Dr Ginevra Liptan
By Ginevra Liptan, MD *Links may generate a commission for this site
Kratom Mitragyna speciosa
Kratom Mitragyna speciosa
Let me start talking about kratom by clarifying that I am not against it (my prior blogs and videos on this topic generated many strong feelings!). Kratom definitely has medicinal properties and many people in chronic report it is helpful for pain. But a wise consumer needs to know all the potential risks along with potential benefits of any medicine or supplement. My biggest concerns about kratom are that because it is so widely available over the counter, even sold at gas stations and liquor stores, that consumers are not taking it seriously as a medicine. My other concern is lack of reliable access to safe sources given products contaminated with toxins and bacteria or adulterated with other medications. Until a major supplement company that does third party testing and complies with GMP regulations starts selling kratom, it is going to remain risky. So Thorne or Pure Encapsulations, get to it!
Kratom comes from the leaves of a tree native to Thailand and swampy areas of Southeast Asia. It is in the plant family Rubiaceae, which also includes the coffee plant. In lower doses it acts as a stimulant, resembling the effect of drugs such as cocaine or amphetamines. In larger doses it acts as a pain reliever and can have sedative effects that resembles drugs such as opiates.
Kratom pharmacology is complex, containing at least 40 different known phytochemicals, and is thought to have actions on many other receptors in addition to the opioid receptors, including dopamine, serotonin, GABA and norepinephrine receptors. However, scientists aren’t even exactly sure how kratom exerts its stimulant effects.
As far as pain, the primary active ingredients of kratom are mitragynine and 7-hydroxymitragynine, which bind to some of the same receptors in the brain as opioids. They have analgesic effects comparable to morphine, but cause less constipation, respiratory depression and tolerance compared to opioids such as morphine. They also have some anti-inflammatory effects. Kratom shares some similarity with opioids in that chronic kratom users can develop a tolerance and experience symptoms of withdrawal that are almost identical to opioid withdrawal (insomnia, anxiety, diarrhea, runny eyes and nose).
Although kratom has less respiratory suppression effects compared to opioids such as morphine, it still can be a deadly substance when mixed with other compounds. There are case reports of overdose deaths due to mixtures of kratom with over-the-counter cold medications, sleep medications, or benzodiazepines. We are also now learning that kratom can have some of the same hormonal side effects as opioids. One of my male patient reported erectile dysfunction due to kratom, and a medical journal published a case of kratom causing increased prolactin and low testosterone levels.
Overall kratom has a better safety and side effect profile than opioids, and hopefully reliable supplement companies will develop products soon so it can really be utilized safely. Learn more about kratom in a prior blog post and video.
Marijuana and Hemp Cannabis Sativa
Humans and the cannabis plant have a long history. Cannabis plants are believed to have evolved on the steppes of Central Asia and its use among humans use goes back as far as 12,000 years, which places it among humanity’s oldest cultivated crops. Burned cannabis seeds have also been found in kurgan burial mounds in Siberia dating back to 3,000 BCE. The plant species Cannabis Sativa has been bred into two different breeds over the millennia- one is rich in fiber and low in THC, this is known as “hemp” and has been used by humans primarily as source of rope and cloth. The other is lower in fiber and high in THC and is used for its medicinal and psychoactive effects and is known most commonly as “marijuana”. Think about dogs. They are all the same species but have been bred over the years into different breeds that have specific characteristics.
The major active medicinal ingredients in cannabis are THC and CBD (cannabidiol). THC is a strong analgesic and is also strong anti-inflammatory— in fact it is 20 times stronger than aspirin—but is also responsible for the psychoactive effects or “high” effects, which can limit its usefulness for pain management. One way around this is to apply marijuana balms (containing both THC and CBD) topically to painful areas, which limits the systemic or brain effects. CBD has the effect of lowering the psychoactive effects of THC, so cannabis products with equal amounts of CBD to THC tend to be the most medicinally effective by providing desired pain relief with less of the undesirable “high.” There is finally some good research showing benefit of cannabis for fibromyalgia pain reduction.
In states where marijuana is legal, it is accessible via dispensaries and usually can also be grown at home or obtained directly from other growers. In states where it is not legal, has to be accessed illegally. Even when marijuana is legal in the state level, it remains federally illegal, so remains in a legal grey zone which is a huge limiting factor for its medicinal usage. As long as it remains illegal federally it will never be accepted by conventional health care providers or employers.
One way around the legality issue is to use ingredients made from hemp, not marijuana plants. Hemp (defined as cannabis plants with less than 0.3% THC) is legal on a federal level since the Farm Bill of 2018. This means that products such as CBD that are derived from hemp are also legal. Hemp-based CBD products are now widely available and are even being sold in major drugstore chains. Clinically CBD on its own is a mild pain reliever but a strong muscle relaxant, with good anti-anxiety and sleep benefits. Read more about CBD for fibromyalgia here and here and access my doctor formulated CBD products here.
I talk a lot about CBD and worry that I may sound like a broken record, so let’s move on to herbal anti-inflammatories in Herbal Analgesics Part 3.
Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You. And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.
Both Kratom and Cannabis have demonstrated ability to reduce pain, but since your doctor may not be comfortable or able to talk to you about their use, it is important to do all the research you can yourself.
Cannabis and Kratom online information in Thailand: Facebook trends 2015–2016
Our study aims to evaluate the trends in online information about cannabis and kratom on Facebook in Thailand, where there is current discussion regarding legalizing these drugs.
Between April and November 2015, reviewers searched for cannabis and kratom Facebook pages in the Thai language via the common search engines. Content analysis was performed and the contents of each page were categorized by the tone of the post (positive, negative or neutral). Then, a one-year follow-up search was conducted to compare the contents.
Twelve Facebook pages each were initially identified for cannabis and for kratom. Follower numbers were higher for cannabis pages. Kratom pages were less active but were open for a longer time. Posts with positive tones and neutral tones were found for both drugs, but none had negative tones. Other drugs were mentioned on the cannabis pages, but they were different from those mentioned on the kratom pages. Issues regarding drug legalization were found on the cannabis pages but not on the kratom pages during the searching period. One year later, the tone of the posts was in the same direction, but the page activity had increased.
The information currently available on the sampled Facebook pages was positive towards the use of cannabis and kratom. No information about harm from these drugs was found through our search.
Cannabis (marijuana) and kratom (Mitragyna speciosa) have been reported to have increasing worldwide use . Studies have shown many negative impacts on health with excessive use of these substances. . Cannabis use is related to many psychological conditions, cardiovascular events, respiratory tract problems and cognitive impairment [10, 28], while kratom could be associated with stimulant effects and opioid-like side effects. Long-term and high-dose usage of kratom has been associated with weight loss, hyperpigmentation, tremor, insomnia, fatigue, poor concentration and possibly seizures [12, 21, 24]. Due to the potential harm, together with the possibility of misuse by users, the Thai Narcotics Control Division has categorized these plants as illicit drug category V, which is illegal to produce, dispose, import, export or possess .
These two drugs have been reported to have various medicinal benefits. Cannabis has been used to decrease nausea, vomiting, and spasticity as well as in pain control and appetite improvement . Kratom was also reported to have positive effects, especially anti-inflammatory, cough-reducing, anti-diarrheal and pain relief effect . Many organizations or groups of people who advocate for legalization use the potential medical benefits of these drugs to drive law changes. However, one study found that cannabis that is legally used for medical purposes is also more likely to be recreationally used by the general population . Thailand is still in discussion regarding legalizing these drugs. As they are still illegal drugs, people are influenced to obtain them from routes outside of government regulation. The online market is one of those routes.
Over the past decade, the internet has become a major location where people communicate and search for information, including that regarding drugs. In Thailand and other countries, illicit drugs and illegal prescriptions drugs are available online with a wide variety of information [4, 11, 15, 20, 22, 23, 27]. The commonly controlled psychoactive substances that have been investigated for online information in prior studies were opiates and cannabis. In contrast, kratom, to the best of our knowledge, has not been studied for online content. This plant is typically used only in a small part of the world, and Thailand is one of the most popular market places . Kratom is currently also available in the European online drug market and is a current topic for legal status debate in the United State. [9, 22, 25]
In recent years, the Thai government has been considering changing the drug schedule for cannabis and kratom. This study aims to evaluate the trend of online information on Facebook pages devoted to cannabis and kratom (the most popular and easily accessible social network site among Thai users)  by categorizing their content based on positive, negative, and neutral tones, determining page activities and noting what other drugs are mentioned in conjunction with cannabis or kratom. These findings of this content analysis may help provide indicators of whether cannabis- and kratom-related content posted on Facebook is potentially harmful to social network users. The findings may also help contextualize the current legal uncertainty of cannabis and kratom in Thailand.
Surveys of content were conducted twice, 1 year apart. The first round of the survey was conducted between April and November 2015. Reviewers manually searched websites daily by entering keywords for cannabis and kratom in the Thai language via the common search engines: Google, Yahoo, and Ask Bing. New keywords obtained during the search process were then used for extended searches. All the keywords are described in Table 1. We additionally conducted a specific search by using “site: Facebook.com” (e.g., กระท่อม site: Facebook.com) to access more pages directly from Facebook via their search engine. We observed the first 300 websites listed from each search, and only Facebook pages were collected for further analysis.
We recorded the names of Facebook pages and page URL addresses in order to track the pages. The number of followers was also recorded as a proxy for the popularity of the page. Content analysis of posts was done by a team of reviewers (KP, WJ, CA). Two independent authors (KP and WJ) individually categorized the first 50 posts. Independently, the two reviewers agreed on 88% of the post. The interrater agreement (kappa) for the first 50 posts was 0.72 (appendix 1). They then collaborated to reach conclusions for the first 50 posts, and then discussed with CA if there was any discrepancy. Afterward, the posts were categorized independently by KP and later reviewed by one of the other two reviewers. The tones of the content were analysed related to the drug and divided into three categories which were positive tone, negative tone and neutral tone. This categorization was adapted from a prior study on marijuana-related traffic on Twitter . A positive tone denoted the text and/or pictures that implied a notably positive attitude towards the use of the drugs. Pictures of smoking people, tools to be used with the drugs, ready-to-use drugs in containers and advertising or marketing of drug-related products were also included. Any content against the use of the drugs was categorized as a negative tone. Neutral tone included the contents that were unlikely to convince people to think positively or negatively about the use of the drugs, for example, a general greeting by an administrator, a picture of the plant or leaves without words, news about laws or research findings without an opinion, and any unrelated topic. Posts about changes in profile picture or cover picture were categorized as neutral. The rate of posting was evaluated by the duration between the last post and the tenth post from the last. A longer period showed less activity on the page. The tones of the posts were obtained and analysed from these last ten posts from each page. The names of other drugs that were suggested to be used with cannabis or kratom in pages were collected to estimate the drugs recommended by the page administrators..
The one-year follow-up search was conducted in October 2016 for 1 week using the URL pages that had been used in 2015. Additionally, new searches were conducted using the 2015 keywords. This follow-up was done in order to estimate the activity and availability of the 2015 pages and to evaluate the content posted on the 2016 pages using the same analysis theme.
Initially, twenty-four total pages were identified, twelve for kratom and twelve for cannabis. These pages had varying numbers of followers. The overall number of followers for cannabis was higher. Posts with positive tones and neutral tones were found for both drugs, but none had negative tones. The results were similar in both periods of searching, 1 year apart. Although there were many posts with a neutral tone about the King who passed away and the country’s great loss during the follow-up period, it seemed that the posts in October 2016 were more likely to have a positive tone about the drugs. Examples of the posts and the categorizations of positive tone are demonstrated in Table 2.
Both drugs had deactivated pages, but new pages were found after 1 year. There was some weak evidence that the number of deactivated pages was higher for cannabis than kratom (p = 0.10). However, ten new Facebook pages for cannabis were found after 1 year, while only three new pages were found for kratom. During the entire study period, we evaluated a total of 24 cannabis pages (267 posts) and 15 kratom pages (206 posts).
Online information for Cannabis on Facebook
The numbers of followers ranged from 225 to 208,695 for the twelve cannabis pages initially found. The average duration between the last ten posts was 46 days (SD 45.8, median 27 days, range 7–148 days). The tone of the posts was likely to be positive towards the use of cannabis (Table 2). Some posts were neutral, but a negative tone was not found. The total number of posts counted for some pages did not reach ten during the searching period. There was one other drug mentioned on the cannabis pages. The administrators mostly discussed cannabis, but one page also mentioned Procodyl® (promethazine hydrochloride). The tones of the posts, numbers of followers, and names of other drugs mentioned on pages for cannabis are shown in Table 3.
One year later, most cannabis pages were not available (9/12 pages), and twelve new pages were found with similar trends in the tone of the posts. The news about the medical benefit and legalization were shared. In 2016, two pages used similar names to those of two pages found in 2015 that were not available when searching by URL. The remaining pages had an increasing number of followers, and the other drug groups mentioned on the cannabis pages were different from those in 2015. We found three cannabis pages that mentioned kratom (not including the kratom pages) and one page about Ya-ba – a tablet containing methamphetamine and caffeine . The duration between the last ten posts was shorter among the cannabis pages, with an average of 29 days (SD 52.4, median 8 days, range 1–160).
Online information for Kratom on Facebook
Followers for the twelve pages ranged from 89 to 7336. The average duration of the last ten posts was 85 days (SD 64.5, median 111 days, range 0–163 days). The tone of the posts was similar to those on the cannabis pages, in that there was more content in positive tones about kratom use. Content about legal issues, which was found on the cannabis pages, was not found on the kratom pages (Table 2). More than half of the kratom pages mentioned other drugs, as shown in Table 4. Two pages mentioned cannabis but were not found when searching for cannabis. Most pages mentioned controlled prescription drugs with sedative effects. The most common one was cough syrup containing antihistamines (chlorpheniramine or diphenhydramine) and ammonium chloride, which was categorized by the Thai Food and Drug Administration as a dangerous drug. These included A-Chlordyl®, Cephendryl®, Bephendryl®, A-waryl®, Iwadil®, Inadril®, and I-22 syrup®.
Five out of twelve of kratom Facebook pages were not available after 1 year, and three new pages were found. The other drugs mentioned in the kratom pages and the tone of the posts were similar to those in 2015. The median duration between the last ten posts was shorter than that in 2015, but the mean was approximately 100 days (SD 114.7, median 54.5 days, range 0–308).
The possession or use of cannabis or kratom is illegal in Thailand. This metanarrative contextualizes the content analysis that was conducted for this study. The majority of public information on Facebook regarding these drugs is positive for the use of the drugs. The contents posted on Facebook pages for both drugs tended towards convincing people to use and buy the drugs online by using invitation text and photos, and this tendency continued at a one-year follow-up. No warning regarding the harm of these drugs was observed. Cannabis pages tended to be more popular and more active than kratom pages.
Cannabis pages were available on Facebook with a high number of followers. At the one-year follow-up, their contents were in the same tones, and the number of followers remained high even though some pages had been deactivated. The content was similar to that found in prior studies conducted in the US [2, 3, 27]. People expressed their good feeling about cannabis, telling other people that they wanted to use it, inviting others to try, mentioning the benefits of the drugs on relieving stress and its medical purposes, suggesting that it should be legalized, and comparing it to other legal drugs by noting its greater benefits and lower risks to health. Posts against cannabis use were comparatively infrequent in the previous study  while we found none in our study.
Kratom was similar to cannabis that the tones of the posts on Facebook were positive and neutral rather than negative in tone. The post contents were mainly about inviting people to try using it and to observe its benefits. However, kratom was less popular by posting rate and number of followers than cannabis was. This effect could result from the fact that kratom is mainly used in the southern part of Thailand, unlike cannabis, which is more common nationwide. Moreover, cannabis social trends in Thailand could be driven by the legalization of recreational cannabis in the US in the recent years. Thus, we observed posts about legalization on the cannabis pages unlike the kratom pages.
Both drugs had deactivated pages, but new pages were found after 1 year. There were a higher number of deactivated pages and new pages for cannabis compared to the number of pages found initially. One limitation of our study was being unable to know the reasons for page deactivation, i.e., whether it was government action or by intention of the administrators to hide from government investigation. This finding could imply that cannabis sellers could be more alert and aware of the action of legal authorities, due to the more serious penalties for cannabis than for kratom under Thai law. They may deactivate and open new pages to avoid this action, and sometimes a similar name might be used for the old page followers to recognize and trace the new page . In contrast, kratom is less popular and carries less serious punishments for possession or distribution than cannabis. This reason may be why fewer new pages and fewer deactivated pages were observed when compared with cannabis pages.
We also observed that online content such as advertising or marketing could raise awareness among regulators. This finding indicates that Facebook may also act as a distributor of the drugs. However, it could be useful that contact details or addresses could help direct investigators of the administrators of these pages to a possible virtual market place for further evaluation. Furthermore, advertising content must be a greater concern. Subjective opinions and recommendations given by users about these drugs without any scientific evidence to support them should be highlighted. In this study, we did not differentiate Facebook pages into user-generated or seller-generated pages, as this difference was not part of our initial aims in the study. However, similar content could be posted by both types of pages and be dangerous to customers if they believe it uncritically. Thus, media literacy education may be helpful, as also suggested in a prior study, which found that most media messages from retailers emphasize unproven health benefits without describing harm .
The trend of recommending other drugs to be used with cannabis was different from that of kratom. Cannabis pages rarely mentioned other drugs, which could indicate that it is primarily used alone. In contrast, kratom tended to be used with additional compounds to enhance the psychoactive effect by adding drugs and/or medication with a hypnotic effect. In Thailand, these drugs are categorized as dangerous drugs, controlled drugs, or illicit drugs that could be harmful to the user [16, 26]. Accordingly, the online information that encourages people to use a combination of these drugs could lead to more troublesome health outcomes.
At the one-year follow-up, increased page activity was observed for both drugs, and the posts were positive towards the use of the drugs. No postings educated people regarding the pros and cons of the drugs without suggesting opinions. Increasing the number of pages containing knowledge about the drugs or support systems for substance-using individuals, such as online therapy, maybe useful in order to facilitate accessibility for at-risk populations .
The strength of our study was that our searching was conducted on search engines that provided additional keywords that the general public could reach by a simple search. In addition, the one-year follow-up with the recorded URLs for old pages helped determine the activity of the pages and compared the trends of posts and tones changes within each page. New searches with the same keywords in the next year helped compare the page activities and the changes in post trends. Although new slang words might be missed that originated in the succeeding year, we hypothesized that only a few new slang words would be created within 1 year. Therefore, we believed that our initial keywords could cover most of the slang used among Thai people regarding these drugs.
The limitations of our study were that only Thai-language Facebook pages were searched, which would underestimate the number of postings with a hashtag that could be searchable through Facebook or pages with other languages which could also be accessed. Our study did not examine online information from other sites which may contain other educational information which could reflect other sources of the information that reaches the general population regarding these drugs.
The current situation on Facebook regarding cannabis and kratom shows a somewhat positive attitude towards the use of these drugs. In addition, the content of some pages was trying to support legalization. No information about harm from these drugs was found through our search.
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This work was funded by the Thailand Substance Abuse Academic Network (58-B-002). The funder had no role in the study design, analysis, interpretation or decision to publish.
Availability of data and materials
Please contact author for data requests.
Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, 50200, Thailand
Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
Kanokporn Pinyopornpanish, Wichuda Jiraporncharoen & Chaisiri Angkurawaranon
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KT, KP, and CA were involved in the conception of the manuscript and the design. KT collected the data. KT, KP, WJ and CA performed data analysis. KT and KP drafted the manuscript. All authors revised, read and then approved the final manuscript.
Ethics approval and consent to participate
This was an observational study of publicly available data and did not involve human participants. Accordingly, approval from an institutional review board was not required.
The authors declare that they have no competing interests.
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Our study aims to evaluate the trends in online information about cannabis and kratom on Facebook in Thailand, where there is current discussion regarding legalizing these drugs. Between April and November 2015, reviewers searched for cannabis and kratom Facebook pages in the Thai language via the common search engines. Content analysis was performed and the contents of each page were categorized by the tone of the post (positive, negative or neutral). Then, a one-year follow-up search was conducted to compare the contents. Twelve Facebook pages each were initially identified for cannabis and for kratom. Follower numbers were higher for cannabis pages. Kratom pages were less active but were open for a longer time. Posts with positive tones and neutral tones were found for both drugs, but none had negative tones. Other drugs were mentioned on the cannabis pages, but they were different from those mentioned on the kratom pages. Issues regarding drug legalization were found on the cannabis pages but not on the kratom pages during the searching period. One year later, the tone of the posts was in the same direction, but the page activity had increased. The information currently available on the sampled Facebook pages was positive towards the use of cannabis and kratom. No information about harm from these drugs was found through our search.