A case of a mixed overdose involving kratom (Mitragyna speciosa) leading to serotonin syndrome

Abstract

Objective: Drug overdose deaths have risen precipitously over the past two years in the United States. Polysubstance overdose with opiates and amphetamines have been of particular concern. Kratom (Mitragyna speciosa) is an unregulated widely available herb with both stimulant and opiate μ-receptor activity. Studies suggest that its use is quickly increasing. Case: We describe a patient who presented to a psychiatric hospital with a mixed toxic syndrome due to chronic kratom and prescribed SSRI use compounded by acute intake of methamphetamine. The patient displayed psychosis, tremulousness, myoclonus, and extreme anxiety. Her clinical picture was consistent with both serotonin syndrome and opiate withdrawal. Conclusion: We call attention to this case because polysubstance overdoses are common, and kratom is widely available. Complex toxic presentations that involve kratom are likely to be increasingly encountered.

Case Report: Possible Serotonin Syndrome in a Patient Taking Kratom and Multiple Serotonergic Agents

“…15,16 The inhibitory effects of kratom and its alkaloids on cytochrome P450 isozymes may not directly potentiate the effects of serotonin, but can lead to excess systemic exposure to medications, increasing the risk for developing serotonin syndrome. While previous case reports vary with regard to psychotropic prescription medications combined with kratom and the amount of kratom ingested, 10,11 the potential pharmacokinetic interactions are similar to the case described here.…”

“…While much is unknown about the pharmacology of kratom and the compounds contained within, this case adds to 2 previously reported cases of serotonin syndrome resulting from coingestion of kratom and serotonergic prescription medications. 10,11 In calculating the likelihood of an adverse drug event, a Naranjo Scale score of 3 was determined using the following criteria: adverse event appeared after the suspected drug was administered (+2), reaction improved when the drug was discontinued or a specific antagonist was administered (+1), alternative causes (other than the drug) that could on their own have caused the reaction (À1), and adverse event confirmed by any objective evidence (+1). 12 Serotonin syndrome was diagnosed in this patient using the Hunter Criteria.…”

Kratom (Mitragynia speciosa), seizure latency, anxiety, and “social” behavior in the zebrafish

“…24 Recent studies 24,25,17 attribute Kratom's reduced respiratory depression to the lack of interaction of mitragynine and several related compounds with the β-arrestin-2 signaling pathway. Kratom also interacts with NE and 5HT, 26,27 and could be mediating the euphoriant, antidepressant, and antipsychotic effects. 28 Seizures are among Kratom's symptoms.…”

Mitragynine (Kratom)—Withdrawal behaviour and cognitive impairments can be ameliorated by an epigenetic mechanism

“…This disparity between MIT and MOR action on μ-receptors may constitute the behavioural changes observed in this study. MIT displays more complex pharmacology as it interacts with several other receptors such as serotonergic (Zweifel et al, 2021), dopaminergic, cholinergic, GABAergic (Suhaimi et al, 2021), and adrenoceptors (Foss et al, 2020), as well as with many liver microsomal enzymes (Kruegel et al, 2019). MIT anti-nociceptive action was reversed following administration of the 5-HT (serotonin) synthesis inhibitor p-chlorophenylalanine or the 5-HT receptor antagonist cyproheptadine.…”