By Stuart Kurtz, D-ABFT-FT,
This past October, I travelled to the annual meeting for the National Association of Medical Examiners (NAME) with our CEO, Phil Roberts, in San José, CA. While there, we had the pleasure of meeting with several of you and discussing how to best serve you and your offices going forward. We always look forward to these conversations both at conferences like NAME and throughout the year as your needs change.
This year I presented a poster that looked at 5 cases of mitragynine overdoses. Details of these cases were provided by the following offices and we thank them for their contributions.
Examination of Several Cases of Mitragynine Toxicity Resulting in Death From 2020-2023
- Office of the District Medical Examiner, District 15 FL, Dr. Wendolyn Sneed
- Office of the Coroner, Lorain County, OH, Dr. Frank P. Miller
- Forensic Medicine and Pathology, Big Horn County, WY, Dr. Thomas L. Bennett
- Office of the Coroner Stark County, OH, Dr. Ronald R. Rusnak
- St. Luke’s Hospital, IA, Dr. Ned Austin
Mitragynine is the primary alkaloid in the kratom plant. While not federally scheduled, some states have restrictions in place on the sale of kratom. At low doses, mitragynine acts as a “cocaine-like” stimulant while at higher doses users report “opioid-like” effects. An important thing to remember is that while mitragynine has activity at the mu opioid receptor, it does NOT affect the β-arrestin pathway. This is responsible for respiratory depression associated with compounds such as fentanyl, morphine, and the nitazenes.
There is no clinical data available for mitragynine so therapeutic, toxic, and fatal ranges are unknown. DUID case reports have found a range of 11-490 ng/mL. Internally, our cases have a median concentration of 76.4 ng/mL. Case circumstances and scene investigation are important in the interpretation of mitragynine levels. Low concentrations of mitragynine in blood are typically not of concern but we are happy to assist in the interpretation of the results.
Mitragynine is often not included in routine toxicology testing and most emergency departments, due to the nature of their testing procedures, will also not test for it. Comprehensive panels such as Axis’ Comprehensive Panel with Analyte Assurance™ will typically include testing for it. Because of the loose regulations regarding the sale of kratom, labelled bags of plant material or bottles of capsules can be identified at the scene. This can be vital in guiding testing recommendations if it’s suspected that it could be involved.
Please reach out to us if you have any questions regarding this poster, kratom in general, or interpretation of results for a case involving mitragynine. We can be reached at 317-759-4869 option 3 or toxicologist[email protected]. We can email a copy of the poster upon request