When It Comes to Kratom and Restless Legs Syndrome, the Natural Choice May Not Be the Better Choice: A ReLACSing Blog #26
You can’t blame them. With the indifference from the insurance-based medical system to restless legs syndrome (RLS), the lack of up-to-date knowledge of the recommended (and not recommended) treatments, and the multitude of side effects and potential risks from prescription medications, it is no wonder why many RLS patients are turning to “natural” or “herbal” remedies (1). Some RLS patients have resorted to kratom, an herbal product originating in Southeast Asia, for relief of RLS symptoms when the U.S. allopathic medical system has failed them. Unfortunately, in the case of kratom, RLS patients may find that the risks of kratom use far outweigh the short-term relief in symptoms; the supposedly safer herbal remedy may be far more problematic than the big bad prescription drugs.
Kratom (Mitragyna speciosa)
Over the past five years or so, I have now seen about a dozen patients who have tried or were consistently taking kratom for treatment of RLS. From what I have seen, it is pretty clear that this natural product does have an impact–perhaps a significant impact–on relieving RLS symptoms. At the same time, however, there are very concerning side effects that make me recommend that kratom not be used by patients with RLS until further notice. Of course, if you are reading this and are currently taking kratom, I am not recommending you stop the medication after reading this. As you know, this blog is not for specific medical advice but is for general medical information only, but I would suggest discussing concerns about taking kratom with a licensed medical professional with some experience with kratom before you do anything. What I am recommending (generally, of course) is that RLS patients should not try or start taking kratom for their RLS. It turns out, I am not alone in this opinion. Say what you will about the FDA, the approval process, the bias, the money involved, etc. One of their missions is to protect consumers and they have also recommended that people not use kratom due to similar concerns.
Let us start with the background on kratom. Kratom comes from the plant species Mitragyna speciosa that is found in many parts of Southeast Asia. From what we know about the pharmacology of this plant, its active components mitragynine and 7-hydroxymitragynine work similarly to opioids but also stimulants. They may both stimulate and depress brain function in certain areas or processes. The effects could actually be on par with prescription opioids and stimulants, so despite this being classified as a nutritional supplement, kratom may not look out of place if it were to masquerade as a fancy combo drug of two pharmaceutical agents without anyone knowing it was a “supplement.”
If we step back and understand how many people view natural agents compared to pharmaceuticals, there could be a few themes. First, there is the assumption that because it is natural, it is likely to be mild–in either effect on symptoms or side effects–so how bad could be the risk? This may be the case for many herbal mixtures, and I will not name any specific ones for risk of dismissing any of these untested natural ingredients as benign (we don’t actually know), but you can just go to the supermarket or drug store and look at all the sleep aids whether in teas or supplement pills to know there are many out there. However, many naturally occurring medicines have been found to be powerful. Have you heard the story of the origins of aspirin coming from the bark of a willow tree? Aspirin remains one of the most common preventative treatments for heart disease and stroke among others. Conversely, the downsides, powerful risks, and significant side effects of herbal supplements can also be present, and one cannot assume that everything natural is mild and benign. Aspirin can also cause a life-threatening reaction in children or others to bleed to death. There are many examples of natural agents that go both ways.
Second, we know many of the side effects of pharmaceutical drugs due to the rigorous testing and trial process for FDA approval. We do not have this for over-the-counter treatments. Sometimes we know next to nothing and there has been no testing. The comparison is unbalanced. Some assume, wrongly, that because they hear so much about the side effects of prescription drug X that herbal remedy Y would be much safer. You have all seen those ads on TV in which they spend 5 seconds telling you the name of the drug and what it does. The remaining 25 seconds is an auctioneer-paced recital of the litany of possible side effects with the microscopic fine print at the bottom. Cannabis products will be the poster child for this misconception. With the widespread legalization of marijuana for both recreational and medical use, many have the impression that this is a miracle drug with no downsides. Yes, there may be tremendous benefits potentially, but let’s put cannabis through the rigorous testing of other pharmaceuticals. It is all but guaranteed that the downsides and limitations will be revealed just like with everything else. No miracles. Kratom is no different, and there is slowly more evidence that the risks of this treatment are quite serious.
It is clear to me that the opioid properties are the mechanism by which kratom provides relief of RLS. Though mainstream medicine may have thrown the baby out with the bathwater when it comes to opioids, these are still a powerful treatment for RLS. Aside from being perhaps the oldest herbal remedy itself for RLS dating back to the mid-17th century, opioids have a biological basis as the opioid system of those with RLS has some defects and providing opioids in the form of medications can greatly relieve symptoms. Methadone and other opioids have been used consistently for several decades now and are generally considered a second-line medication class for the treatment of moderate to severe RLS or for those with dopaminergic augmentation.
The difference between kratom and prescription opioids is first the stimulant effect, and second, the exact way in which kratom affects the opioid system to produce RLS relief. The field has a great idea of exactly how buprenorphine, methadone, and oxycodone work but is kratom doing the exact same thing, or is it opioid-like? We don’t know. Isn’t the devil you do know supposed to be better than the devil you don’t? Rather than being bedeviled by whether the natural opioid is better than the manufactured opioid, simply seeing the effects of kratom should be enough to avoid it, whether they are from the opioid side or the stimulant side.
With increasing observation of kratom use, several publications like this and this have reported that kratom can cause drug dependence and withdrawal symptoms after discontinuation, with some similarities to opioids. I have seen the dependence on kratom nearly a half-dozen times in my own practice. Additionally, other symptoms, perhaps from the stimulant effects, can emerge while taking the medication, and these can be quite unpleasant. Some patients begin to feel depressed or highly anxious. Others can have racing thoughts or even delusions. In a few of the patients I have treated for RLS who were taking kratom daily, they describe an emotional rollercoaster not seen in patients on prescription opioids. I suspect this is due to the stimulant effects of this drug. They take too much kratom, they will feel like their emotions are out of control, but if they do not take enough, they feel like they will have withdrawal symptoms or their RLS will become intolerable. Many have felt completely trapped and desperate for a way out.
What should be done for those dependent on kratom for RLS? For some patients, buprenorphine can be an option. There have been some case reports and series illustrating that kratom withdrawal or dependence can be treated by replacing it with buprenorphine similar to other forms of opioid dependence. I have had a small number of patients in which I have personally prescribed buprenorphine to replace kratom or relieve the residual RLS left after coming off kratom previously. Treatment of kratom dependence or withdrawal may require an addiction medicine specialist, who is usually a psychiatrist or internal medicine doctor with subspecialization training in addiction medicine. Despite winging it by starting on kratom, it is best not to wing it by going off kratom without medical supervision.
OK, so I have described the potential harms of kratom, but what are the reasons for a person with RLS to seek kratom when other treatments exist? I’ve discussed many of these issues in previous blogs and the reasons can include:
An utter indifference to RLS by the medical field including neurology and sleep medicine. This leads to patients seeking out treatment on their own, often out of desperation.
IV iron is hard to obtain. Most practitioners have no knowledge of the role of iron in RLS, including appropriate iron levels or facts about iron infusions. Thus, they are hard to get, and of course they aren’t covered by insurance without a second indication like anemia or chronic kidney disease. Good luck finding a transparent and fairly priced cash payment estimate. This is a consensus first-line treatment for RLS that almost nobody with RLS actually gets.
Dopamine agonists are bad for RLS and used to be a first-line treatment, so there are countless swaths of RLS patients with a worsened overall condition due to exposure to these medications for the past 2+ decades.
Alpha-2-delta ligands like gabapentin or pregabalin (Lyrica®) may not be effective, particularly for those with previous augmentation from dopamine agonists. These may not be tolerated due to sleepiness and dizziness to attain an effective dose.
Opioids…need I say more? One of the less obvious downsides of overregulating the prescribing of opioids by government agencies like the DEA is that making opioids nearly impossible to obtain will drive desperate patients to illegal opioids as well as alternatives like kratom. The devil you know, and the devil you know that works pretty darn well in RLS, is better than the devil you don’t know (kratom, cannabis, quinine, etc.).
Some turn to alternative treatments due to skepticism of the pharmaceutical industry and financial ties with doctors, medical institutions, political bodies, etc. Duly noted! I can’t argue with this. I can (and may) write entire blogs on how the pharmaceutical industry combined with the insurance-driven medical establishment has brainwashed doctors into prescribing stimulants to sleepy people, hypnotics to those with trouble sleeping, and dopamine agonists to those with RLS. I will also say definitively, however, that medications cannot be all bad and herbal remedies cannot be all safe and good.
The bottom line is kratom has become a cautionary tale that natural is not necessarily safer or better. There are numerous ways to mitigate symptoms of RLS naturally through lifestyle changes that do not even involve taking supplements or medications. For those for whom lifestyle changes are not enough, there are plenty of natural and artificial remedies that we do know that work, and we are comfortable with the known risks and side effects. Sometimes, the devil we do know is better than the devil we don’t.
-Andy Berkowski, MD of ReLACS Health, who suddenly has a taste for deviled eggs
1. I will try my best to limit using “so-called” quotes for every “so-called” term referenced in this “blog” post.
