上週,密西西比大學有兩名年輕男子在同一天、不同地點被發現身亡。艾登·漢密爾頓(Aidan Hamilton)是來自科羅拉多州英格爾伍德的18歲大一新生;羅伯特·斯特朗(Robert Strang)則是來自亞特蘭大的20歲大三學生。牛津市警方表示,兩起案件的調查現場都發現了在零售商店購買的包裝卡痛葉(kratom)。警方同時也謹慎而正確地指出，目前沒有任何人證實卡痛葉或其他物質造成了任何一人的死亡。毒物檢驗結果尚未出爐,在下結論之前，家屬與校園社群都應該先得到答案。

然而；即使答案還沒有出來，這件事已經做到了一件重要的事:它讓許多家長、室友和朋友心裡浮現同一個安靜的疑問。這到底是什麼東西?為什麼在牛肉乾旁邊就能買到?

我是一名精神科醫師，這些年來，我在診間和急診室裡,越來越常回答這個問題。讓我告訴你我學到了什麼，以及我多希望在下一包卡痛葉被拆開之前,更多人能知道這些事。

一棵樹、一種傳統,以及一場變形

卡痛葉來自帽柱木(Mitragyna speciosa),這是一種與咖啡同科的熱帶樹木,生長在東南亞。幾個世代以來,泰國、馬來西亞等地的勞工會咀嚼它的葉子,或把葉子泡成茶,好撐過漫長而辛苦的一天。少量時,葉子的感覺有點像濃咖啡;量大一點,感覺就更像鴉片類藥物。

這是了解卡痛葉的第一件事:它不像一種藥物,它依劑量不同,表現得像兩種藥物。

這片葉子含有數十種活性成分。主要的一種是米特拉吉寧(mitragynine)。另一種含量較少的成分是7-羥基米特拉吉寧(7-hydroxymitragynine),通常簡稱7-OH,它對腦中鴉片受體的作用強得多。在天然的葉子裡,7-OH只有微量存在。但在現代市場上,廠商可以用化學方式濃縮它,或從卡痛葉的其他成分製造出來,再壓成藥錠、做成飲用的小瓶裝,或調成軟糖。今天擺在加油站櫃檯上的東西,往往和人們當年在田野間咀嚼的那片葉子大不相同。

悄悄爬升的曲線

卡痛葉過去是小眾的好奇之物,現在不是了。調查研究顯示,相當比例的美國成年人曾經嘗試過它,有些估計甚至認為終身使用率高達約9%。在原本就有物質使用困擾的人當中,這個數字更高。

人們為什麼會用它?近期一項使用者調查發現,多數人是為了「治療」某些問題:最常見的是疼痛,其次是專注力、情緒、睡眠,甚至是想戒掉其他藥物。這說明了一件重要的事:大多數開始使用卡痛葉的人,並不是為了狂歡一夜。他們只是想讓自己好過一點,而且有人告訴他們,植物比藥丸溫和。

過去十年,與卡痛葉相關的毒物中心通報持續攀升。聯邦藥品主管機關也看到,涉及7-OH的不良事件通報明顯激增。美國緝毒局(DEA)在今年夏天的公告中指出,自2019年以來,經實驗室確認的7-OH相關案例有數十件,其中超過半數是致命的。美國食品藥物管理局(FDA)甚至形容,7-OH可能是另一波鴉片危機的開端。用詞或許可以討論,但趨勢的方向很難否認。

從裡面感受起來是什麼樣子

人們形容低劑量的體驗是精力充沛、善於交際、注意力集中,像是一種帶著溫暖邊角的興奮劑。隨著劑量提高,感覺會翻轉:平靜、沉重、疼痛融化、憂慮安靜下來。第二種模式就是類鴉片模式,也是真正讓人上癮的那一種。

卡痛葉的成分同時作用在好幾個系統上。它們會作用於鴉片受體,也會影響腎上腺素通路和血清素通路。米特拉吉寧對主要的鴉片受體是部分活化劑,同時對其他受體則有阻斷或減弱的作用。這也是卡痛葉之所以難以歸類的部分原因,連經驗豐富的臨床醫師都可能被它嚇一跳。

慢慢收緊的網

沒有人會在某天早上醒來,決定要染上卡痛葉的問題。它通常是分階段發生的。

一開始往往是出於好奇或需要:痠痛的背、糟糕的一週、朋友的建議、網路上看到的影片。最初幾次使用,感覺像是愉快的發現。接著劑量悄悄增加,因為身體會適應。原本兩茶匙有效,後來兩茶匙就沒用了。然後使用的理由,從「我需要的時候」變成「這樣我才不會難受」。

最後這一步是轉捩點。當一個人使用卡痛葉是為了避免不適,而不是為了感覺良好,依賴就已經悄悄住進來了。少吃一次,就會出現坐立不安、流汗、流鼻水、肌肉痠痛、起雞皮疙瘩、腹瀉、失眠、易怒,以及深入骨髓的焦慮。這和鴉片類藥物戒斷症狀看起來、感覺起來非常相似,因為在許多方面,它就是。在使用量較大的人身上,戒斷還可能引發癲癇,這也是自己突然停用可能有風險的原因之一。

渴求、一再減量失敗,以及生活開始繞著下一次用藥打轉,都是我們在其他成癮問題中看到的同樣特徵。在這個過程中,身體也會受到傷害:噁心、便祕、體重下降、顫抖,有些人甚至出現肝損傷、心律問題或癲癇,即使沒有用藥過量也可能發生。

(本文中的病人皆經其同意,並更動了細節以保護隱私)

每當我描述這個進展過程,我都會想起S太太。她是一位溫暖又風趣的四十多歲女士,最初來找我,是為了她口中的「一點點焦慮」。多年前的一場車禍讓她留下慢性背痛,處方止痛藥停掉之後,她找到了卡痛葉。那感覺像是有人把她的人生還給了她。她依然做飯、依然接送孩子、依然在教會裡面帶微笑。但兩年之間,早晨茶裡的一茶匙,變成一天好幾次的一大把膠囊。有一次全家旅行,她先生把她的存貨藏了起來,她出現顫抖、盜汗,以及一種讓兩人都驚慌的恐懼。我們早期工作中最困難的部分,不是藥物,而是幫助她明白:需要這個「天然」的東西,並不代表她軟弱或愚蠢。

我們如何發現它,又如何為它命名

我經常面對一個很實際的問題:卡痛葉很難被檢測出來。大多數診所和急診室使用的標準尿液藥物篩檢並不會檢驗它。一位病人可能真的因為卡痛葉而病得很重,篩檢結果卻是「乾淨」的。特殊的實驗室檢驗確實存在,但並非常規項目。

我是在急診室裡,從M先生身上學到這一課的。那是凌晨兩點多,救護人員推進來一位21歲的大學生。他的室友發現他失去意識地躺在公寓地板上,呼吸緩慢而淺,瞳孔縮得很小。例行的藥物篩檢結果是陰性,而這個結果差點把我們帶往錯誤的方向。直到室友拿出一小包從加油站買來的藥錠,標示為「保健補充品」,我們才明白自己面對的是什麼。M先生在給予過量逆轉藥物後有了反應,醒來時又驚嚇、又尷尬,還有點生氣,氣別人竟然認為他有問題。「那只是補充品而已。」他對我說。為了撐過期末考,也為了避免少吃一次時那種難受的感覺,他好幾個星期來越吃越多。他是幸運的那一個,協助及時趕到了。

所以在實務上,診斷是從醫學最古老的工具開始的:一場好好的談話。我會問補充品、茶、粉末、小瓶飲品、藥錠,以及任何在菸酒店、加油站或網路上買的東西。我會問疼痛、情緒和睡眠。我會問,如果他們一天不用會發生什麼。病人往往想不到要提卡痛葉,因為他們不把它當成毒品。

正式來說,我們的診斷手冊中並沒有一個獨立叫做「卡痛葉使用障礙」的診斷。臨床醫師通常套用其他物質使用障礙相同的標準,例如失去控制、渴求、耐受性、戒斷,以及明知有害仍持續使用,並將它歸入「其他或未特定物質」的類別。標籤本身不如它開啟的東西重要:一條通往治療的路。

為什麼這一種不一樣

我治療酒精、古柯鹼、海洛因和處方藥物成癮已經很多年了。卡痛葉的不同之處,讓它格外棘手。

第一,它在美國大部分地方是合法的,並以補充品的名義販售,這傳遞出一個強而有力卻錯誤的訊息:如果它危險,就不會擺在架上。第二,它便宜又隨處可得。不用去找藥頭,沒有被逮捕的風險,沒有任何門檻。第三,它披著健康的外衣。它以茶包和鮮豔的包裝出現,標榜「活力」、「舒緩」和「專注」。

第四,也是最讓我擔憂的一點:它是一種兩面性的藥物。它可以在週一是興奮劑,到了週五變成鎮靜劑,幾乎能貼合任何需求。一個絕不會碰海洛因的人,可能在讀書前喝下一瓶卡痛葉飲品,然後在不知不覺間滑進一種作用類似鴉片的東西裡。最後,由於市售產品的強度差異極大,沒有人真正知道自己吃下的劑量是多少。對任何可能讓呼吸變慢的東西來說,這都是危險的用法。

它從哪裡來,法律怎麼說

走進大多數城鎮的便利商店、菸品店或電子菸店,你都能找到卡痛葉粉末、膠囊和萃取物。越來越常見的,還有濃縮的7-OH藥錠、小瓶飲品和糖果。網路販售與社群媒體宣傳則承擔了其餘的通路。其中許多是以年輕成人為行銷對象,口味與包裝看起來更像糖果,而不是藥物。

法律的圖像像一塊拼布,而且還在變動。卡痛葉本身並不是聯邦管制物質。包括阿拉巴馬州、阿肯色州、印第安納州、佛蒙特州和威斯康辛州在內的少數幾個州,完全禁止它。其他州則訂定了年齡限制、標示與含量的規定。例如科羅拉多州通過了一項以丹尼爾·布雷格(Daniel Bregger)命名的法律,他是丹佛的一名男子,2021年在同時服用卡痛葉和一種抗組織胺後身亡。該法禁止向21歲以下的人販售、限制7-OH含量,並要求清楚標示。

在聯邦層級,政府已經開始針對濃縮產品採取行動。今年7月,美國緝毒局宣布有意將超過特定門檻的7-OH暫時列入第一級管制藥品,也就是最嚴格的分類,而這項提案的設計,是讓一般的卡痛葉葉片不受影響。最近,美國司法部又宣布緊急列管三種相關的強效化合物,這些化合物是在實驗室中製造出來的,而不是植物中天然存在的。由於規定正在變動,任何想知道7-OH本身最新現況的人,都應該向聯邦或州的主管機關查證。

漣漪效應

成癮常被形容為一場私人的掙扎,但它幾乎從來不會只停留在私人層面。

在感情關係中,傷害往往從小小的不誠實開始:藏起來的一包東西、含糊的回答、一個沒有守住的減量承諾。信任慢慢被侵蝕。伴侶形容,自己像是和一個人在一起,對方明明在場,卻搆不著:早上情緒起伏,晚上又平淡而易怒。S太太的先生告訴我,他覺得自己被欺騙了,而她覺得自己被評判了,有一段時間,他們兩個都沒有錯。父母則形容,看著年輕的孩子漸漸漂走時的恐懼,以及不知該推一把還是該等待的無力。

在工作和學校裡,影響表現為錯過的期限、被放棄的課程,以及一個人的能力與實際表現之間越拉越大的落差。金錢也隨之流失,因為每天的使用很花錢,而後果同樣代價高昂。

接下來是更嚴酷的邊緣。卡痛葉會讓呼吸變慢,尤其是與酒精、鎮靜劑、抗組織胺或其他鴉片類藥物併用時,許多用藥過量的案例中都出現了合併使用的情形。酒駕般的藥駕是另一項嚴重風險,而且即使路邊檢測無法辨識出那種物質,駕駛人仍可能被起訴。懷孕則增添了另一層風險,因為在子宮內暴露的嬰兒,出生後可能已經產生依賴並經歷戒斷。而正如密西西比州的家庭現在正在面對的,最壞的結果,是無法挽回的那一種。

T先生是一位三十多歲、經營小型事業的工程承包商,他讓我看見這些邊緣能來得多快。他一開始使用卡痛葉,是為了在漫長的工作日裡保持清醒,後來為了應付之後的低落而增加劑量。有一天下午,他昏昏沉沉、反應遲緩,車子偏出了車道,撞上另一輛車。沒有人死亡,但另一名駕駛受了重傷。由於路邊檢測沒有辨識出他吃了什麼,這場官司變得漫長又複雜。他面臨刑事指控、駕照被吊扣、不斷累積的律師費,最後連事業也失去了。他來找我的時候,並不是為了求一個診斷,而是想找到一個方法,止住這場自由落體。「我從沒想過,一片葉子能讓我失去一切。」他說,而我一直忘不了這句話。

有什麼幫得上忙

希望的部分在這裡:卡痛葉依賴是可以治療的。

對於高度依賴的人,第一步往往是找到一個安全、有醫療監督的方式來停用,因為戒斷既不舒服,有時也有風險。有些臨床醫師會用緩解症狀的藥物來處理睡眠、噁心、焦慮和肌肉痠痛,另一些則採取逐步減量。

對許多病人來說,最有用的工具是丁基原啡因(buprenorphine),這是一種已被證實對鴉片成癮有效的藥物。它能緩解渴求與戒斷,卻不會帶來同樣的快感。2022年發表的一項病例系列,追蹤了28位以卡痛葉為主要使用物質的病人,並以丁基原啡因加納洛酮(naloxone)治療。追蹤時,仍有20位持續在門診接受治療,有些人已近兩年。這是一項規模小、沒有對照組的研究,所以它是一個有希望的訊號,而不是證明,仍需要更大型、有對照的試驗。其他研究者也注意到,已經因為鴉片成癮而使用丁基原啡因的人,似乎比較不會使用卡痛葉,這與丁基原啡因滿足了相似需求的想法相符。

藥物只是整體的一部分。心理諮商,特別是幫助人們了解自己使用誘因的方法,以及支持進步的獎勵式方案,都能帶來實質的差別。治療人們當初開始使用的原因也同樣重要。如果有人是為了疼痛、焦慮、憂鬱或創傷而開始使用卡痛葉,那麼在這些問題也被妥善治療之前,它們會一直把人拉回去。

那未來呢?科學家正在研究卡痛葉的成分如何作用於大腦,包括相關分子有一天是否能提供風險較低的止痛效果。這方面的研究還很早期,大多在實驗室階段,而且由於其中一些最引人注目的化合物如今受到嚴格管制,反而更難研究。就目前而言,任何宣稱卡痛葉是經證實的止痛、抗焦慮或戒癮療法的說法,都走在證據前面了。

給家人,也給悄悄讀這篇文章的你

如果你是家長、伴侶或朋友,我想對你說的是:

去問,而且問的時候不要指責。「我讀到卡痛葉的報導,有點擔心,你有試過嗎?」比「你怎麼會這樣?」能打開更多扇門。留意那些看起來陌生的包裝、藥錠或小瓶飲品,以及情緒、睡眠或精力上說不通的變化。要認得用藥過量的徵象:極度嗜睡、呼吸非常緩慢或淺、瞳孔很小、嘴唇發紫,以及叫不醒。如果看到這些,請立刻撥打911。納洛酮這種過量逆轉噴劑可能有幫助,而且越來越容易取得,包括在許多校園裡。

而如果你是那個悄悄讀這篇文章的人,因為你一直在使用卡痛葉,而它已經不再像是一種選擇,請聽我說:你並不軟弱,你也不孤單。你做了許多人在受苦時會做的事,你伸手去找解脫。伸手求助是下一步,而且是更勇敢的一步。

密西西比州兩位年輕人的家人此刻正在悲痛之中,而我們還不知道事情的全貌。我們唯一確定的是,卡痛葉的故事比任何一則新聞標題都更大。這是一片葉子被改造成強得多的東西,卻被當成溫和得多的東西販售,再交到一整個被告知它很安全的世代手中的故事。我們至少能做的,就是把真相說出來,說得溫暖、清楚,而且趕在下一個家庭必須用最痛的方式學到這件事之前。

如果您或您所愛的人需要協助,美國藥物濫用與心理健康服務署(SAMHSA)的全國求助專線提供免費、保密的服務,全天24小時開放,電話為1-800-662-4357。

作者：Dr. Bob Lee, DO, MS, MBA
Chief Resident Physician, Department of Psychiatry & Behavioral Sciences
Child and Adolescent Psychiatry Fellow
Nassau University Medical Center

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Two Faces of One Leaf

Why kratom is both a stimulant and an opioid, and why that matters

Last week, two young men at the University of Mississippi were found dead on the same day, in separate places. Aidan Hamilton was an 18-year-old freshman from Englewood, Colorado. Robert Strang was a 20-year-old junior from Atlanta. Police in Oxford said that packaged kratom, bought at a retail store, was found during both investigations. They also said, carefully and correctly, that no one has confirmed that kratom or any other substance caused either death. Toxicology results are still pending, and the families and the campus deserve answers before anyone draws conclusions.

But even without those answers, the story has done something important. It has made a lot of parents, roommates, and friends ask the same quiet question: What exactly is this stuff, and why can you buy it next to the beef jerky?

I am a psychiatrist, and I have spent a growing part of my working life answering that question in exam rooms and emergency departments. Let me tell you what I have learned, and what I wish more people knew before the next package gets opened.

A tree, a tradition, and a transformation

Kratom comes from Mitragyna speciosa, a tropical tree in the coffee family that grows in Southeast Asia. For generations, laborers in places like Thailand and Malaysia chewed the leaves or brewed them into tea to get through long, hard days. In small amounts, the leaves feel a bit like strong coffee. In larger amounts, they feel more like an opioid.

That is the first thing to understand about kratom. It does not behave like one drug. It behaves like two, depending on the dose.

The leaf contains dozens of active compounds. The main one is mitragynine. A smaller one, 7-hydroxymitragynine, usually called 7-OH, is far more potent at the brain’s opioid receptors. In the natural leaf, 7-OH exists only in tiny traces. But in the modern marketplace, manufacturers can chemically concentrate it or make it from other kratom compounds, then press it into tablets, pour it into shots, or blend it into gummies. What sits on the gas station counter today is often a very different thing from the leaf that people chewed in the fields.

A quiet climb

Kratom used to be a niche curiosity. It is not anymore. Survey research suggests that a meaningful slice of American adults have tried it at some point, with some estimates of lifetime use running as high as about 9 percent. Among people who already struggle with substance use, the numbers run higher.

Why do people take it? A recent survey of users found that most were treating something: pain, most often, followed by focus, mood, sleep, and even attempts to get off other drugs. That tells you something important. Most people who start kratom are not chasing a wild night out. They are trying to feel better, and they have been told that a plant is a gentler answer than a pill.

Poison center calls tied to kratom have climbed steadily over the past decade. Federal drug regulators have also seen a sharp jump in adverse event reports involving 7-OH in particular. The Drug Enforcement Administration, in its own notice this summer, counted dozens of laboratory-confirmed 7-OH cases since 2019, more than half of them fatal. The Food and Drug Administration has gone so far as to describe 7-OH as the possible start of another wave of the opioid crisis. You can debate the language, but the direction of the trend is hard to argue with.

What it feels like from the inside

People describe the low-dose experience as energetic, sociable, and focused. Think of a stimulant with a warm edge. As the dose goes up, the feeling flips: calm, heavy, pain melting away, worries going quiet. That second mode is the opioid mode, and it is the one that hooks people.

Kratom compounds work on several systems at once. They touch the opioid receptors, but also adrenaline pathways and serotonin pathways. Mitragynine acts as a partial activator at the main opioid receptor, while blocking or dampening others. This is part of why kratom can feel so hard to categorize, and why it can surprise even experienced clinicians.

The slow tightening

Nobody wakes up one morning and decides to develop a kratom problem. It tends to happen in stages.

It often starts with a curiosity or a need: a sore back, a bad week, a friend’s suggestion, a video online. The first few uses feel like a pleasant discovery. Then the dose creeps up, because the body adapts. What worked at two teaspoons stops working at two. Then use shifts from “when I need it” to “so I don’t feel bad.”

That last step is the pivot. Once someone is using kratom to avoid discomfort rather than to feel good, dependence has quietly moved in. Missing a dose brings restlessness, sweating, runny nose, muscle aches, goosebumps, diarrhea, insomnia, irritability, and a bone-deep anxiety. It looks and feels a lot like opioid withdrawal, because in many ways it is. In heavier users, withdrawal can also involve seizures, which is one reason stopping abruptly on your own can be risky.

Cravings, failed attempts to cut down, and a life that begins to orbit the next dose are the same hallmarks we see in other addictions. There is also physical harm along the way: nausea, constipation, weight loss, tremor, and in some people liver injury, heart rhythm problems, or seizures, even without an overdose.

(The patients in this article are described with their permission, and with details changed to protect their privacy.)

I think of Mrs. S when I describe this progression. She is a warm, funny woman in her mid-forties who first came to me for what she called “a little anxiety.” Years earlier, a car accident had left her with chronic back pain, and when her prescription pain medicine ended, she found kratom. It felt like being handed her life back. She was still cooking, still driving carpool, still smiling at church. But over two years, one teaspoon in her morning tea became a handful of capsules, several times a day. When her husband hid her supply during a family trip, she developed shaking, sweats, and a dread that frightened them both. The hardest part of our early work was not the medicine. It was helping her see that needing this “natural” thing did not make her weak or foolish.

How we find it, and how we name it

Here is a practical problem I face constantly: kratom is hard to detect. The standard urine drug screens used in most clinics and emergency rooms do not look for it. A patient can be truly sick from kratom and have a “clean” panel. Specialized laboratory testing exists, but it is not routine.

I learned this lesson in the emergency room, with Mr. M. It was a little after 2 a.m. when paramedics wheeled in a 21-year-old college student. His roommate had found him unresponsive on the apartment floor, breathing slowly and shallowly, his pupils tiny. The routine drug screen came back negative, and that result almost sent us down the wrong path. Only when the roommate held up a foil packet of tablets from a gas station, labeled as a “wellness supplement,” did we understand what we were treating. Mr. M responded to the overdose reversal medication and woke up frightened, embarrassed, and a little angry that anyone thought he had a problem. “It’s just a supplement,” he told me. He had been taking more and more for weeks to get through finals, and to avoid feeling awful when he skipped a dose. He was one of the lucky ones. Help reached him in time.

So in practice, diagnosis begins with the oldest tool in medicine: a good conversation. I ask about supplements, teas, powders, shots, tablets, and anything bought at a smoke shop, a gas station, or online. I ask about pain, mood, and sleep. I ask what happens when they go a day without it. Patients often do not think to mention kratom, because they do not think of it as a drug.

Officially, there is no separate diagnosis called “kratom use disorder” in our diagnostic manual. Clinicians generally apply the same criteria used for other substance use disorders, such as loss of control, cravings, tolerance, withdrawal, and continued use despite harm, and record it under the category for other or unspecified substances. The label matters less than what it opens: a path to treatment.

Why this one is different

I have treated alcohol, cocaine, heroin, and prescription pills for many years. Kratom is different in ways that make it especially tricky.

First, it is legal in most of the country and sold as a supplement, which sends a powerful, false message: if it were dangerous, it would not be on the shelf. Second, it is cheap and everywhere. There is no dealer to meet, no risk of arrest, no barrier. Third, it wears a wellness costume. It comes in tea bags and bright packaging, promoted for “energy,” “relief,” and “focus.”

Fourth, and this is the part that troubles me most, it is a two-faced drug. It can be a stimulant on Monday and a sedative on Friday, and it fits neatly into almost any need. Someone who would never touch heroin might drink a kratom shot before a study session, and slide, without noticing, into something that acts like an opioid. Finally, because commercial products vary so widely in strength, no one really knows what dose they are taking. That is a dangerous way to use anything that can slow breathing.

Where it comes from, and what the law says

Walk into a convenience store, smoke shop, or vape shop in most towns, and you can find kratom powders, capsules, and extracts. Increasingly, you will also find concentrated 7-OH tablets, shots, and candies. Online sales and social media promotion carry the rest. Much of this is marketed to young adults, in flavors and packaging that look more like candy than medicine.

The legal picture is a patchwork, and it is changing. Kratom leaf itself is not a federally controlled substance. A handful of states, including Alabama, Arkansas, Indiana, Vermont, and Wisconsin, ban it outright. Others have passed rules on age limits, labeling, and potency. Colorado, for example, passed a law named for Daniel Bregger, a Denver man who died in 2021 after taking kratom together with an antihistamine. It bars sales to people under 21, caps 7-OH content, and requires clear labeling.

At the federal level, the government has been moving against the concentrated products. In July, the Drug Enforcement Administration announced its intent to temporarily place 7-OH above a set threshold into Schedule I, the most restrictive category, and this proposal is designed to leave ordinary kratom leaf alone. More recently, the Justice Department announced emergency scheduling of three related potent compounds that are made in labs rather than found in the plant. Because the rules are shifting, anyone wanting the current status of 7-OH itself should check with federal or state authorities.

The ripple effect

Addiction is often described as a private struggle. It almost never stays private.

In relationships, the damage often begins with small dishonesties: a hidden bag, a vague answer, a promise to cut back that does not hold. Trust erodes slowly. Partners describe feeling like they are living with someone who is present but unreachable, mood swings in the morning, flat and irritable by evening. Mrs. S’s husband told me he felt lied to, while she felt judged, and for a while they were both right. Parents describe the terror of watching a young adult drift, and the helplessness of not knowing whether to push or wait.

In work and school, the effects show up as missed deadlines, dropped classes, and a growing gap between how capable someone is and how they perform. Money drains away, because a daily habit is expensive, and because the consequences are too.

Then there are the harder edges. Kratom can slow breathing, especially when mixed with alcohol, sedatives, antihistamines, or other opioids, and combined use appears in a number of overdose cases. Impaired driving is another serious risk, and drivers can be charged even when the substance is not one that a roadside test can identify. Pregnancy adds another layer, since babies exposed in the womb can be born dependent and go through withdrawal. And, as the Mississippi families are now learning, the worst outcome is the one that cannot be undone.

Mr. T, a contractor in his late thirties who ran a small business, showed me how fast those edges can arrive. He had started kratom to stay sharp through long workdays, then increased it to manage the crash afterward. One afternoon, drowsy and slow, he drifted across a lane and hit another car. No one died, but the other driver was seriously hurt. Because roadside tests did not identify what he had taken, the legal case grew long and complicated. He faced charges, a suspended license, mounting legal fees, and eventually the loss of his business. When he came to see me, he was not looking for a diagnosis. He was looking for a way to stop the freefall. “I never thought a leaf could cost me everything,” he said, and I have not forgotten it.

What helps

Here is the hopeful part: kratom dependence is treatable.

For people who are heavily dependent, the first step is often a safe, supervised way to come off it, because the withdrawal is uncomfortable and sometimes risky. Some clinicians treat withdrawal with symptom medicines for sleep, nausea, anxiety, and muscle aches. Others use a gradual taper.

For many patients, the most useful tool has been buprenorphine, a medication already proven for opioid addiction. It calms cravings and withdrawal without the same high. A published series from 2022 followed 28 patients who identified kratom as their main substance and treated them with buprenorphine and naloxone. Twenty were still in outpatient treatment at the time of follow-up, some for nearly two years. That is a small study without a comparison group, so it is a promising signal rather than proof, and larger, controlled trials are still needed. Other researchers have also noted that people already on buprenorphine for opioid addiction seem less likely to use kratom, which fits the idea that it fills a similar need.

Medication is only part of the picture. Counseling, especially approaches that help people understand what triggers their use, and reward-based programs that support progress, can make a real difference. So does treating the reasons people started in the first place. If someone began using kratom for pain, anxiety, depression, or trauma, those problems will keep pulling them back until they are properly treated too.

What about the future? Scientists are studying how kratom compounds work on the brain, including whether related molecules could someday offer pain relief with fewer risks. That research is early and mostly in the lab, and it is complicated by the fact that some of the most interesting compounds are now tightly restricted, which makes them harder to study. For now, anyone telling you that kratom is a proven treatment for pain, anxiety, or addiction is getting ahead of the evidence.

A word to families, and to anyone reading in secret

If you are a parent, a partner, or a friend, here is what I would say.

Ask, and ask without accusing. “I read about kratom and it worried me. Have you ever tried it?” opens more doors than “How could you?” Pay attention to packages, tablets, or shots that seem new, and to changes in mood, sleep, or energy that do not add up. Know the signs of an overdose: extreme sleepiness, very slow or shallow breathing, tiny pupils, blue lips, and being unable to wake. If you see them, call 911. Naloxone, the overdose reversal spray, may help and is increasingly available, including on many campuses.

And if you are the one reading this in secret, because you have been taking kratom and it has stopped feeling like a choice, please hear this: you are not weak, and you are not alone. You did what many people do when they hurt. You reached for relief. Reaching out for help is the next step, and it is a braver one.

The families of two young men in Mississippi are grieving right now, and we do not yet know the full story of why. What we do know is that the story of kratom is bigger than any one headline. It is the story of a leaf that got remade into something far stronger, sold as something far gentler, and handed to a generation that was told it was safe. The least we can do is tell the truth about it, warmly, clearly, and before the next family has to learn it the hard way.

If you or someone you love needs help, the free, confidential SAMHSA National Helpline is available 24 hours a day at 1-800-662-4357.

作者：Dr. Bob Lee, DO, MS, MBA
Chief Resident Physician, Department of Psychiatry & Behavioral Sciences
Child and Adolescent Psychiatry Fellow
Nassau University Medical Center

【Published by Chicago Chinese News/芝加哥時報】