Assessing the quality of information provided on websites selling Kratom (Mitragyna speciosa) to consumers in Canada

Canada is in the midst of an opioid crisis; over 15,000 Canadians have lost their lives in opioid-related deaths from 2016 to 2019 [1, 2]. Given the severity of the opioid crisis, many individuals have turned to alternative therapies, including natural health products as they are commonly considered to be safer alternatives by the average consumer [3, 4]. Health Canada defines natural health products as naturally occurring substances that are used to restore or maintain good health and divide them into the following six categories: vitamins and minerals; herbal remedies; homeopathic medicines; traditional medicines such as traditional Chinese medicine or Ayurveda; probiotics; and other products, such as amino acids and essential fatty acids [5]. Kratom (Mitragyna speciosa) is one herbal natural health product commonly used to remedy opioid withdrawal, improve stamina, increase sexual performance, and/or relieve anxiety and chronic pain [6‐8]. Despite the potential benefits, kratom is also associated with side effects including skin discoloration, constipation, and weight loss [9, 10]. Kratom is also used recreationally by some to achieve a euphoric high, and such individuals may do so without consulting or seeking supervision from a qualified healthcare professional [3‐5]. Others may be using kratom for perceived health-related benefits.

Kratom is a tropical evergreen tree indigenous to Thailand, Malaysia, Myanmar, and Papua New Guinea, where it has commonly and historically been used as an herbal medicine [10]. Although kratom is indigenous to these aforementioned East Asian nations, today kratom products are produced and distributed in many other countries across the world. Kratom is available to consumers in various forms including pills, capsules, powder, and leaves [11]. Kratom contains multiple psychoactive alkaloids, all of which are naturally occurring [12]. Two main active compounds are mitragynine and 7-α-hydroxymitragynine, which interact with opioid receptors in the central nervous system to produce sedative effects and decrease sensitivity to pain [13, 14]. The most abundant compound is mitragynine, which makes up approximately 66% of its alkaloid content [13]. In contrast, 7-α-hydroxymitragynine only makes up 0.02% of kratom by mass [14, 15]. Although mitragynine is more abundant than 7-α-hydroxymitragynine in kratom by mass, 7-α-hydroxymitragynine is far more potent because it has an affinity for opioid receptors that is 46 times that of mitragynine [16]. The exact mechanism through which kratom alkaloids interact with opioid receptors is still unknown [16]. It is important to note that due to the diversity of alkaloids present in kratom, it possesses both stimulant and opiate-like properties [13, 17]. At lower dosages, kratom may demonstrate stimulative effects, but at higher dosages, opiate-like properties are thought to be predominant [13, 17]. Other research reveals kratom’s potential to alleviate pain without the addictive characteristics akin to opioids currently used for pain management, such as codeine [14]. With respect to the safety profile of kratom, current reports suggest that deaths caused by kratom are usually in association with other substances or due to underlying health issues [18‐20]. Some of these substances include fentanyl, heroin, and other prescription opioids [21]. Despite its use for various purposes, an absence of evidence supports the many purported benefits of kratom [7, 17, 22]. Much of the information available about kratom is based on anecdotal reports, user experiences, and case studies [19]. As of September 2020, several trials studying kratom pharmacokinetics were registered on ClinicalTrials.​gov, a database of privately and publicly funded clinical trials conducted across the world [23], however, none have been completed or published to date [23]. Due to the possible risks associated with kratom, it is not present on the United States Food and Drug Administration’s (FDA) Generally Recognized as Safe list, but it is included in the FDA Poisonous Plant Database. Kratom is legal in Canada provided that it is not used for human consumption [24, 25], however, many vendors are still selling kratom that appears to be intended for consumption, while stating that the product is for “education and research purposes” or for aromatherapy [26, 27]. Kratom, therefore, remains readily available and easily accessible to consumers through online vendors [3‐5]. As individuals in Canada increasingly consult the internet to seek medical advice, self-diagnose, or self-medicate with products such as kratom, it is crucial to understand the quality of consumer health information provided by vendor websites [28]. Although some individuals may use kratom for non-health purposes (i.e. recreationally), the objective of this study is to assess the quality of consumer health information provided on the websites of online kratom vendors which sell their products to consumers in Canada.

To our knowledge, this is the first study to focus on assessing the quality of consumer health information provided by websites of online vendors selling kratom products. However, similar investigations have been conducted regarding other herbal remedies which present findings that are comparable to the present study. A similar study assessed the quality of consumer health information presented by online vendors selling Ephedra sinica to consumers in Canada. The results of the study outlined that the majority of the websites failed to present the information necessary to make an informed purchase decision [31]. Another study examined the quality of information present at the intersection of complementary alternative medicine and arthritis. The DISCERN instrument was used to rank the quality of consumer health information, revealing that the subset of websites assessed underreported the risks associated with specific treatment options [32]. Furthermore, a study examined the quality and readability levels of information provided by websites selling herbal supplements marketed as remedies for menopausal symptoms. This study also used the DISCERN instrument to assess the quality of health-related information provided about each product [33]. The results of all three studies were similar as they identified that the quality of consumer health information provided by online sources was poor [31, 33] or variable [32].

The poor quality of consumer health information identified across online kratom vendor websites may be explained by their commercial nature. Sharing with consumers that their products are associated with potentially harmful health risks may negatively impact the volume of sales. Thus, such retailers are in a perpetual conflict of interest with respect to providing accurate, high-quality consumer health information [34]. Given a general lack of available high-quality research evidence (i.e. clinical trials) examining the purported benefits of kratom, it is unsurprising that the majority of the websites we assessed provided information about kratom which relied upon personal experiences and historical claims.

With respect to clinical practice, this study’s findings suggest the importance of healthcare provider education about kratom. It is necessary that they take a full substance use history including natural products such as kratom, regardless of whether these were bought online or locally by the patient. A warranted direction for future research includes evaluating the accuracy of information provided by online vendors selling kratom to consumers in Canada, as this was beyond the scope of what the DISCERN instrument measures. Evaluating content accuracy will not only provide a better understanding of health-relatedinformation present on the internet, but it can also pinpoint specific factual inaccuracies and errors. An additional future direction can involve conducting a qualitative content analysis of the consumer health information presented on this subset of websites to examine and better understand patterns in communication. Collectively, the results of these additional investigations can further inform healthcare providers about the sources of information their patients may be consulting prior to deciding to purchase and consume kratom. Additionally, healthcare providers can use this information to promote public health initiatives which aim to inform the public about the poor quality of consumer health information pertaining to kratom that is available online.

In light of the ongoing opioid crisis in Canada, kratom is sought by many facing opioid withdrawal as a potential solution, and is easily accessible for purchase and consumption through online vendors. We sought to assess the quality of consumer health information provided on the websites of online vendors that sold kratom products to consumers in Canada. This study found that the quality of information presented across the majority of websites was poor, with many failing to provide sufficient information about the benefits, risks, and uncertainties of kratom needed for consumers to make an informed decision about its purchase and use. Given the increased popularity of this herbal product, this study can further inform healthcare providers about the types of information their patients may be consulting prior to purchasing kratom. It is important that healthcare providers are educated on the topic of kratom, and ensure that they take a full patient substance use history that includes inquiring about kratom. The information from this study can be used to better equip healthcare providers in promoting informed decision making about the use of kratom.