2023 FSA Podium and Poster Abstracts

P027: KRATOM USE AND ANESTHESIA: CONSIDERATIONS FOR PERI-, INTRA-, AND POST-OPERATIVE CARE
Rudresh Patel, BS; Darshil Patel, BS; Nisarg Shah, BS; Karim Zaki, BS; Hoang Nguyen, MD, PhD, RPH; Nova Southeastern University Kiran C. Patel College of Osteopathic Medicine

Introduction: Kratom (Mitragyna speciosa) is a tropical tree native to Southeast Asia that has a long history of traditional use in that region. In recent years, kratom has gained popularity in the United States (U.S.) as an alternative to prescription painkillers and as a means of reducing opioid dependence. However, it is important to note that kratom is commonly also misused recreationally for its euphoria inducing properties. The number of kratom users in the U.S. has been steadily increasing in recent years, with an estimated 10-16 million current users. As a result, anesthesia providers are more likely to encounter patients with long-term use of kratom, which presents unique challenges due to its effects on various body systems. Understanding the peri-operative considerations in patients with chronic kratom use is crucial for anesthesiologists to ensure patient safety and optimal outcomes.

Methods: In order to comprehensively examine the peri-, intra-, and post-operative considerations pertaining to anesthesia administration in kratom users, an exhaustive systematic literature search was conducted utilizing the databases of PubMed and Google Scholar. The following keywords were utilized in combination for data extraction purposes – (Kratom AND Anesthesia) OR (Kratom AND Pharmacology) OR (Kratom AND Anesthesia AND Complications).

Results: Patients that are considering surgery should go through standard preoperative screening which should include inquiries about kratom use. Although kratom is being explored as an alternative to opioids, it is important to keep in mind that it possesses its own adverse effects. Kratom has opioid-like effects by acting on opioid receptors, which are shared by certain anesthetics such as sufentanil. Not only would this lower the efficacy of various anesthetic medications but using kratom may also lead to toxic effects on the body due to medication cross-reaction. Kratom is metabolized primarily by the cytochrome P450 enzyme isoforms. Therefore, it is crucial to recognize interactions with both isoforms and other substrates that also utilize these enzymes for metabolism. Creating competition for the cytochrome P450 binding sites via kratom use may increase circulating levels of other medications, leading to drug toxicities. Multiple studies were analyzed to reveal that moderate to heavy kratom use can cause anesthetic complications such as intravenous anesthetic resistance, refractory hypertension, emergence delirium, and poorly controlled pain. It is presumed that the refractory hypertension is due to severe intra-operative pain secondary to kratom-induced opioid resistance. Intraoperatively, this correlates to difficulty maintaining a safe mean arterial pressure. Postoperatively, emergence delirium has been documented in several case studies, manifesting as a result of kratom withdrawal.

Conclusion: Kratom use, and its peri-operative considerations have not been extensively studied due to its limited use in the past. However, recent trends suggest that its use is increasing, highlighting the need for further research. The challenges related to kratom use are mainly linked to opioid resistance. Hence, providers should conduct a comprehensive assessment of each patient before administering anesthesia to identify potential complications. This approach can help optimize patient outcomes and overall well-being.