Interview with Marc Swogger, University of Rochester social scientist

Interview with Marc Swogger, University of Rochester social scientist

An audio version of this interview can be found here.

Dr. Marc Swogger is an associate professor at the University of Rochester Medical Center, Department of Psychiatry. Dr. Swogger is a social scientist and psychologist who studies substance use. He has co-authored multiple studies on the individual and public health effects of the use of kratom. 

Kratom Science: My first question is, did your interest in The Fall and Mark E. Smith lead you to study substance use?

Marc Swogger: *laughs* He certainly studied substance use from an experiential standpoint! He was much more into speed and alcohol. So, no, but I would bet that a number of different substances do contribute to many Fall fans’ enjoyment of the band.

Is clinical psychologist the right term for your profession?

Yeah, I guess I’m a clinical psychologist, that’s true. I’m more of a social scientist now. I’m expanding my work to do research on therapeutic and harmful use of substances.

I kind of got into kratom by accident. I don’t know if you know the Erowid.org site. It’s a wonderful site for fairly objective information on substances and substance use experiences. I ran across kratom and I was looking at some of the experience reports. People use substances and send in a description of their experiences. I realized there hadn’t been a lot of work done on kratom in the West, or really, there hadn’t been a lot of science done on it anywhere. People were using it and reporting positive results for pain. I became more interested in that, being a substance use researcher, and was able to work with Earth and Fire Erowid to publish a paper on those experiences. We sort of distilled them into themes and realized that people were really using kratom for a number of different reasons. Sense of well being, or relaxation. People were reporting that it made them more sociable, which was interesting for something that other people were reporting has an opioid-like effect.

So it just turned out to be a really interesting plant. And it was right after we published that paper on people’s experiences with kratom, that the DEA indicated their intent to schedule it. That’s when everything became interesting.

When you went to do that study, how did you process all that information? What was your methodology? I’m doing a similar thing on our website. We have thousands of comments and I plan on putting them into some kind of database.

It’s not super easy to distill that, and it’s qualitative research for the most part. We had close to 200 reports, and then we eliminated ones from the same user, so that we didn’t do any doubling and have any redundancy. We excluded some because we couldn’t really understand what they were getting at. So you’ll run into things like that.

What we wound up with is 161 independent reports of experiences with kratom. So at that point we began to look for themes in the reports. We had an algorithm that we worked through, but it became pretty easy because we were seeing the same things over and over and over again. We were seeing people using it for pain and reporting pain relief, or using it for relaxation and reporting that it worked for that. And we were seeing themes on the negative side, too. By far the most troubling negative side effect was nausea. Some people had vomiting, and things like alternating chills and sweats and dizziness.

So, basically breaking it down into themes and then having somebody go through it again with our algorithm to see if they came up with the same sorts of themes to provide a little bit of a reliability check on it.

It’s not particularly rigorous science but it does provide some standardization and control that’s necessary. There have been better surveys done since then. There was a really good one by Jack Henningfield’s team – I think Coe was the first author – that was published in Drug and Alcohol Dependence. They did a survey of thousands of kratom users. They found that people were using it primarily for pain, but also for things like anxiety, depression, and Post Traumatic Stress Disorder. And that is what we found in a previous paper. Zach Walsh and I did a systematic review of all the studies we could find on kratom use and mental health and published that in Drug and Alcohol Dependence. This was 2018, so there were only thirteen studies of adequate rigor that we included in that review. But we found the same thing. It’s interesting that the surveys that have been done thus far in the West really do converge to say that people are using kratom for pain and to get off of opioids and other drugs that they don’t want to be on, and they’re reporting positive effects. They’re reporting that they’re getting off of opioids. They’re reporting pain relief. They’re reporting relief of anxiety and depression.

There’s a certain group of people that like to use kratom at lower doses because there’s sort of a different effect. It’s more stimulating at lower doses. So people are also using it for energy and focus, which is consistent with traditional uses in the East. Workers will use it to focus on their work and to get through some long workdays.

So, really, there’s a very clear picture that has emerged across these studies, East and West, of what the range of experiences with kratom looks like.

I wonder if it’s a better sample when you do surveys in Southeast Asia because many users are getting kratom from trees there, and here you’re not sure if it’s adulterated.

There are pros and cons, I guess. Generalizing from what people are getting there to what we would get here is kind of tough, like you said. That being said, there haven’t been a lot of adulterated kratom products when they look at this. But you never know, and there have been some, and some cases of kratom combined with things that have been deadly. So it’s different across cultures in that way. It’s also difficult to get dosage when you’re looking at people using it traditionally.

I don’t want to neglect the part of it where the is some addictive potential with kratom. It seems quite mild relative to opioids. But it does exist, and some people who use high doses, say, higher than five grams a day for weeks do run the risk of having withdrawal symptoms if they stop.

I’ve interviewed heroin addicts for the podcast, who now they use kratom every day, and I ask “Are kratom withdrawals anything like opiate withdrawals?” They usually kind of laugh and say, maybe I get a headache for a couple days. Do you find that withdrawals are milder, even for people who have a habit of using a lot of kratom?

Oh, yes. It’s a much more forgiving plant than the opioids are. The opioid withdrawal symptoms tend to be pretty severe. Kratom mimics some of those symptoms, but it doesn’t tend to last as long, and it doesn’t tend to be as severe. So people are not on the floor throwing up and unable to do anything.

But I don’t want to minimize the [kratom] withdrawal potential, because if people are out there thinking they can use it and it’s risk-free, that’s probably not true. For most people, they don’t wind up having withdrawal symptoms when they stop using it. But there are some people who get into some trouble with it.

In the article you co-authored in International Journal of Drug Policy called “Kratom policy: The challenge of balancing therapeutic potential with public safety” the FDA is quoted as saying “Real world data (RWD) and real world evidence (RWE) are playing an increasing role in health care decisions”. But in most studies I read it concludes that we do need more human clinical trials. So what is it going to take to go from the collected evidence of user reports to human clinical trials?

That’s a good question. As a social scientist, I mainly study people who are using it already. But there’s some science that’s being funded at the University of Florida that is moving in that direction. I’m not sure that it’s human clinical trials yet. But it is looking from a more basic science perspective at the potential of kratom to move through the usual process that drugs do in the United States. This is a difficult thing. Normally drugs will go through early phase trials where it’s mostly about safety and preliminary indications of efficacy. Then they’ll move onto larger trials, and then if the data look good, eventually the FDA approval happens, the drug is marketed, etc. And of course that happened with the drugs they’re using for medication assisted therapy like buprenorphine, that people use to get off of opioids.

What has happened though with kratom is quite different. People in the West gained access to kratom. The advent of internet certainly aided that. Word of mouth spread, and they began to use it to ease opioid withdrawals, and to get off of opioids, as well as other drugs that they didn’t want to be using. There are quite a few reports of people getting off of SSRIs using kratom, which have their own withdrawal syndrome.

So basically by the time the DEA got around to saying, Hey we should make this illegal, millions of Americans were already using it. You’ve got a situation where, clinical trials or not, it’s a little late. There are now, I don’t know what the latest estimates are, but it was over 10 million Americans are using kratom. They’re using it by-and-large, overwhelmingly to positive effect with little real evidence of adverse effects, despite what some of the media reports have suggested and what the FDA has come out with that’s not particularly good science.

So given that we have this information that all these people are using kratom, most of them to good effect, what would it do now to remove that from the market? What would it do to ban kratom and take that away from those people so that clinical trials can be completed? A number of us, Jack Henningfield, Oliver Grundmann, and myself argue that because of the situation with opioids and what addiction is like, taking kratom away now would be cruel. And it would lead to people going back onto opioids, and a certain percent of those people would overdose and die.

The main thing with kratom is that there’s little to no respiratory depression, so people are not overdosing on kratom and dying in large numbers. I’m not convinced there’s been one. I haven’t found good data to indicate that. Indeed in the East, in Malaysia where kratom has been used for at least a century, nobody’s talking about people dying from it. There’s a lot of talk about the risks of kratom that’s been overblown. It’s not like it’s not harmful if you take it away from people at this point.

Do you think there’s part of the drug rehabilitation industry that has a stake in drugs being illegal because they get court-ordered patients? I might be getting too far into the woods.

I think that’s always possible. I have not seen that. I do a fair amount of work with people who are running recovery centers and I haven’t seen it. Certainly kratom is akin to medication assisted treatment for opioid use disorders including methadone and buprenorphine. Without going too far into people’s motives, I think it’s just a lack of education. There may be some people at the top who are saying We want the money that’s going to be associated with kratom when we can monetize it. I think that’s going on. But as far as recovery systems, I don’t think they quite understand kratom yet. It’s just a matter of more education. Kratom has not been well understood. We’re working on that, but it’s going to take time.

Kratom is called an opioid by the FDA. Do you agree with the use of that term as applied to kratom?

Well, it’s really difficult. It’s a partial opioid agonist. So it does act on opioid receptors. It’s got other things going on though, that we don’t really know about. We don’t quite know the mechanisms, which is common with pharmaceuticals and plants. I don’t know if I disagree with that term but it’s certainly not a classical opioid. I’ve heard the term atypical opioid. Maybe I agree with that. I think the problem with labeling it an opioid is that people have an idea of an opioid crisis that’s going on now. We certainly have an overdose crisis. Labeling it an opioid lumps it in with the medications and illicit drugs that people are overdosing on, and really obscures clarity. It doesn’t do anything to clarify the situation. It makes it more messy. So it’s important to distinguish an atypical opioid like kratom that does not cause respiratory depression from the drugs that people are dying from.

“Public Perceptions Toward Kratom (Mitragyna Speciosa) Use in Malaysia” was a Journal of Psychoactive Drugs study that you were on. You mentioned opioids and kratom being lumped together. Cannabis has had negative views, especially decades ago, and its been illegal. Kratom is prohibited in Malaysia. Are the negative views caused by its prohibition?

I think in general, people tend to just believe what they hear. If something’s illegal, they make the leap to, There must be a good reason for that. In Malaysia I don’t think kratom is viewed as negatively as cannabis is. It’s sort of a matter of, if the public is convinced that something is a scourge and is going to lead to death, then it’s very easy to promote a certain drug policy that may benefit pharmaceutical companies, and may lead to more sales of other drugs. We don’t know what all of the goals are with some of these policies. I just pay attention to the point where, what’s the public health potential of this? It looks like the public health potential is vast with a plant that people are able to get and use and they are reporting that it’s decreasing all kinds of negative things, depression, and anxiety, and heroin use. Public perceptions of any specific drug are really fed by a lot of things that aren’t grounded in reality. You can see that, obviously, with the policy on cannabis and psychedelics in the United States. Now it’s becoming very clear that cannabis and psychedelics can be helpful, and in the case of psychedelics may be one of the more potent psychiatric treatments available. But for years and years, and it’s still happening, people were getting locked up. Here in New York state, people are still getting locked up for having cannabis. It’s sort of a political thing, and I try to stick to the public health part of it.

To that, a lot of Americans are kind of forced into self-treatment because they either can’t afford health insurance or they can’t afford medication. Are there a lot of doctors and psychologists who take into consideration that somebody might be helped by kratom or cannabis even where it’s illegal? Or do most doctors have to follow the FDA guidelines?

There are more and more. That’s a really good point. You mentioned that people can self-treat with this. Sometimes doctors look at that as a negative thing. It depends. There are a lot of people who are benefiting from this who would never go into a hospital or a doctor’s office and get a prescription for something because of healthcare costs or whatever reason. The medical system is not for everybody. We’d like to think it is. We’d like to make it for everybody, but it’s not at this point. So those people who won’t do that or can’t do that, it’s important that they have access to reasonably safe plants like kratom.

As far as the doctors that understand its potential, I think it’s growing. It’s a matter of education, because we have a system that splits things into “good drugs” and “bad drugs”, and it’s much more complicated than that. Because kratom does have some potential for tolerance and withdrawal, doctors are wary of it at the outset. But as more papers are published and more doctors are educated on the potential benefits of kratom and what the risks are – the serious adverse events, I mean it’s really a low number – I think it’s moving in the right direction at this point. There are some doctors who will listen to patients and their experiences that value that first, and most of all. They’re out there.

Not a lot of doctors have heard of it, I imagine.

And then if you do look it up, there is so much misinformation on the internet about kratom that it’s not helpful. I can see why people avoid talking about it. The best situation is if you can find a doctor who will listen to you and understand why you’re using it and what it’s doing for you and really do some research. That’s great when that happens. It’s just hard because doctors are not trained on plants like kratom.

There was a study that came out called “Kratom Use and Toxicities in the United States” by Eggleston. You were on a critique of that. They looked at poison control center calls. I once called a poison control center because I was bit by a brown spider and I thought it was a brown recluse. The guy who answered already know that it wasn’t, because he gets so many calls like that. Is it good to rely on poison control center calls to make an assessment of how dangerous kratom is?

No. Absolutely not. When Zach Walsh and I published the “Kratom Use and Mental Health” review, we did include a couple of poison control center studies just to round out the information. But any time you look at a study like that, there are numerous biases that are not controlled for. You pointed it out perfectly. If somebody takes a plant, and then has any kind of reaction, and doesn’t know much about that plant, maybe they took it intentionally or unintentionally, they might call the poison control center. They might report specific symptoms. Those symptoms may or may not have anything to do with what they took, and what they took may or may not have been kratom. It’s a messy way to collect data. It’s useful for monitoring general trends. But when you try to make causal connections, you can’t. When scientists publish papers like that, where they look at poison control center studies or case studies, and they over-interpret, they go too far and say, or at least imply that kratom caused what came after, that’s not rigorous science. It’s got to be questioned.

I think that’s what’s happened with kratom. Because it’s something that people are talking about for reasons of regulatory policy and politics, it is now something that is easier to get published on. So if you’ve got a case study of somebody who it looks like used kratom and had some kind of result, why not write that up and send it in and see if you can get published? The problem is that it’s just from case-study designs. You cannot draw causal conclusions in the way that people want to. We don’t have data that say kratom will kill you if you take it. There’s just none that are that rigorous. But, you know, can’t rule it out either. But it certainly doesn’t look that way in most peoples’ case.

The media took that study and ran with it. I wrote down some of the headlines: “Herbal supplement used to treat addiction and pain found unsafe by researchers”, “Kratom unsafe for treating addiction and pain, reveals new research”, and “Kratom Supplements Are Unsafe for Use, Causes Seizures and Liver Toxicity, Says Study”. Do scientists often get frustrated with the media?

Absolutely. Especially when the FDA seems to be complicit in the promotion of data that are weak, and all negative, by the way. There are a number of us who have done reasonably high quality science on kratom users and their experiences, is how I would put it — it’s observational science, distinct from clinical trials. We do take it seriously, and we do interpret it very carefully. Our studies, you’re right, they’re not splashing across the papers. It seems like, whether it’s because of the FDA or because of the exciting nature of the scary findings that some people have got, those are the studies that have the bullhorn. And yeah, it’s frustrating. But we just keep doing what we’re doing, and publishing critiques of those studies.

It seems like there’s a drug-horror fiction genre in the news. You can plug information into the format and get a story from that.

Oh yeah, for the last, what, 80 years, 90 years? Longer than that even. Our fear of drugs is used to advance all kinds of political and policing agendas, and it works, so they keep using it.

How much does prohibition and drug fear harm people who actually need help for substance abuse?

Oh I think it’s terribly damaging. It’s part of the reason people go into doctor’s offices and won’t talk about their use of something like kratom. We’ve got this idea that there are certain drugs that are bad and will take you down if you take one hit. And that idea is used to incarcerate people, which is just one of the many factors that go into the reason that people use drugs in the first place. They don’t have jobs, they don’t have good lives, they’ve got early trauma, they’re in poverty. By coming down so hard legally on people who are using certain substances, we just keep the cycle going. Certain people get paid, drug users get stigmatized. It’s really sad, and we should be doing better at this point. It’s been going on for long enough. And there’s enough science out there to say it doesn’t work. Harm reduction strategies like kratom do work. Treating people who use drugs like they’re people also works. So I hope we’ll get there. And I think kratom’s been a nice way of showing that, because nobody wants to incarcerate somebody’s gramma for treating her pain with a plant that’s relatively innocuous.

I’ve read somewhere that the average age is about my age, which is 43. It’s not a young people, fun party drug.

Yeah, nobody’s getting their next “fix” of kratom to go to a rave or something.

In one of the Malaysian studies you did, it showed that people who initiated the use of kratom got out of other risky behaviors, not necessarily just the use of illegal drugs, but prostitution and stuff like that. Why do you think that is?

Yes, HIV risk behaviors. That’s a good question. We don’t know the mechanism from that study in particular. This is just speculation, but once you have stopped using heroin, say, or another drug that you will do anything to get, you put yourself in fewer risky situations. So by cutting down the use of cocaine and heroin, kratom may indeed put people on a better path.

There was also another study – I think this was Darshan Singh out of Malaysia. He’s the lead author on a lot of those studies. He’s doing a lot of good work there. It was interesting. It was a study of social functioning among kratom users that indicated that even people who are heavy into kratom, even people who are experiencing withdrawal and such, they’re still holding down jobs. Their relationships are okay.

Now I can’t say that for everybody. You can go too far with anything. But I think it says something about the nature of this plant that it didn’t take over people’s lives. They used it and continued to function whereas things like heroin can take over your life and bring you down pretty quickly.

Keeping people out of risky situations is part of harm reduction, and so finding that the more people replaced things with kratom, the less they were in risky situations is a pretty good finding.

Do you know of anything research studies to look for that will be published soon?

There are some people who I have run across recently, at least one clinical trial on kratom and pain that looked pretty good. It was a study out of Malaysia using some pretty good methods for assessing pain reduction. But because those studies haven’t passed peer review yet, I don’t want to get too far along with that.

But that is the fight now, to get more clinical trials done and move kratom along in that system so that we can know even more about potential subtle adverse events or effects that happen when you study people more systematically. There’s always the risk that there are things going on we don’t know about long-term effects of kratom use that we can’t get from these studies of kratom users that were surveyed.

Do you think kratom could possibly be a tool in rehabilitation?

I think so. The problem is we have a system that has been in place for a long time and it includes a process for getting these medications onto the market. Because this isn’t something that’s a medication – it’s a largely unregulated plant – it’s been a lot more difficult to do research on and a lot more difficult to get the word out.

I think it’s already playing a role, since people are already using it for harm reduction purposes and to get off of opioids. There are a few forward-thinking clinicians — there was a program in Maine that was using medical cannabis and kratom for addictions. There are those programs that exist. There aren’t many of them, and there’s not a lot of research on how well they’re doing, but I think it’s got potential. There are enough surveys now that show that people are using it for those purposes, whether medical doctors or psychologists are acknowledging it or not.

It’s amazing how people speak about it. “It changed my life.” I get that a lot.

Oh yeah. I’ve met those people too. I’m always saying, well, you’ve got to be careful about case studies and such. And that includes the positive ones. The observational research shows that it’s not just you, or the guy you know, or the guy I know. When you look at people who have used kratom, this is by and large their experience. Not that everybody’s had their life turned around, but that it has made a positive impact. And some people’s lives do get changed by this plant.

I think that may be, in part, why it’s so controversial. Because if it didn’t do anything, nobody would be after it. Think of maybe salvia, or something. It has hardcore psychedelic effects, and no clear medical uses. Nobody’s really going after salvia. It’s not about the effects, it’s about the utility of it. I think somebody wants a piece of that.

Studies discussed in this interview:

Marc T. Swogger, Elaine Hart, Fire Erowid, Earth Erowid, Nicole Trabold, Kaila Yee, Kimberly A. Parkhurst, Brittany M. Priddy & Zach Walsh (2015) Experiences of Kratom Users: A Qualitative Analysis, Journal of Psychoactive Drugs, 47:5, 360-367, DOI: 10.1080/02791072.2015.1096434

Coe MA, Pillitteri JL, Sembower MA, Gerlach KK, Henningfield JE. Kratom as a substitute for opioids: Results from an online survey. Drug Alcohol Depend. 2019;202:24‐32. doi: 10.1016/j.drugalcdep.2019.05.005 https://pubmed.ncbi.nlm.nih.gov/31284119/

Swogger MT, Walsh Z. Kratom use and mental health: A systematic review. Drug Alcohol Depend. 2018;183:134‐140. doi:10.1016/j.drugalcdep.2017.10.012 https://pubmed.ncbi.nlm.nih.gov/29248691/

Prozialeck WC, Avery BA, Boyer EW, et al. Kratom policy: The challenge of balancing therapeutic potential with public safety. Int J Drug Policy. 2019;70:70‐77. doi:10.1016/j.drugpo.2019.05.003 https://www.sciencedirect.com/science/article/pii/S0955395919301252?via%3Dihu

Grundmann O, Brown PN, Henningfield J, Swogger M, Walsh Z. The therapeutic potential of kratom. Addiction. 2018;113(10):1951‐1953. doi:10.1111/add.14371 https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.1437

Singh D, Narayanan S, Suraya S, et al. Public Perceptions toward Kratom (Mitragyna Speciosa) Use in Malaysia [published online ahead of print, 2020 Mar 10]. J Psychoactive Drugs. 2020;1‐7. doi:10.1080/02791072.2020.1738603 https://pubmed.ncbi.nlm.nih.gov/32153252/

Saref A, Suraya S, Singh D, et al. Self-Report Data on Regular Consumption of Illicit Drugs and HIV Risk Behaviors after Kratom (Mitragyna Speciosa korth.) Initiation among Illicit Drug Users in Malaysia [published online ahead of print, 2019 Nov 4]. J Psychoactive Drugs. 2019;1‐7. doi:10.1080/02791072.2019.1686553 https://www.ncbi.nlm.nih.gov/pubmed/31682782

Singh D, Müller CP, Vicknasingam BK, Mansor SM. Social Functioning of Kratom (Mitragyna speciosa) Users in Malaysia. J Psychoactive Drugs. 2015;47(2):125‐131. doi:10.1080/02791072.2015.1012610 https://pubmed.ncbi.nlm.nih.gov/25950592/

Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom Use and Toxicities in the United States. Pharmacotherapy. 2019;39(7):775‐777. doi:10.1002/phar.2280 https://pubmed.ncbi.nlm.nih.gov/31099038/

Grundmann O, Brown PN, Boyer EW, et al. Critique of “Kratom Use and Toxicities in the United States”. Pharmacotherapy. 2019;39(11):1119‐1120. doi:10.1002/phar.2336 https://accpjournals.onlinelibrary.wiley.com/doi/full/10.1002/phar.2336

Kratom Science blog post on Jack Henningfield’s initial statement about “Kratom Use and Toxicities in the United States” https://www.kratomscience.com/2019/07/17/widely-publicized-report-on-poison-control-calls-about-kratom-is-flawed-says-kratom-expert/

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