The research on kratom’s harms seems to point two ways at once. Most writing on kratom picks one side and stops there. One side says kratom kills people. The other side says every reported death also involved other drugs. Both claims come from the same set of published cases.
This article is in two parts. It explains what that evidence shows, what it cannot show, and which risks are firm enough for you to act on. Part 1 covers the published case reports, liver injury, and dependence and withdrawal. Part 2 covers drug interactions, concentrated 7-OH products, who should not use kratom, and what is still unknown.
Two compounds come up again and again. Mitragynine is the main active compound (alkaloid) in kratom leaf. 7-hydroxymitragynine (7-OH) is a related compound that is much stronger. Fresh leaf contains little or none of it. Kratom: Botany, Alkaloids, and How It Actually Works explains how both act in the body.
This article gives no dosing guidance. Nothing in it encourages you to use kratom. The law on kratom is different in each Southeast Asian country. Thailand regulates kratom under the Kratom Act B.E. 2565. Malaysia still controls it under its Poisons Act 1952, and Myanmar bans it under its Narcotic Drugs and Psychotropic Substances Law. Kratom Law in Thailand After 2021, and Across the Region gives the details. Nothing here encourages use anywhere kratom is banned.
Translator’s note: Some readers of this forum grow kratom or sell leaf in Thailand. Customers, workers and family members often ask them whether kratom is safe. Use the facts in these two parts to give accurate answers that neither play down the risks nor exaggerate them.
What the published case reports actually contain
A case report is a written description of one patient, usually by a doctor or a forensic pathologist. The most careful analysis of these reports is a 2025 review in the journal Frontiers in Pharmacology. Its authors collected every published case report that blamed kratom for a sudden (acute) harmful effect.
Here is what they found:
- 95 cases drawn from 59 published papers.
- In 55 cases, a laboratory test of blood, urine or tissue confirmed mitragynine in the body (toxicological confirmation). 35 of these people died and 20 survived.
- In 40 cases, no such test was done. The report authors still blamed kratom.
The third point matters. Nearly half of the published “kratom cases” rely only on what the patient or a relative said. No laboratory test confirmed that kratom was actually involved.
Who died and who survived
Other substances were found in 32 of the 35 deaths (91%). Among the 20 survivors, other substances were found in only 7 (35%). The statistical test gives p = 0.0002. That means a gap this large would turn up by pure chance only about 2 times in 10,000 if there were no real difference.
Three types of medicine came up most often in the deaths:
- Benzodiazepines: sedative and anti-anxiety medicines, such as diazepam.
- SSRIs: a widely used group of antidepressants.
- Opioids: painkillers in the morphine family.
The review recorded the following causes for the 35 deaths:
| Cause recorded in the report | Deaths |
|---|---|
| Mitragynine poisoning alone | 6 |
| Poisoning by a mix of drugs | 15 |
| Natural death, cause unknown | 3 |
| Possible kratom or drug poisoning, not definite | 2 |
| Drug poisoning, kratom a possible contributor | 2 |
| Drug poisoning, kratom did not contribute | 2 |
| Kratom poisoning, with possible interactions between drugs | 1 |
| Other specific causes: breathing vomit or food into the lungs (aspiration), cardiac arrest, asthma attack, severe narrowing of the heart arteries (coronary atherosclerosis) | 4 |
| Total | 35 |
Lung findings appeared in 74.3% of the deaths. These were fluid in the lungs (oedema), blood pooling in the lung tissue (congestion), or fluid around the lungs (pleural effusion).
Seizures in the survivors
The most common problem in survivors was seizures (fits). The review’s tables count 12 of 20 survivors with seizures, but its text says 11. In six seizure cases, the tests found no other substance.
These seizure data have two weak points:
- All six cases with no other substance come from one case series, which did not list which compounds it tested for.
- The tests did not cover antihistamines. Two patients whose screens were negative said they had taken kratom with diphenhydramine. This is an older antihistamine found in some sleep aids and allergy medicines.
The review authors concluded: “the literature provides insufficient evidence to support the claim that kratom consumption alone increases the risk of severe acute adverse health effects,” and “most adverse effects coincided with polypharmacy, not kratom alone.” Polypharmacy means taking several drugs at the same time.
How to read this result
The review does not show that kratom is safe. It shows something narrower. In most of the deaths, the published reports cannot separate the harm done by kratom from the harm done by the other drugs. That is a gap in the evidence, not proof of safety.
Six deaths were blamed on mitragynine alone, and six is not zero. Some survivors had seizures with no other substance detected. Because the testing had gaps, this warning sign needs more study.
What you can do:
- Do not combine kratom with sedatives, sleeping pills, opioid painkillers or antidepressants. Other substances were present in 32 of the 35 deaths, and these three groups came up most often.
- If someone who has used kratom has a seizure, get emergency help. Tell the responders about the kratom and every other medicine the person took. Without that list, they cannot tell what caused the seizure.
Translator’s note: In Thailand, the emergency medical number is 1669. Save it in your phone and in the phones of the people you live or work with.
Liver injury: the risk with the best evidence
This is the harm with the strongest evidence that kratom itself is the cause, yet it is rarely discussed.
LiverTox is a free online database about liver damage caused by medicines and supplements. It is run by the US National Institutes of Health (NIH), the US government’s medical research agency. LiverTox gives kratom a likelihood score of B. This means kratom is a likely cause of liver injury that shows clear symptoms. That is a firm classification, not a theoretical worry.
What the liver injury looks like:
- Type of damage: usually cholestatic, meaning bile cannot drain out of the liver and builds up. Sometimes it is mixed, meaning bile builds up and liver cells are damaged too. It can be severe. Bilirubin is the yellow pigment that causes jaundice. Blood levels above 20 mg/dL have been documented, which is many times the normal level.
- When it starts: usually 1 to 8 weeks after starting regular use of powder or tablets. The US Drug-Induced Liver Injury Network is a group of US hospitals that collects cases of liver damage from medicines. Its kratom case series found a median of about 22 days, with a range of 15 to 49 days. Median means half the patients fell ill sooner and half later.
- Amount taken: reported amounts vary widely, and no safe amount has been established.
- Outcome: patients usually recover after they stop kratom. The bile blockage can last a long time. Doctors have tried corticosteroids (anti-inflammatory steroid medicines) and N-acetylcysteine (a medicine used for paracetamol poisoning), but neither has a proven benefit.
What you can do: Watch a regular kratom user for these signs: yellow skin or eyes, dark urine, pale stools, or itching with no clear cause. If any appear, do not wait for them to go away. Stop the kratom, see a doctor, and tell the doctor about the kratom. Patients often leave it out because they think of kratom as a herb, not a drug.
Translator’s note: At a Thai hospital, say the word clearly: ใบกระท่อม (bai kratom). Bring the product or a photo of its label. The doctor can only link the symptoms to kratom if they know you used it.
Dependence and withdrawal
Researchers no longer seriously dispute this risk.
Two clinical reviews document it. One is a 2026 review of 7-OH in the journal Current Addiction Reports. The other is StatPearls, a peer-reviewed medical reference published on the US National Library of Medicine’s NCBI Bookshelf. Both describe:
- Withdrawal symptoms similar to opioid withdrawal when a regular user stops.
- Tolerance: the same amount gives a weaker effect over time, so users take more.
- Kratom use disorder: the medical term for dependence, where use continues despite harm.
- Case reports of people admitted to hospital.
The similarity to opioid withdrawal is expected. Kratom’s alkaloids act on the same brain receptors as opioid medicines, as the chemistry topic linked above explains.
Treatment exists
Several case series support buprenorphine-based treatment for kratom withdrawal. Buprenorphine is an opioid medicine that only partly activates opioid receptors. Doctors use it to ease withdrawal and prevent relapse in opioid dependence.
Doctors reason from similar cases that it may also help 7-OH use disorder, although this has not been tested directly. Part 2 explains why the prescribing doctor needs to know about the kratom use.
If someone tries to stop and cannot, they have a treatable medical condition with an established treatment. It is not a moral failure, and they should not handle it alone.
Translator’s note: In Thailand, treatment for opioid dependence has relied mainly on methadone at authorised clinics. This article could not confirm how easy it is to get buprenorphine in Thailand. Ask the doctor which treatments are available. To get help, ask at any government hospital. You can also contact the Thanyarak Institute (สถาบันบำบัดรักษาและฟื้นฟูผู้ติดยาเสพติดแห่งชาติบรมราชชนนี), Thailand’s national drug-treatment institute. The drug-treatment hotline 1165 is open 24 hours.
What you can do before the appointment: Write down how much kratom you use, how often, and for how long. Add every medicine and supplement you take. With this list, the doctor can judge how severe the dependence is and choose a treatment that is safe with your other medicines.
Main points of Part 1
- Of the 95 published cases blamed on kratom, 40 had no laboratory confirmation.
- Other substances were found in 32 of the 35 deaths. Six deaths were blamed on mitragynine alone.
- Liver injury is the best-proven harm. It usually appears within 1 to 8 weeks of regular use.
- Dependence and opioid-like withdrawal are well documented and can be treated.
Questions, or experience from Thai clinics and hospitals? Post them below this topic.
References (Part 1):
- “The acute adverse health effects of kratom: an evaluation of case reports”, Frontiers in Pharmacology, 2025
- “Kratom”, LiverTox: Clinical and Research Information on Drug-Induced Liver Injury, NIH
- US Drug-Induced Liver Injury Network kratom case series (Navarro et al.), The Liver Meeting, 2019
- “Kratom”, StatPearls, NCBI Bookshelf
- “7-Hydroxymitragynine (7-OH): Clinical Implications of a Potent, Unregulated Opioid Partial Agonist Derived from Kratom”, Current Addiction Reports, 2026
- Kratom Act B.E. 2565 (Thailand)
Continued in Part 2: Kratom Risks: Drug Interactions, Concentrated 7-OH Products, Who Should Not Use It and What Is Still Unknown (Part 2 of 2)