(72) Kratom Use in Pregnancy

Treatment of opioid use disorder (OUD) in pregnancy with methadone or buprenorphine (with or without naloxone) is considered standard of care and supported by American College of Obstetrics and Gynecology (ACOG) and American Society of Addiction Medicine (ASAM) (1,2). Kratom (Mitragyna speciosa) is a chemical extracted from a plant native to southeast Asia that has been shown to have opioid properties, and is believed to relieve opioid withdrawal, pain, and depressed mood. The ease with which Kratom can be obtained makes it possible that pregnant women will consider Kratom use as a viable option to substitute for opioids and should be considered whenever assessing for substance use (3).
Here we consider the cases of two pregnant women, aged 34 (Patient A) and 27 (Patient B), who presented to our clinic for treatment of Kratom use. Both patients had started to use Kratom to avert opioid withdrawal. Within a short time both women nevertheless found that they were experiencing opioid withdrawal symptoms when they tried to discontinue Kratom. Patient A had disclosed her Kratom use to her obstetrician, who had prescribed a weaning course of methadone prior to her appointment in our clinic. She was taking 30 mg of methadone per day and experiencing symptoms of opioid withdrawal when she was evaluated. Patient B was taking 30 grams of Kratom per day and experiencing signs and symptoms of opioid use.
Patient A transitioned to buprenorphine-naloxone with an initial dose of 8-2 mg bid for the first 3 weeks, and then increased to 8-2 mg tid as she was still experiencing craving and withdrawal symptoms. She delivered a female infant at 39 weeks estimated gestational age (EGA) by normal spontaneous vaginal delivery (NSVD). The infant did not experience withdrawal symptoms (NOWS) and was discharged at 4 days of life. Growth and development have been appropriate.
Patient B was transitioned to buprenorphine 12 hours after discontinuation of Kratom, at which time she had a COWS score of 15. She required 4 mg of buprenorphine bid. During the third trimester, her dose was changed to buprenorphine-naloxone 6-1.5 mg every morning and 8-2 mg qhs per her request due to an increase in opioid withdrawal symptoms and her desire to change to a film formulation. She delivered a female infant at 40 weeks EGA by NSVD . The infant required medication for NOWS for 18 days starting at 3 days of life and was discharged at 28 days. She has been diagnosed with formula intolerance and colic but has been growing and achieving developmental milestones appropriately.
These cases illustrate the need for obstetricians and other delivering physicians and pediatricians to maintain a high index of suspicion for Kratom use during pregnancy (4). It is important to have knowledge of the pharmacodynamics of Kratom and how it can both mimic and differ from effects of the opioids. As we could find no literature showing a toxic effect of Kratom on the developing fetus, treatment with methadone or buprenorphine provides an alternative to repeated maternal intoxication and withdrawal associated with attempts to discontinue opioids without medication treatment for OUD or to the unknown effects of Kratom on the developing fetus (3,4).

1. Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017 May/Jun;11(3):178-190. doi: 10.1097/ADM.0000000000000308. PMID: 28406856; PMCID: PMC5457836.
2. Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81–94.
3. Wright ME, Ginsberg C, Parkison AM, Dubose M, Sherbondy M, Shores E. Outcomes of mothers and newborns to prenatal exposure to kratom: a systematic review. J Perinatol. 2021 Jun;41(6):1236-1243. doi: 10.1038/s41372-021-00952-8. Epub 2021 Feb 15. Erratum in: J Perinatol. 2021 Sep 28;: PMID: 33589723; PMCID: PMC8225511.
4. Zedler BK, Mann AL, Kim MM, Amick HR, Joyce AR, Murrelle EL, Jones HE. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction. 2016 Dec;111(12):2115-2128. doi: 10.1111/add.13462. Epub 2016 Jun 30. PMID: 27223595; PMCID: PMC5129590.
5. Hagle HN, Martin M, Winograd R, Merlin J, Finnell DS, Bratberg JP, Gordon AJ, Johnson C, Levy S, MacLane-Baeder D, Northup R, Weinstein Z, Lum PJ. Dismantling racism against Black, Indigenous, and people of color across the substance use continuum: A position statement of the association for multidisciplinary education and research in substance use and addiction. Subst Abus. 2021;42(1):5-12. doi: 10.1080/08897077.2020.1867288. Epub 2021 Jan 19. PMID: 33465013.