Recently, we’ve had several adults report using Sassafras (or “Sass”) to get high at concerts and in social situations. In researching sassafras, this is what we learned.
Like Sassafras… the plant?
Sort of. Safrole (4-allyl-1,2-methylenedioxy-benzene) is a phenylpropene oil derived from sassafras plants (typically root bark and fruits). Safrole can be isolated from camphor oil, and can also be synthesized from catechol. Naturally-occurring sassafras oil contains approximately 80% safrole. However, safrole is prohibited from inclusion in food products since the 1960s due to concerns about its carcinogenicity (linked to liver cancer). Safrole is used in the production of insecticides and fragrance.
Why would anyone use safrole?
Safrole is also a precursor for MDA (methylenedioxyamphetamine) and MDMA (Ecstasy). In one 2015 drug lab raid, the Royal Canadian Mounted Police seized 1500 kg of sassafras oil. News media reported that those 1500 kg could ultimately be converted into 4.2 million tablets of MDMA . Sassafras has been around for years; user reports go back to at least 2010. The terms Sass or Sassafras are sometimes used to refer to MDA itself, and users may refer to Sassafras as “natural Ecstasy.”
Can safrole make you sick?
Clear reports of safrole-induced illness are lacking. However, MDA and MDMA toxicity are well-described, and can include agitation, high temperature (hyperthermia), seizures, abnormal cardiac rhythms (dysrhythmias), and death . Since drug names can be used inaccurately, Sassafras cannot be linked to an actual drug without rigorous drug testing. In one death reported in the media, Sassafras was reported by witnesses as the culprit agent.
Is safrole legal?
Safrole is a List I Chemical in the United States. A chemical is designated as List I by the DEA if in addition to legitimate uses, it is used in manufacturing a controlled substance or is important to the manufacture of a controlled substance.
Right now, “It is unlawful for any person knowingly or intentionally to possess or distribute safrole, knowing, or having reasonable cause to believe, the safrole will be used to manufacture MDMA.”
Will we be seeing more of this?
We don’t know yet. But we’ll be looking for it. Any more information on Sassafras? Feel free to Tweet at us @umasstox.
Authors: Dr. Albert Conicella and Dr. Kavita Babu
Links for further reading:
A US Department of Justice advisory on safrole and sassafras oil.
A description of the role sassafras may have played in singer Scott Weiland’s death.
A news story on a death attributed to sassafras in Chicago.
A DEA description of what makes a List I Chemical.
On August 31, 2016, the Drug Enforcement Administration (DEA) temporarily placed mitragynine and 7-hydroxymitragynine into Schedule I status, then withdrew the intent to schedule in favor of a public comment period until December 1, 2016. The status of Kratom remains undetermined. Mitragynine and 7-hydroxymitragynine are the active alkaloids found in Kratom, a plant-derived product that has recently been used by patients to self-treat opioid withdrawal and addiction. Two strong camps are advocating for and against scheduling with patient safety in mind.
History
Kratom is derived from a plant native to Southeast Asia. For centuries, Kratom was used by manual laborers in countries like Thailand to mitigate the boredom and fatigue of working outside in the midday sun. At low doses, Kratom (usually chewed or taken as a tea) caused stimulant effects; at higher doses, an analgesic effect occurred. Kratom was made illegal in Thailand in 1943. Accounts of Kratom addiction entered the medical literature as early as the 1960s, with subsequent accounts describing a syndrome of malaise, apathy, and facial hyperpigmentation among the “Kratom eaters.”
This Century
Circa 2005, Kratom became increasingly available over the Internet as plant material, tea, and extracts. On forums like Bluelight, chronic opioid users began describing the use of Kratom to decrease their opioid tolerance during “opioid holidays,” and to manage withdrawal symptoms.
Adverse Events
Reports of adverse events followed, including hepatic injury, seizures, and deaths. However, the Kratom in several of these cases was contaminated with other agents. In one series of deaths in Europe, Kratom under the brand name “Krypton” was adulterated with a pharmaceutical, O-desmethyltramadol, an opioid analgesic with potentially deadly side effects in overdose.
The Kratom Prohibition Camp
Arguing for placement in Schedule I, the DEA entry in the Federal Register contained the following:
Kratom does not have an approved medical use in the United States and has not been studied as a treatment agent in the United States. Kratom has a history of being used as an opium substitute in Southeast Asia. Kratom has also been used to self-treat chronic pain and withdrawal symptoms from opioid use. Especially concerning, reports note users have turned to kratom as a replacement for other opioids, such as heroin. In the United States, kratom is misused to self-treat chronic pain and opioid withdrawal symptoms, with users reporting its effects to be comparable to prescription opioids.
The entry also notes that there are no pending Investigational New Drug (IND) applications pending for Kratom – an initial step required for formal study.
The Free-the-Kratom Camp
Advocates for patients with addiction have responded to the scheduling of Kratom with frustration. Many perceive Kratom as safer than pharmaceutical opioids, citing the limitations of drug treatment availability in describing the continued need for Kratom availability. Others have pointed to a knee-jerk response to new opioids in the midst of the opioid epidemic as the reason for the momentum in scheduling this drug.
The Bottom Line
Like other opioids, the potential for Kratom addiction and complications of use exist. However (from my perspective), Kratom has been used for centuries, with a handful of reported adverse events. The funds and effort required to enforce a Kratom ban would be better spent elsewhere. Yet, consumers must remain wary regarding Kratom safety, since there is no guarantee that the purchased Kratom today resembles the Kratom of old. Adulteration with pharmaceuticals and laboratory grade agents (including 7-hydroxymitragynine) have been reported, and many Kratom products are noted to be “enhanced.” Without safeguards on mitragynine and 7-OH-mitragynine concentrations, patients are at increased risk for adverse events. Limits on mitragynine and 7-OH-mitragynine concentration seem more warranted and reasonable than Schedule I status.
Author: Dr. Kavita Babu
Links for Further Reading
An awesome podcast featuring Dr. Alicia Lydecker on Kratom:
Smart Drug Smarts
A discussion of the scheduling debate with Drs. Boyer and Babu:
NY Times: Room for Debate
A recent publication from our group on the adulteration of Kratom:
Recent publication from our group
Fentanyl has been used as a painkiller for decades. Recently though, fentanyl has been mixed with heroin, or sold alone as a street drug. Clusters of fentanyl-related deaths have occurred in heroin users sporadically over the years. The current outbreak is unusual for its duration, widespread geographic pattern, and the sheer number of associated deaths. Of the 1374 opioid-related deaths in Massachusetts where toxicology data were available, fentanyl was found in 75% of cases.
Where is the fentanyl from?
Historically, the fentanyl that made its way into circulation came from patients and providers who had access to medical fentanyl, or from pharmacy thefts and fraudulent prescriptions. In the mid-2000’s, clandestine fentanyl manufacturing in the United States was slowed by limits placed on precursor chemicals. Recently, those fentanyl precursors have been available in China, and clandestine fentanyl has been exported to the United States, Mexico, and Canada. The Chinese government has made several of those precursors illegal, and placed limits of several fentanyl derivatives; the impact of these laws remains unclear.
Why is fentanyl causing a spike in deaths?
The amount of fentanyl required to produce an overdose is the size of a few grains of salt, because fentanyl is a stronger (more potent) opioid* than heroin. Like other opioids, fentanyl causes users to stop breathing in high doses, which can rapidly lead to death. Many heroin users are unaware that their heroin contains fentanyl. In these cases, a fatal overdose can happen easily.
Does naloxone still work for fentanyl?
Naloxone reverses the effect of opioids, and is available for bystander use in many communities. Naloxone will reverse a fentanyl overdose, but high doses are sometimes required to reverse the effects of fentanyl. So it is always safest to call emergency medical services for a suspected opioid overdose – they will bring more naloxone to the scene in case it is needed.
*Opioids are a class of medications and drugs that are often used as painkillersn or to “get high.” Common opioids include heroin, morphine, codeine, Vicodin, Percocet, methadone, and fentanyl.
Authors: Dr. Matt Griswold and Dr. Kavita Babu
Further reading:
CNN article on Chinese government action to limit fentanyl availability:
A CDC report on a fentanyl-associated cluster of deaths in Connecticut.
2016 data on opioid-related overdose from Massachusetts
An interview with Dr. Griswold from the Telegram Gazette.