Sections

Introduction
Results
Discussion
Acknowledgement

Introduction

Kratom is indigenous to Thailand. Market gardeners, peasants and laborers often become addicted to kratom leaf use. In certain respects kratom addiction resembles addiction to a drug with narcotic properties, except that long-term kratom addicts develop a dark skin, particularly on the cheeks. The age of onset is apparently later than in heroin addiction, and females are rare amongst those who use the substance. Because of the harmful effects which may result from the use of kratom leaf, the Government of Thailand passed a law (Kratom Act 2486) which came into force on 3 August 1943 and by virtue of which it is forbidden to plant the tree; and existing ones are to be cut down. Kratom, known botanically as Mytragyna speciosa Korth., is a large tropical tree cultivated in Thailand, especially in the central and southern regions; it is rarely found in the northern and north-eastern parts of the country. The kratom leaf has long been known to possess narcotic properties and the beginning of its use in Thailand cannot be dated. Kratom is also called Kakuam, Ithang and, in the south of the country, Thom. In Thai folk medicine the leaf is used for the treatment of diarrhoea and as a substitute in cases of opium addiction. Some villagers use it as an ingredient for cooking. Market gardeners, peasants and labourers become easily addicted to the use of the leaf; they reason that it helps them to overcome the burden of their hard work and meager existence. Several alkaloids have been derived from the plant such as mytragynine, speciofoline, rhynchophylline, and stipulatine. In the present study thirty male and female cases of kratom addiction were selected from the Nondhaburi province and from the suburbs of Bangkok for the purpose of an intensive study. The interview method was used with a questionnaire consisting of 30 items. In addition five cases of psychotic patients with a history of kratom addiction were studied at Srithunya Psychiatric Hospital in Nondhaburi. Findings from psychiatric and physical examinations as well as treatment results were evaluated.

Results

DEMOGRAPHIC CHARACTERISTICS

Table 1 shows the demographic data collected from the subject sample. Twenty-nine of the kratom users were male and one was female. The addicts ranged in age between 31 and 77 years. Market gardeners, peasants and labourers were the predominant occupations in the sample. The social composition was: middle-class cultivators, low-class peasants and labourers.

* Based on a paper read at the 31st International Congress on Alcoholism and Drug Dependence held at Bangkok in February 1975, organized by the International Council on Alcohol and Addictions.

** For further details please see "The alkaloids of Mitragyna", by E. J. Shellard in: Bulletin on Narcotics, vol. XXVI, No. 2 (1974).

TABLE 1

Demographic characteristics of 30 Thai kratom eaters

Characteristic	Number of subjects
Age
Under 20	0
20-29	0
30-49	15
50-59	6
60-69	6
70 or over	3
Sex
Male	29
Female	1
Marital status
Single	1
Married	26
Divorced	2
Widowed	1
Social class
Upper	1
Middle	19
Lower	10
Ethnic background
Thai	30
Chinese	0

TABLE 2

Onset and duration of kratom addiction

Characteristic	Number of subjects
Age at onset
Under 20	2
20-29	7
30-39	13
40-49	8
Date of onset
1945-1949	6
1950-1954	4
1955-1959	9
1960-1964	4
1965-1970	6
1971-1975	1
Number of years addicted
1-5	1
6-10	6
11-15	4
16-20	9
21-25	4
26-30	6

METHOD OF CONSUMPTION AND ONSET AND DURATION OF ADDICTION

There are two kinds of popular kratom uses among Thai addicts in this area; the kratom leaf contains either a red or a white vein and the latter has a stronger effect. The persons in the sample preferred either a mixture of the red and white vein (73.3%), red vein (16.6%) or a white vein (10%). 90% of kratom use is by chewing the fresh leaf or by grinding the dried leaf. This can then be eaten without further preparation or after having been placed into warm water. Some people also grind the fresh kratom leaf. For each preparation the vein in the leaf is extracted and in some cases salt is added to prevent constipation. Consumption is usually followed by a drink of warm liquid: warm water (40%); warm water and hot coffee (30%) or hot coffe alone (30%). In the early stages of addiction the user may take only a few leaves to obtain satisfactory results. The dosage is then increased in varying degrees among individual subjects: 10-20 leaves daily (40%); 21-30 leaves daily (36.6%); while the remainder of the sample increased its daily use to an indefinite number of leaves. The addicts chew about 3-10 times a day, depending on their sensation of weariness to be overcome. Amattayakul (1960) reported that an average green leaf weighs about 1.7 g and a dry leaf about 0.43 g. Twenty kratom leaves contain about 17 mg of mitragynine.

Kratom tree (tall one)

Table 2 shows the onset and duration of kratom addiction and the duration of addiction at five year intervals. Almost all subjects in the sample became addicted to kratom because they wanted to work more efficiently. The subjects in this sample had been addicted for a period of from 3 years to 30 years, with a mean of 18.6 years.

PSYCHOLOGICAL EFFECTS

Five to ten minutes after kratom consumption the user described himself as feeling happy, strong and active. The most important aspect for this kind of addict is a strong desire to work on his plot, in the rice field, or do other manual work.

Kratom leaf: white and red

Kratom leaves and flowers

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He can work from morning until evening, even though it may be very hot and the sun bright at midday. Addicts are, however, afraid of the rain which causes.them to catch cold easily. They mention that their mind is calm and that they prefer to stay alone. Sexual desire is limited in about 30% of the subjects under study who need a combination of kratom and alcohol for sexual stimulation (26.3%). In 63.3% there was a normal sex life and only 6.6% used the leaf to prolong sexual intercourse. Anorexia, weight loss and insomnia are common among long-term kratom addicts. As these symptoms are similar to those of depression, it might be difficult to differentiate between depression and kratom addiction if one were to ignore an addict's case history.

Kratom flower

Kratom, dried and fresh flower

PHYSIOLOGICAL EFFECTS

Long term addicts become thin, their skin darkens, particularly in the face on both cheeks which gives an appearance similar to a hepatic face. Dryness in the mouth is common as well as frequent micturition and often constipation. Some mention that the faeces are black and tend to be small in shape similar to goat faeces (Norakarnphadung, 1968). Withdrawal symptoms include, for example, hostility, aggression, flow of tears, wet nose, inability to work, aching in the muscles and bones, jerky movement of the limbs. These are all typical symptoms of kratom addicts.

KRATOM PSYCHOSIS

There were five cases of kratom addiction revealing psychotic symptoms; these had been seen by the author in the last year (1974) in the outpatient department. Initially three cases were suspected of having kratom psychosis on the basis of their history of addiction and their general appearance and on psychiatric examination.

Case 1: A 55-year old Thai subject had begun eating kratom at the age of 20. His complaints were convulsions and mental confusion over the past few weeks. He was thin, his skin had become dark, particularly in the face on both cheeks, and it had an appearance similar to a hepatic face. Clouding of consciousness, experiencing of delusions and hallucinations were clearly evident.

Case 2: This 32-year old Thai was a labourer. He had begun using the kratom leaf daily at the age of 22 and had combined his kratom addiction with alcohol consumption for the past two years. He was confused and experienced persecutory ideation. He was admitted for two weeks; the result of the treatment was satisfactory.

Case 3: This 31-year old Thai was a married labourer who had begun eating kratom when he was 14. He complained of dizziness and headaches. He experienced hallucinations, delusion and confusion.

Only case 2 was admitted to the hospital, where major tranquillizers and supportive treatment were given. Cases 1 and 3 were out-patients, treated with major tranquillizers.

Cases 4 and 5 were psychotic patients. They had been multiple addicts, combining the use of kratom with alcohol, amphetamines and heroin. There were two cases of schizophrenia who had a history of kratom addiction and who were still users. While they were limited in social activity, they were good workers. None of them has relapsed during the past 10 years.

Discussion

Kratom addicts in the sample studied were all Thai subjects, no Chinese addict was found in the area. The only discovered kratom addiction occurred among the Thai ethnic group. Norakarnphadung (1968) analysed data of drug addicts in 1960. There Were 3,384 cases registered who were admitted to the government opium treatment centre at Rangsit. Of these, only 2,000 were selected for investigation. These patients were divided into three groups: (i) Thai heroin addicts with a recent date of onset of use, combining heroin with kratom, about 5.5%; no Chinese were amongst these users; (ii) opium users who had switched to heroin, using the kratom leaf as well, about 11.5%; in this group Chinese users were represented by 0.93%; (iii) opium addicts also using the kratom leaf, 6.5%, with no Chinese amongst this group. It may be concluded that kratom addiction is culture-bound.

The reasons for starting the use of kratom are different from those given by opium users (Westermeyer, 1974). There was no subject in the sample who took kratom because of chronic illness. Kratom users have a strong desire to do more work and to make more money. They learned how to use the leaf from others. One factor in kratom leaf addiction is its cheapness and relative availability within the area, another is the cost factor, 100 kratom leaves costing 5 baht (25 United States cents).

Subjects in the sample began addictive use between adolescence and their mid30s. The mean age is higher than that of heroin addicts (Norakarnphadung, 1968). The proportion between male and female Thai addicts indicated a much higher ratio for the male group. Kratom use is rural in origin, with a cultural factor playing an important role; apparently society accepts male addicts who work to support their family, but do not accept female addicts.

Progression to kratom addiction is a gradual process with increases in dosage and frequency of use. Withdrawal symptoms of either minor or major severity are similar to those observed during withdrawal from other narcotics. There was only one who wanted to terminate addiction. In the early stages of addiction subjects can work hard and make good progress in semi-skilled and unskilled manual work. However after prolonged addiction their energy store often drops because of physical and psychiatric disturbances. There is no report of kratom use amongst students.

The measure chosen by law to control kratom addiction by banning the cultivation of the tree has not been found to be effective, since it is a local plant. It is hoped that drug education for the rural youth in areas where kratom can be grown will be a more effective step towards its control.

Acknowledgement

The author is deeply indebted to Professor Phon Sansingkeo for his help in the preparation of this paper, and to many co-workers without whose co-operation these studies could not have been accomplished.

Bibliography

Amattayakul T., The kraton leaves. J. Department of Medical Sciences, Thailand, vol. 2: 2, 104-108, 1960.

Norakarnphadung P., Analytic Data of Drug Addicts in Management of Narcotic Drug Dependence in Thanyarak Hospital, Thailand, 1968.

Phillipson D. J. and J. E. Shellard. The Alkaloid Content of some Asian Species of Mitragyna. School of Pharmacy, Chelsea College of Science and Technology, London, 1965.

Westermeyer J., Opium Smoking in Laos: A survey of 40 addicts. Am. J. Psychiatry, 131: 2, 165-170, 1974.