The informal use of ketum (Mitragyna speciosa) for opioid withdrawal in the northern states of peninsular Malaysia and implications for drug substitution therapy

Abstract

Background

Ketum (krathom) has been mentioned in the literature as a traditional alternative to manage drug withdrawal symptoms though there are no studies indicating its widespread use for this purpose. This study examines the reasons for ketum consumption in the northern areas of peninsular Malaysia where it is widely used.

Methods

A cross-sectional survey of 136 active users was conducted in the northern states of Kedah and Penang in Malaysia. On-site urine screening was done for other substance use.

Findings

Ketum users were relatively older (mean 38.7 years) than the larger substance using group. Nearly 77% (104 subjects) had previous drug use history, whilst urine screening confirmed 62 subjects were also using other substances. Longer-term users (use >2 years) had higher odds of being married, of consuming more than the average three glasses of ketum a day and reporting better appetite. Short-term users had higher odds of having ever used heroin, testing positive for heroin and of using ketum to reduce addiction to other drugs. Both groups used ketum to reduce their intake of more expensive opiates, to manage withdrawal symptoms and because it was cheaper than heroin. These findings differ from those in neighbouring Thailand where ketum was used primarily to increase physical endurance.

Conclusions

No previous study has shown the use of ketum to manage opioid withdrawal symptoms except for a single case reported in the US. Ketum was described as affordable, easily available and having no serious side effects despite prolonged use. It also permitted self-treatment that avoids stigmatisation as a drug dependent. The claims of so many subjects on the benefits of ketum merits serious scientific investigation. If prolonged use is safe, the potential for widening the scope and reach of substitution therapy and lowering its cost are tremendous, particularly in developing countries.

Introduction

A major concern amongst those working in the field of harm reduction is to prevent opiate users from converting to injecting drug use since the latter behaviour increases the risks of HIV/AIDS significantly. The current programme of harm reduction that relies substantially on methadone therapy faces at least two problems: first, in order to benefit from methadone substitution, users must adhere to a strict regimen supervised by a physician—a challenge to non-urban drug dependents who live at a distance from the management centres. Second, methadone itself is an expensive drug and even if dependents may not be charged for it, taxpayers bear the burden of the rising expenditure.

The efficacy of ketum or Mitragyna speciosa in managing withdrawal symptoms has appeared from time to time in the literature. It is a medicinal herb long used in southern Thailand (where it is known as krathom) and the northern states of peninsular Malaysia to increase physical endurance and as a folk remedy for a variety of maladies including fever and pain. One of the earliest reports of it being used to treat opium withdrawal is a widely cited study published in 1932 (Grewal, 1932). The results of subsequent studies on the pharmacological properties of ketum and its effects (based on animal models) have been well summarised (Babu, McCurdy, & Boyer, 2008). Two alkaloids in ketum—mitragynine and alkaloid 7-hydroxyminitragynine—act as agonists to supraspinal mu- and delta-opioid receptors and produce effects similar to morphine. In fact, the latter exhibited about 13 times higher potency than morphine and about 46 times higher potency than mitragynine in animal studies (Matsumoto et al., 2004). The ability of both alkaloids to activate supraspinal mu- and delta-opioid receptors lend credence to claims by users that it mitigates opioid withdrawal symptoms (Babu et al., 2008)

However, the widespread use of ketum to ameliorate opiate withdrawal has only been inferred from the increasing number of Internet vendors and the Internet postings on ketum purchase, preparation, use and benefits, including the management of withdrawal pains (Boyer, Babu, Macalino, & Compton, 2007). There have been no actual studies suggesting that users were relying upon it to manage opioid withdrawal symptoms, with the exception of a single case reported recently in the US (Boyer, Babu, Adkins, McCurdy, & Halpern, 2008). Two previous studies of ketum users in Thailand confirmed its traditional use to enhance physical effort and endurance but not for withdrawal management (Suwanlert, 1975, Assanangkornchai et al., 2006). This was somewhat surprising given the claim that ketum has traditionally replaced opiates in addiction treatment in Thailand (cited in Jansen & Prast, 1988).

Ketum may hold the potential for being a cheap herbal preparation that could be used in helping drug users reduce their opiate addiction and the closely related danger of HIV/AIDS. To date there have been no closely monitored studies of the effects of ketum in opioid withdrawal management amongst human subjects; neither have there been reports of its wide use in this respect in a casual setting.

This motivated us to initiate a study in the northern states of peninsular Malaysia that border Thailand and where ketum consumption has always been popular. We were curious to find out if ketum users were utilising it to ameliorate the effects of opioid withdrawal. The primary objective of this study was, therefore, to investigate the major reasons for ketum consumption and to examine the socio-demographic characteristics of users.