opioids are concerned, and that's the number one thing matching your description to be concerned with, I still think the idea of cracking down on supply (which seems to be somewhat resurgent?) is ultimately misguided. Look what we're getting now instead - not even heroin but ultrapotent fentanyl analogues! So I say dramatically increase the availability of naloxone and buprenorphine, maybe go after sales of some of the sketchier synthetics, allow some legitimate or semi-legitimate distribution channel to exist for the well-studied opioids - this last part I admittedly have no idea exactly how to do. And yeah, improving living conditions and giving people other shit to do will help.
(biases: some personal experience)
posted by atoxyl at 11:36 AM on December 22, 2016 [4 favorites]
1) recovering opiate addicts find themselves more likely to relapse with continued kratom use than sobriety
2) kratom can be dangerous when combined with certain other drugs
3) stopping habitual use results in mild withdrawal
4) some users end up spending huge amounts of money to support their habit (which seems like a failure to shop around - it's about ten times as expensive in head shops as online, where a typical dose costs less than $1)
5) there are some unknowns about how it works due to lack of studies
There probably is some legitimate risk of Kratom being a... you know, (sigh) gateway into other opioids - 5/500 hydrocodone/APAP is a pretty weak/terrible drug but still the starting point for plenty of people - and I'm not sure it's established that chronic high doses are entirely safe? On the other hand it doesn't seem especially acutely dangerous, chronic high doses of aforementioned Tylenol preparations are definitely not safe, and it has some maintenance/comedown value for people dependent on stronger drugs.
posted by atoxyl at 11:45 AM on December 22, 2016 [2 favorites]
2) kratom can be dangerous when combined with certain other drugs
3) stopping habitual use results in mild withdrawal
4) some users end up spending huge amounts of money to support their habit (which seems like a failure to shop around - it's about ten times as expensive in head shops as online, where a typical dose costs less than $1)
5) there are some unknowns about how it works due to lack of studies
There probably is some legitimate risk of Kratom being a... you know, (sigh) gateway into other opioids - 5/500 hydrocodone/APAP is a pretty weak/terrible drug but still the starting point for plenty of people - and I'm not sure it's established that chronic high doses are entirely safe? On the other hand it doesn't seem especially acutely dangerous, chronic high doses of aforementioned Tylenol preparations are definitely not safe, and it has some maintenance/comedown value for people dependent on stronger drugs.
posted by atoxyl at 11:45 AM on December 22, 2016 [2 favorites]
I mean opioids are probably not going away because they are pretty fucking good drugs (medically and otherwise) so what real options does that leave you except maximal harm reduction?
(okay I'm done now, for a bit anyway)
posted by atoxyl at 11:48 AM on December 22, 2016 [1 favorite]
(okay I'm done now, for a bit anyway)
posted by atoxyl at 11:48 AM on December 22, 2016 [1 favorite]
I suspect most folks on Metafilter are aware that there is massive misunderstanding of addiction and abuse at the federal level, and within the medical field. Medical folks are more likely to be knowledgeable and empathetic, but they don't make the laws.
Kratom shows a ton of potential, but it's quite likely to be criminalized due to lobbying from big pharma and other opposition.
One current issue faced by folks who might benefit from Kratom is that there are a bewildering number of varieties, and the quality can vary greatly from vendor to vendor. Very few vendors lab test their products. It requires research to find a source that is remotely trustworthy. Effects vary greatly depending on strain, dose, and vendor.
A few states have already moved to make kratom illegal, likely due to pressure from the pharma industry as much as anything else. Indiana is home to Eli Lilly, BMS, and a bunch of other Pharma companies, and has one of the more idiotic anti-Kratom laws. It's classified as a synthetic marijuana variant, which is ridiculous and completely incorrect medically/scientifically.
The DEA seems to believe that you can simply eliminate drug abuse if you spend enough money on enforcement and incarceration. This fails to recognize that drug abuse is nearly always a symptom as opposed to the root cause of a person's problem. Again, I'm sure I'm preaching to the choir, but criminalizing addicts is tragically wrong-headed. There's also a total failure to understand that addiction is a continuum, and that the attendant mental health issues can appear almost anywhere on that continuum at almost any level of severity.
I am very close to a wounded veteran in his late sixties who suffered a crushed ankle many years ago. He wasn't in the service at the time, but was wearing his Army-issue paratrooper boots when the accident happened, and the break was described as a "classic parachute landing break." His options for treatment aren't great: he can either get all of the bones fused, or he can have his foot amputated above the ankle. Both have a number of serious potential consequences. He has other service-related medical issues that make him a poor candidate for surgery, so both options carry serious risk in addition to the potential negative side effects. He has used prescription opiate medications for many years to manage his pain, which is quite severe. He's one of those rare patients who has never abused his medication. He takes it only as prescribed, and tries to use as little of it as possible. His usage is tightly controlled and very light compared to what might be thought of as a traditional opiate addict. Despite all that, he is terrified by and ashamed of his use of these drugs. He worries that he will never be able to stop taking them. He has developed a physical dependency and experiences mild withdrawal symptoms when he tries to stop. The reality is that there's not actually a very good reason for him to stop. These drugs help to manage his severe pain, which allows him to walk and participate in the world around him. Acetaminophen isn't good for you, but the FDA did a good thing by recommending a reduction in the amount of acetaminophen in these drugs several years ago. The opiates themselves do have some negative long-term effects on hearing, cognition, joints, and cardiac health, but all of those have to be carefully balanced against the benefits provided by relieving chronic, severe pain. For instance, without the drugs, he has serious mobility problems, which means that he doesn't get the physical activity that he needs to maintain cardiovascular health.
Thanks to the new crackdown on opiate medications, the VA has decided that he should no longer be taking these meds. At first, they were simply going to stop providing them with no notice whatsoever, which is not only cruel, but almost insane in terms of its medical impact. The most serious complication with opiate withdrawal is that it can cause serious spikes in blood pressure. If you're already someone with poor cardiac health who has to take several medications to manage blood pressure, opiate discontinuation can pose serious risk of stroke. To make matters worse, when a patient like this complains, no matter how appropriate, they are often treated very poorly by medical professionals. There's very little support for proper titration, and any push-back is seen as "drug-seeking behavior." This seems to be especially the case within the VA system, which has a huge host of other problems in addition to being behind the times on medicine and addiction.
So, what do you do with a patient like this? The current guidelines at the VA seem to recommend that the patient simply live with debilitating pain and all of the attendant complications. This is guaranteed to have a negative impact on lifespan, not to mention general quality of life. It's exactly the kind of situation that ends up pushing a person into the arms of heroin and fentanyl dealers.
Kratom is a possible alternative. It's not 100% effective for the kind of acute pain experienced by this patient, but it works well enough that it makes a measurable difference in his quality of life. The physical dependency is significantly less serious than any prescription opiate. It can be abused, but it doesn't usually cause the kind of euphoria that you might get from a typical opiate, so the drive to abuse it is usually far lower than with typical opiates. There's not a ton of research available on long-term impacts, so I can't really speak to that, but I suspect it's a lot less harmful to the body than acetaminophen. For this particular vet, it probably isn't viable as a 100% replacement for prescription opiates, but it might get him to the point where those meds can be used only for acute, break-through pain, which is what they are really intended to treat. Prescription opiates aren't great for chronic pain for a huge number of reasons, but they are very effective when used appropriately.
In my mind, one of the most significant problems in medicine today is that we don't really have any good options for long-term treatment of chronic pain, be they pharmaceutical or otherwise.
Anyway, this all strikes very close to home for me, not just because of my personal connection to the above patient, but also because I suffer from debilitating cluster headaches and migraines, sometimes as often as 10 - 15 days every month. I have MRI scans indicating that these headaches cause demyelinating lesions. I've been through zillions of treatment options, but have never found a solution. Prescription opiates work for me, but they aren't likely to be available for much longer where I live. At this point, I've sort of resolved myself to living with chronic pain until the US manages to adopt better policies around these issues.
I've followed the Kratom saga very closely, and was shocked when the DEA delayed classification. It seemed like a very rare step in the right direction for an agency that, in my opinion, has done infinitely more harm to our country than good. I'm not all that hopeful about its future, though, because there are a lot of political and special interests that hold much greater power than the patients who actually benefit from these drugs.
posted by drklahn at 12:19 AM on December 23, 2016 [10 favorites]
Kratom shows a ton of potential, but it's quite likely to be criminalized due to lobbying from big pharma and other opposition.
One current issue faced by folks who might benefit from Kratom is that there are a bewildering number of varieties, and the quality can vary greatly from vendor to vendor. Very few vendors lab test their products. It requires research to find a source that is remotely trustworthy. Effects vary greatly depending on strain, dose, and vendor.
A few states have already moved to make kratom illegal, likely due to pressure from the pharma industry as much as anything else. Indiana is home to Eli Lilly, BMS, and a bunch of other Pharma companies, and has one of the more idiotic anti-Kratom laws. It's classified as a synthetic marijuana variant, which is ridiculous and completely incorrect medically/scientifically.
The DEA seems to believe that you can simply eliminate drug abuse if you spend enough money on enforcement and incarceration. This fails to recognize that drug abuse is nearly always a symptom as opposed to the root cause of a person's problem. Again, I'm sure I'm preaching to the choir, but criminalizing addicts is tragically wrong-headed. There's also a total failure to understand that addiction is a continuum, and that the attendant mental health issues can appear almost anywhere on that continuum at almost any level of severity.
I am very close to a wounded veteran in his late sixties who suffered a crushed ankle many years ago. He wasn't in the service at the time, but was wearing his Army-issue paratrooper boots when the accident happened, and the break was described as a "classic parachute landing break." His options for treatment aren't great: he can either get all of the bones fused, or he can have his foot amputated above the ankle. Both have a number of serious potential consequences. He has other service-related medical issues that make him a poor candidate for surgery, so both options carry serious risk in addition to the potential negative side effects. He has used prescription opiate medications for many years to manage his pain, which is quite severe. He's one of those rare patients who has never abused his medication. He takes it only as prescribed, and tries to use as little of it as possible. His usage is tightly controlled and very light compared to what might be thought of as a traditional opiate addict. Despite all that, he is terrified by and ashamed of his use of these drugs. He worries that he will never be able to stop taking them. He has developed a physical dependency and experiences mild withdrawal symptoms when he tries to stop. The reality is that there's not actually a very good reason for him to stop. These drugs help to manage his severe pain, which allows him to walk and participate in the world around him. Acetaminophen isn't good for you, but the FDA did a good thing by recommending a reduction in the amount of acetaminophen in these drugs several years ago. The opiates themselves do have some negative long-term effects on hearing, cognition, joints, and cardiac health, but all of those have to be carefully balanced against the benefits provided by relieving chronic, severe pain. For instance, without the drugs, he has serious mobility problems, which means that he doesn't get the physical activity that he needs to maintain cardiovascular health.
Thanks to the new crackdown on opiate medications, the VA has decided that he should no longer be taking these meds. At first, they were simply going to stop providing them with no notice whatsoever, which is not only cruel, but almost insane in terms of its medical impact. The most serious complication with opiate withdrawal is that it can cause serious spikes in blood pressure. If you're already someone with poor cardiac health who has to take several medications to manage blood pressure, opiate discontinuation can pose serious risk of stroke. To make matters worse, when a patient like this complains, no matter how appropriate, they are often treated very poorly by medical professionals. There's very little support for proper titration, and any push-back is seen as "drug-seeking behavior." This seems to be especially the case within the VA system, which has a huge host of other problems in addition to being behind the times on medicine and addiction.
So, what do you do with a patient like this? The current guidelines at the VA seem to recommend that the patient simply live with debilitating pain and all of the attendant complications. This is guaranteed to have a negative impact on lifespan, not to mention general quality of life. It's exactly the kind of situation that ends up pushing a person into the arms of heroin and fentanyl dealers.
Kratom is a possible alternative. It's not 100% effective for the kind of acute pain experienced by this patient, but it works well enough that it makes a measurable difference in his quality of life. The physical dependency is significantly less serious than any prescription opiate. It can be abused, but it doesn't usually cause the kind of euphoria that you might get from a typical opiate, so the drive to abuse it is usually far lower than with typical opiates. There's not a ton of research available on long-term impacts, so I can't really speak to that, but I suspect it's a lot less harmful to the body than acetaminophen. For this particular vet, it probably isn't viable as a 100% replacement for prescription opiates, but it might get him to the point where those meds can be used only for acute, break-through pain, which is what they are really intended to treat. Prescription opiates aren't great for chronic pain for a huge number of reasons, but they are very effective when used appropriately.
In my mind, one of the most significant problems in medicine today is that we don't really have any good options for long-term treatment of chronic pain, be they pharmaceutical or otherwise.
Anyway, this all strikes very close to home for me, not just because of my personal connection to the above patient, but also because I suffer from debilitating cluster headaches and migraines, sometimes as often as 10 - 15 days every month. I have MRI scans indicating that these headaches cause demyelinating lesions. I've been through zillions of treatment options, but have never found a solution. Prescription opiates work for me, but they aren't likely to be available for much longer where I live. At this point, I've sort of resolved myself to living with chronic pain until the US manages to adopt better policies around these issues.
I've followed the Kratom saga very closely, and was shocked when the DEA delayed classification. It seemed like a very rare step in the right direction for an agency that, in my opinion, has done infinitely more harm to our country than good. I'm not all that hopeful about its future, though, because there are a lot of political and special interests that hold much greater power than the patients who actually benefit from these drugs.
posted by drklahn at 12:19 AM on December 23, 2016 [10 favorites]
drklahn There's little need to speculate about the pharmacology of Kratom.
I can't get into what's ethical or not about drug policy, or what pharmaceutical companies should or should not do, save to say that I am a democrat, and I generally favor liberal positions, personally. I don't have any expectation that US will handle this issue any better than we've handled the previous 10,000,001 drug issues.
posted by mrdaneri at 7:10 AM on December 23, 2016 [1 favorite]
I can't get into what's ethical or not about drug policy, or what pharmaceutical companies should or should not do, save to say that I am a democrat, and I generally favor liberal positions, personally. I don't have any expectation that US will handle this issue any better than we've handled the previous 10,000,001 drug issues.
posted by mrdaneri at 7:10 AM on December 23, 2016 [1 favorite]
Forgot to add to the above that I am also a chronic pain patient, who cannot take opiates, for personal reasons, so I would love to have another pain treatment modality-- but with the mu receptor activity in Kratom-- I'm not going to take that addiction risk.
posted by mrdaneri at 7:19 AM on December 23, 2016 [1 favorite]
posted by mrdaneri at 7:19 AM on December 23, 2016 [1 favorite]
The fact that something has addictive potential does not in itself suggest that any harm results from being addicted to it. Addictive potential increases the level of harm that may be caused because of the ways it influences behaviour and results in people continuing to do things that are clearly having negative effects on their health or relationships, but being addicted to a relatively harmless substance has few consequences. Unless, of course, that substance is banned and you are criminalised because your choice of intoxicant differs from the intoxicants that the people in power like to use.
I do voluntary work in harm reduction, but I hate the term for the implied judgement and condescension. "Yes, of course you should stop, but since you're incapable of making the right choices, we'll throw you the barest bones of compassion and maybe provide information/needles/whatever". The way most harm reduction is provided is profoundly dis-empowering and makes it very obvious that what drug users get is actually crumbs from the table from people who think they know better.
In the UK, we had Angelus, a drug charity that claims to take a harm-reduction based approach (and has special access to government policy makers) advocating for prohibition of what used to be 'legal highs' (including kratom). How can an organisation both claim to be working to reduce harms to drug users while lobbying to increase their legal and health risks? Unfortunately this seems to be the status quo among many (though not all) harm reduction organisations. If you want to engage usefully with people, you have to both understand and respect their choices. And that means not delivering harm reduction as a compromise position short of abstinence, but as a way to help people who choose to use drugs to use them better - to maximise the benefits they get from them as well as reduce their exposure to risk of harm.
Tackling these conversations from the mainstream position of harm reduction as compromise doesn't work - the ideological framework accepts many of the same positions as prohibition, differing only really in the value it places on human life versus 'saving' innocents from 'corruption'. The alternative is to empower people to make good choices about their drug use, to use intentionally and purposefully rather than reflexively and to understand (and avoid or mitigate where possible) the risks they are taking. Many drug users already do those things - a lot of the kratom users I've talked to certainly seemed to be making sensible and rational choices with few illusions about what they were doing.
posted by xchmp at 8:12 AM on December 28, 2016 [1 favorite]
I do voluntary work in harm reduction, but I hate the term for the implied judgement and condescension. "Yes, of course you should stop, but since you're incapable of making the right choices, we'll throw you the barest bones of compassion and maybe provide information/needles/whatever". The way most harm reduction is provided is profoundly dis-empowering and makes it very obvious that what drug users get is actually crumbs from the table from people who think they know better.
In the UK, we had Angelus, a drug charity that claims to take a harm-reduction based approach (and has special access to government policy makers) advocating for prohibition of what used to be 'legal highs' (including kratom). How can an organisation both claim to be working to reduce harms to drug users while lobbying to increase their legal and health risks? Unfortunately this seems to be the status quo among many (though not all) harm reduction organisations. If you want to engage usefully with people, you have to both understand and respect their choices. And that means not delivering harm reduction as a compromise position short of abstinence, but as a way to help people who choose to use drugs to use them better - to maximise the benefits they get from them as well as reduce their exposure to risk of harm.
Tackling these conversations from the mainstream position of harm reduction as compromise doesn't work - the ideological framework accepts many of the same positions as prohibition, differing only really in the value it places on human life versus 'saving' innocents from 'corruption'. The alternative is to empower people to make good choices about their drug use, to use intentionally and purposefully rather than reflexively and to understand (and avoid or mitigate where possible) the risks they are taking. Many drug users already do those things - a lot of the kratom users I've talked to certainly seemed to be making sensible and rational choices with few illusions about what they were doing.
posted by xchmp at 8:12 AM on December 28, 2016 [1 favorite]
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posted by whorl at 2:56 AM on December 22, 2016