Using heroin was always dangerous, but not like it is today. Since fentanyl arrived in B.C., an addiction has become a daily game of Russian roulette.

The surge in overdose deaths—more than 1,500 projected for 2017—has sent a lot of users looking with a renewed sense of urgency for a path off opioids.

In recent years, B.C. doctors have put more people on methadone and Suboxone. But those traditional treatments don’t work for everybody. And even when they do, many people don’t like that a prescription to one of those drugs requires daily visits to a pharmacy.

In Vancouver, where B.C.’s fentanyl crisis is killing more people than in any other jurisdiction in Canada, one possible alternative that’s gaining chatter is Mitragyna speciosa, or kratom.

Patrick Smith is a well-known member of the Downtown Eastside arts scene. He’s been down the road of addiction before.

“I was clean for 16 years,” Smith began. “Then I had this kidney stone, had this chronic pain going on, and, before I knew it, I was up to six Dilaudids a day.” Dilaudid is the brand name for hydromorphone, a prescription painkiller similar to heroin.

“I got to get off these,” he said he told himself. “I’ve been a heroin addict and I don’t want to go back there.”

Smith scoured the Internet for alternatives.

“I was in pain,” he continued. “And so I felt like I didn’t have a choice but to take these [Dilaudid]. And I could see where my life was going to spiral back down, out of control. I was scared shitless. And then I found kratom.”

Smith gives himself a dose each morning but remains clear-headed throughout the day. He’s focused at work and doesn’t look impaired after taking kratom. “You wouldn’t know,” he said.

A 2015 paper by UBC’s Zach Walsh (among a list of coauthors) describes kratom as a “psychoactive plant that has long been used in Southeast Asian countries”. In Malaysia and Thailand, its recorded use as a pain medication and energy supplement dates back to at least as early as the 1830s, according to the paper.

“Kratom has also been used in Asia as an opium substitute,” it continues, citing British research from the 1930s, “a practice that continues today due to the plant’s reported utility as an aid for opioid withdrawal.”

Kratom is usually ingested as a green powder, mixed into a liquid such as tea or sometimes pressed into gel caps. To get a sense of how it feels, imagine a spectrum of highs that runs from a cigarette to a shot of heroin. Kratom is on the left of it, with its exact placement depending on how much one ingests. One or two grams can compare to the strength of a cup of coffee while five grams or more gets closer to a mild prescription pain killer. In lower doses, it feels more like a mild stimulant, while in higher doses it has more of a calming effect.

A scientific explanation

Mikhaila Elise became a convert when she started using kratom six years ago to manage pain related to scoliosis and arthritis. She works at one of Vancouver’s new overdose-prevention sites, where people bring drugs—usually cocaine and heroin—to use under staff supervision. Interviewed there, Elise told the Straight that she has offered kratom to a number of opioid addicts who later told her it helped them manage drug cravings.

“I’ve been carrying it around lately, talking to people here who want to get off of down [heroin],” she recounted. “And so I give out a handful every once in a while.

“There was one guy who I gave it to, an intravenous-heroin user,” Elise said. “He tried it and came back and he was like, ‘I can’t believe it.” Taken regularly, kratom minimized his symptoms of withdrawal, allowing him to transition off heroin, she continued.

A 2008 paper published in the journal Clinical Toxicology explains how, for some people, kratom can work as an opioid substitute.

“Both kratom alkaloids [mitragynine and 7-hydroxymitragynine] are reported to activate supraspinal mu- and delta- opioid receptors, explaining their use by chronic narcotics users to ameliorate opioid withdrawal symptoms,” it reads.

According to a 2012 paper in the Journal of the American Osteopathic Association, “A variety of chemical compounds have been isolated from kratom and shown to exhibit opioid-like activity on smooth muscle systems and in ligand-binding studies.”

“Most notably,” it continues, “many of the central nervous system and peripheral effects of these kratom-derived substances are sensitive to inhibition by opioid antagonists.”

Translated, it all means that while kratom is not an opioid, it does interact with opioid receptors in the brain. Therefore, while experts agree further study is needed, kratom has the potential to at least partially address cravings that someone who is addicted to opioids feels when they stop using drugs such as heroin or OxyContin.

The overdose-prevention site where Elise works is managed by Sarah Blyth, who also helps run a small medicinal-marijuana dispensary nearby. Called High Hopes, Blyth said they started offering kratom there last summer. Since then, she continued, kratom has attracted an increasing amount of buzz as a safer alternative to drugs purchased on the street. (Other kratom vendors requested the Straight leave them out of this article. The plant is available across Metro Vancouver and can be found with a quick Google search.)

“We started giving it out and now we have quite a few people who just swear by it,” Blyth said. “It’s a viable option and it doesn’t hurt anybody. And that’s what we’re looking for.

“People who take kratom swear it gets rid of the pain and the stress that’s associated with opioid withdrawal,” she continued. “I’ve seen people use it to get off of hard drugs.”

Government urges caution

Health Canada is less of a fan.

An information package supplied to the Straight describes Kratom as a “herbal product that may pose serious health risks when swallowed or inhaled,” and which, “has the potential for problematic use and dependence.”

It lists potential side effects as “drowsiness, nausea, vomiting, seizures, liver toxicity, and excessively rapid heartbeat.”

Kratom is not licensed as a health product in Canada, which makes its sale, distribution, and marketing as a health product illegal. At the same time, kratom’s possession is not prohibited by Canada’s Controlled Drugs and Substances Act. That means it can be sold without any special permission, as long as it is not sold for consumption.

While the tone of Health Canada’s information about kratom is negative (or at least cautionary), it states that dating back to 1965, federal authorities have never received an “adverse reaction report” related to kratom, and that in Canada, the plant has never been associated with a death.

South of the border, the U.S. Drug Enforcement Administration (DEA) said in August 2016 that it was classifying kratom as a Schedule I substance, placing it alongside cocaine and heroin. An unexpected backlash ensued and the government agency backed off. The DEA delayed any action on kratom pending further consultation. That process remains ongoing.

More questions than answers

On the phone from St. Paul’s Hospital, Dr. Sharon Vipler described herself as an initial skeptic whose interest in the plant was perked.

“I’m not someone who frequents health-food stores,” she joked. “If it wasn’t for a patient, I would have never even heard of it.”

Vipler, an addictions physician who also works for Fraser Health Authority, recounted her first experience with kratom. A patient at St. Paul’s Hospital showed signs of opioid withdrawal but swore she had not taken drugs. Shortly after, the patient told Vipler that she was ingesting kratom on a daily basis. Vipler read what literature she could find about the substance and determined it might account for the withdrawal symptoms she was seeing.

Another patient similarly insisted they were not using illicit opioids but, when administered prescription painkillers following an operation, exhibited an unusually high tolerance. Again, the patient revealed they were regularly using kratom.

Both patients told doctors they were taking kratom to manage past addictions to opioids.

Despite those incidents putting kratom’s negative effects on display, Vipler said she is convinced the plant’s possible benefits are worth of attention.

“It’s filling a gap in terms of treatment for patients who feel that the current infrastructure that we have for opioid-agonist therapy is either too restrictive or not acceptable,” she explained.

Vipler said she suspects that an increased interest in kratom is related to the arrival of fentanyl in B.C. Since 2012, the synthetic opioid has driven a sharp increase in overdose deaths, from 269 that year to a projected 1,520 by the end of 2017.

“People are so desperate to manage their opioid-use disorder that they are willing to turn to these remedies that don’t have enough research to be safely recommended,” Vipler said. “And so they are potentially putting themselves at risk.”

Since meeting those first two patients, Vipler has made an effort to learn about kratom. Her assessment: “It’s a fascinating plant that we most certainly have to study more,” she said. “For now, I think we have more questions than we have answers.”