Addiction Medicine Made Easy | Fighting back against addiction

How One of My Patients Quit Kratom

• Casey Grover, MD, FACEP, FASAM

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Dr. Casey Grover shares his clinical experience treating Kratom Use Disorder through a detailed case presentation of a 38-year-old man who struggled to find medical professionals knowledgeable about kratom addiction.

• Many healthcare providers lack knowledge about kratom, causing delays in patients receiving proper treatment
• Kratom creates opioid dependence similar to traditional opioids, leading to withdrawal symptoms when stopping
• The convenience of buying kratom at smoke shops contrasts sharply with the barriers of traditional medical care
• Patients often use kratom to self-medicate underlying conditions like anxiety, ADHD, or pain
• Effective treatment involves addressing opioid dependence with buprenorphine (or methadone) plus treating underlying conditions
• Once dependent on opioids, patients must either use medications like Suboxone/methadone or endure withdrawal
• Understanding the "feel something, take something" pattern is key to breaking the addiction cycle
• Long-acting injectable buprenorphine (Sublocade) combined with as-needed oral doses proved effective

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department, seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. Today we are going to be talking about kratom. Now Kratom gets a lot of airtime on my podcast and it's actually because I am seeing more and more of it in my addiction medicine practice.

Speaker 1:

I've had several patients referred to me in just the past few weeks who use Kratom, and they are so relieved to hear that I have a lot of experience in treating patients with kratom use disorder. Earlier this month, I was asked to speak as a part of a virtual conference on the topic of opioids and I chose to speak about kratom. The lecture involved two parts First, an overview of kratom, which we have covered in detail on this podcast, but the second was a case presentation. And just in case you don't know what a case presentation is, it's where doctors and other healthcare providers discuss a patient's care in a de-identified fashion to learn about the patient's condition and treatment and I find, as a doctor, that going through a case like this is very educational. In fact, my favorite lectures in medical school were presentations where the lecturer would describe a patient's condition and use the patient's experience, diagnosis and treatment to teach us. So I recorded the second part of the lecture and I wanted to share it with all of you. So here we go with a case presentation of a patient I have treated who uses Kratom. Okay, so we are going to do a case presentation for a patient I treated who was using Kratom. I've changed some of the details, just so nothing about this case is recognizable, but this is someone that I treated myself and I will go through their experience getting off of Kratom.

Speaker 1:

So this is a 38-year-old male that presented to me in the outpatient clinic setting. The patient had completed a high school education and I practice medicine in Monterey County. We make lots of agriculture, so there's a lot of fairly rural areas around us and this particular individual lived in a rural area on a family ranch and was very isolated. He had his own online auto parts business. He would basically go to a wrecking yard and collect functional parts and then sell them in a secondhand fashion online. Had family that was supportive of him, but not anything local, so really didn't have a lot of local human connection or support.

Speaker 1:

The patient came to me, we did our first intake visit and he had a history of alcohol use disorder but was in remission. He had gotten successfully treated for alcohol use and he presented asking for help with Kratom. And you know he'd made an appointment with one of the other doctors in the practice and the doctor was like I really don't know anything about Kratom, go see Dr Grover. And so I walked into clinic and the office staff came up to me. They're like Dr Grover, you have a new Kratom patient today. Do you know anything about Kratom I like? Well, hopefully a little bit.

Speaker 1:

So he was particularly frustrated that no one seemed to know how to help him and he had been using kratom for well over a year and, as we see with most substances, he had developed both dependence, which leads to withdrawal when he stops, and then tolerance, and just a Dependence is when you use a substance regularly and your brain chemistry changes and then when you stop using the substance you feel withdrawal. So for kratom that's opioid withdrawal, nausea, vomiting, diarrhea, restlessness, body aches, chills, goosebumps, very uncomfortable. The other thing is tolerance, which is that, again, when a person uses a substance regularly, their brain chemistry changes and it means that basically the brain needs more of the substance to feel the same effects over time. We see that with alcohol, people say they can quote hold their liquor. That means they have tolerance to alcohol. So for him he was just I'm so done with Kratom. It doesn't work anymore. I'm taking more and more. I'm sick all the time.

Speaker 1:

So he made an appointment to be seen Again in terms of his substance use history. He was successfully treated for alcohol use disorder in 2012. I don't have further details on that, I don't know if it was residential treatment and again, he had just decided to use Kratom on his own, had seen escalating use and had tried to stop on his own with really bad withdrawal symptoms, and so he was referred to a psychiatrist and was referred to my clinic. He initially saw one of our pain doctors, because my practice is both pain medicine and addiction medicine, and the pain doctor was just man, I'm not sure you know, go see addiction medicine. And then he was able to connect with me Medications.

Speaker 1:

The patient had a history, as I mentioned, of alcohol use disorder and had been put on topiramate, also known as topamax. There was a history of migraines so there probably was double duty with the topiramate there. Just a level set. Topiramate can be used for migraines but can be used to reduce the desire to use substances. The patient was also on desvenlafaxine I apologize for the typo there, that's generic for Prostique to help with some underlying depression, and then the psychiatrist had put him on ritazapine, also known as Remeron for sleep.

Speaker 1:

Medical history was notable for depression as well as anxiety and attention deficit, hyperactivity disorder or ADHD. We'll come back to that in just a little bit. Otherwise, no medical history, just psychiatric. In terms of what was tried before medication. He tried just to wean off of Kratom. He tried to use less and less every day and just had debilitating withdrawal. And that's a pretty common experience as to what I hear from my patients. Most of them, once they realize they're dependent, think uh-oh, I got to get off of this stuff. And he was really not able to because of withdrawal symptoms and he was using Kratom multiple times a day. Ultimately, his psychiatrist, to address underlying anxiety and depression, referred him to a therapist which he was seeing.

Speaker 1:

My medical workup on the day I saw him was pretty simple. I did a urine drug test and it was positive for Kratom and negative for any other substances. Just to level set, if you get a urine drug test from Amazon or from Rite Aid or Walgreens, most of these will not test for kratom and kratom, because it's structurally dissimilar to opiates, will not come up positive. So in my lab we actually had to add kratom specifically as a substance. And this comes up at the hospital not infrequently. Someone gets admitted to the hospital for, say, appendicitis. They disclose that they've got, say, an alcohol history. A urine drug test is ordered, they're test negative and then day two of the hospitalization they're completely miserable and then they say oh, by the way, I'm on kratom. It really doesn't pop up on a urine drug test unless you're specifically testing for kratom. All right.

Speaker 1:

So on our first visit we wanted to level set what are the goals that we want to achieve, and he wanted to get off of kratom and remain abstinent from it, and I was 100% on board with that. So in terms of frustrations or barriers or struggles that he had, the biggest one is that he didn't really meet a medical provider that was informed about Kratom to be able to help him. He had asked multiple times of his regular doctor, they sent him to psychiatry. The psychiatrist wasn't really familiar with it. He was ultimately sent to my practice and because he mentioned having pain as a reason why he was using Kratom, they sent him. He was ultimately sent to my practice and because he mentioned having pain as a reason why he was using Kratom, they sent him to the pain side of the practice. They weren't sure, so they sent him to me. So it was actually weeks, if not months, after he asked for help before he was able to get to me. And, as I mentioned, in my practice we have two addiction doctors and then one doctor who's addiction-focused, and between the three of us, I'm really the Kratom geek. So this actually happened. On Monday, a Kratom use disorder patient was referred to one of the other doctors, who has actually re-referred them back to me.

Speaker 1:

So yeah, I mean considering you can walk into a smoke shop and buy it. We probably, as a medical community, need to do better education around Kratom. The next part to me is really fascinating, which is let's talk about the difference between going and buying Kratom and going to see a medical professional, and I have to give kudos to my colleagues who do the Addiction Medicine Journal Club podcast, drs John Keenan and Dr Sonia Deltredici. I've done a couple of joint episodes between our two podcasts about Kratom, and Dr Sonia was on it, so she, like me, was just hey, grover, I heard you went into a smoke shop Like I got to do that too, and her point when she walked into a smoke shop was this is so easy and convenient to get.

Speaker 1:

Let's imagine that you have anxiety and ADHD and your back hurts. Okay, you can go into a smoke shop and buy Kratom as much as you want and walk out in just a few minutes. If you need more, they don't deny you early refills. You just go get more. It's very consumer-friendly. And same thing with going online and going to Kraken Kratom you just put in your credit card and the stuff shows up.

Speaker 1:

Now let's imagine you have anxiety and ADHD and your back hurts and you're going to go through the medical community. Okay, let's say you have a good primary care position. You might call them and it takes three weeks to get an appointment and then you might have a copay and then you got to sit in the waiting room and then you have to talk to the doctor and the doctor might order tests and you've got to get those tests done. And then you got to see the doctor again. And then they're going to order your medicines and, oops, the pharmacy's out of stock and oh, you've got to co-pay. And then, oops, you needed a higher dose and you can't get a hold of the doctor to get a refill. Like it's fairly inconvenient to go through the traditional medical channels as compared to just walking to a smoke shop and buying Kratom. So kudos to Dr Sonia Deltrenici for her wisdom around that, because that was a really good point.

Speaker 1:

And many people who use Kratom do not have a lot of confidence in the traditional medical community, which is why they go to Kratom. And then the last point for this patient is he has untreated ADHD, which I had to work on. So what has he tried before that didn't work? We talked about the fact that he tried to wean himself off the Kratom and just wasn't able to do it, which is fairly common with all of my opioid use disorder patients. My patients using fentanyl just can't wean themselves off. So what did I do? So the first thing is we had to address his opioid dependence, and I'm going to go on a little rant here for just a second, okay.

Speaker 1:

Opioid dependence happens when any human being on planet Earth is exposed to an opioid or something that activates the opiate receptor, like Kratom, for about 10 to 14 days. There is no quick fix to manage opioid dependence. The options are we treat you with an opioid so that you don't withdraw, and the two we use are methadone and buprenorphine, also known as Subutex or Suboxone, or you have to withdraw. There is nothing else. So people will talk to you about kratom and they'll say, well, I don't want to be on suboxone, because then I'm hooked on suboxone. Suboxone is not the problem, it's the opiate dependence that is the problem. Or sometimes you'll hear people say, well, don't go on methadone. That's just trading one addiction for the other. That's not the issue. The issue is the opioid dependence. Once a person is dependent on opioids, we only have two treatments. Like I said, we can either manage their dependence with methadone or buprenorphine, or they have to go through withdrawal. That's it. We can wean people off of methadone or buprenorphine, but they still have to go through withdrawal. In other words, weaning involves stretching out the withdrawal over as long as the weaning period is, and so I just want to be very clear. The issue is the opioid dependence.

Speaker 1:

So for this patient, I had to get him to where he wasn't sick all the time. So I put him on buprenorphine. He had a fantastic response. He took eight milligrams of buprenorphine in the form of Suboxone twice a day. No more withdrawal Great. I also put him on some adamoxetine, also known as Drotera. That's a non-addictive medication for ADHD. He had a very good response there as well. Now he did not really want to be on Suboxone or buprenorphine every day, so I transitioned him to long-acting injectable buprenorphine.

Speaker 1:

What is this stuff? It's an injection that you receive once a month under your skin that releases the medicine, buprenorphine, over about four to six weeks. So, in other words, instead of taking a medicine every day to stay out of withdrawal, you get a shot once a month to stay out of withdrawal. It works amazing. And there are two products. I have no financial ties to them. One is Berksadi, that's one brand. The other is Sublocade, that's the other brand. In his case, I used Sublocade and he did great. Used sublocate and he did great until he relapsed.

Speaker 1:

So I tell my patients when they relapse, you are not in trouble, it means you need another appointment with me right. I'm treating their addiction. Relapse can be part of addiction, so when they relapse, I need to talk to them. We've got to figure out what went wrong. It's almost like we do a debrief like what went wrong, to talk to them. We've got to figure out what went wrong. It's almost like we do a debrief like what went wrong and what we found. And I have to give credit for one of the other addiction doctors in my practice, the very lovely Dr Reb Close, who I happen to be married to. We talk about these sort of cases all the time and she created this little catchphrase that really helps me, and she describes her addiction patients as the way their brain works. It's feel something, take something right. What is addiction? Fundamentally, people use substances to regulate how they feel, and what I need to get them to do is to learn to self-regulate without substances.

Speaker 1:

Okay, so this patient was used to taking alcohol when he didn't feel good. He's in recovery. He's used to using kratom when he doesn't feel good, and when he was on the shot and wasn't taking suboxone every day, he didn't have something to take when he didn't feel good, so he went back to kratom. So what we actually did for him is. We gave him a little baby, tiny dose of buprenorphine again. That's the medicine in Suboxone or Subutex to take when he was having negative feelings or needed something. So the shot provided him with a stable dose of buprenorphine. So he didn't withdraw. He took his adamoxetine or Stratera for his ADHD and if he was having a bad day or had a breakthrough craving he would take an extra dose of a small amount of buprenorphine in the form of, actually, subutex. That was his preferred product and with that I was actually able to keep him in recovery as of December. That was the last time he used. I'm seeing him this week. He's doing great. He's about four months sober.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together, we can make it happen. Thanks for listening and remember treating addiction saves lives. I'll see you next time.