|Year : 2020 | Volume
| Issue : 5 | Page : 450-454
General knowledge of marijuana and kratom in an urban dental patient population: A cross-sectional study
Farzad Baghaie, Sarah Chamseddine, Shaza Awad, Michelle Wheater
University of Detroit Mercy School of Dentistry, Division of Integrated Biomedical Sciences, Detroit, Michigan, United States
|Date of Submission||08-Jan-2020|
|Date of Decision||18-Mar-2020|
|Date of Acceptance||03-Apr-2020|
|Date of Web Publication||21-Oct-2020|
Dr. Michelle Wheater
Division of Integrated Biomedical Sciences, University of Detroit Mercy School of Dentistry, 2700 Martin Luther King Jr. Boulevard, Clinic Building Room 465, Detroit, Michigan, MI.
Source of Support: None, Conflict of Interest: None
Aim: To analyze the knowledge of dental patients in an urban setting regarding the legality and potential clinical benefits of marijuana and kratom. Materials and Methods: This presented cross-sectional study had 18-item questionnaire consisting of four demographic questions, six questions focused on marijuana, and eight questions focused on kratom, which was distributed in paper and pencil format to a convenience sample of 400 dental patients in the waiting area of an urban dental school. Data were entered into Qualtrics Research Suite software and analyzed using descriptive statistics and χ2 test with significance at P < 0.05. Results: Four hundred (400) surveys were completed anonymously by adult volunteers. Results showed a variable level of knowledge regarding the legality and potential clinical use of marijuana and tetrahydrocannabinol (THC). With some questions, a statistically significant difference in knowledge was observed relative to age and highest level of education of the respondent. In contrast, compared to any knowledge of marijuana, respondents had little to no knowledge of kratom or mitragynine legality, health benefits, or potential as a substitute for opioids. Conclusion: Knowledge of marijuana is to be expected as its widespread use and debates of its legality have been in the public eye for years in the United States. Although similar debates regarding whether kratom should be legal continue, this survey suggests that the public has little to no knowledge of what it is. As opioid use disorder increases, so does the search for opioid substitutes. It is important that the public be made aware of potential opioid substitutes other than marijuana so that personal choices and decisions can be made with current and correct information.
Keywords: Kratom, Marijuana, Mitragynine, Tetrahydrocannabinol
|How to cite this article:|
Baghaie F, Chamseddine S, Awad S, Wheater M. General knowledge of marijuana and kratom in an urban dental patient population: A cross-sectional study. J Int Oral Health 2020;12:450-4
|How to cite this URL:|
Baghaie F, Chamseddine S, Awad S, Wheater M. General knowledge of marijuana and kratom in an urban dental patient population: A cross-sectional study. J Int Oral Health [serial online] 2020 [cited 2020 Nov 29];12:450-4. Available from: https://www.jioh.org/text.asp?2020/12/5/450/298802
| Introduction|| |
As the public knowledge of opioid use disorder increases, so has the use of potential opioid substitutes. Marijuana and kratom are two such substitutes. Marijuana, the term used interchangeably with cannabis, is derived from the plant Cannabis sativa. Marijuana buds and leaves are smoked or ingested. Increasingly marijuana is inhaled by vaporization using delivery systems similar to those used for e-cigarettes. For adults, potential clinical applications for marijuana include management of nausea, poor appetite, and pain, as well as treatment of glaucoma, multiple sclerosis, and epilepsy. Δ-9-tetrahydrocannabinol or THC is the major psychoactive ingredient in marijuana.
A survey study determined that a substantial number of adults in the United States reported that they substituted marijuana for opioids for pain management. Indeed, marijuana has been legally approved for the management of pain in many of states in the United States. In Colorado, Illinois, and New York, health professionals are legally permitted to recommend marijuana instead of OxyContin, Percocet, or Vicodin. In New Mexico, New Jersey, New York, and Pennsylvania, people with an opioid addiction may qualify for a medical marijuana card. In addition to states in which marijuana is legal for medicinal use, there are states that have legalized recreational use. Michigan is one of the states that has legalized marijuana for recreational use. In the United States, each state has its own rules for how much marijuana people can possess and grow.
Kratom (Mitragyna speciosa Korth.) is a plant indigenous to Thailand, Malaysia, Myanmar, and other areas of Southeast Asia, where traditionally it was used to combat fatigue and improve work productivity., The leaves and stems are harvested and dried to provide the psychoactive ingredients that are ingested, often as a tea. Increasingly kratom is being taken by opioid users, who say it helps them curb their addiction and manage opioid withdrawal symptoms. In a survey study focused on kratom use and motivations in a population of patients in a residential program, the drug was mainly used as a means of reducing or abstaining from nonprescription opioids and/or heroin, and as a substitute for such. The rise in kratom sales in the United States is due in part to multiple websites marketing the leaves as alternative treatment for reducing chronic pain and managing opioid withdrawal., Pharmacological analysis shows that kratom contains the alkaloids mitragynine and 7-hydroxymitragynine, which interact with opioid receptors, and render morphine-like effects.
Currently, kratom is not controlled under the Federal Controlled Substances Act, but is labeled a Drug and Chemical of Concern. Even with warnings of its label by the Food and Drug Administration (FDA) as “an opioid,” kratom remains legal and unregulated in the United States at the federal level and continues to be sold at gas stations, smoke shops, and online from multiple companies. As of the date of this article, kratom is legal in the state of Michigan.
The objective of this study was to determine knowledge of dental patients in an urban dental school in the state of Michigan, United States, regarding the legality, use, and potential clinical benefits of marijuana and kratom.
| Materials and Methods|| |
This survey study used a cross-sectional study design. An 18-item questionnaire, along with a research information sheet, was distributed in paper and pencil format to dental patients in the waiting area of an urban dental school by three researchers. Before distribution, the questionnaire was piloted to a group of adults who were not a part of the research team to determine readability and ease of understanding. The survey research study was approved by the University of Detroit Mercy Institutional Review Board (Protocol no. 1819–42).
There were no specific inclusion or exclusion criteria for recruiting volunteers for this survey other than participants were at least 18 years of age. This study used a convenience sample consisting of any adult patient in the waiting area of an urban dental school who consented to participate in the survey. As a cross-sectional study, the final sample size consisted of all volunteers recruited in a 4-month study time frame.
Study method and data collection
Risks and benefits to participation were provided to potential volunteers by reading the research information sheet, which was included with the questionnaire. Volunteers completed the questionnaire in their own time and returned completed surveys to a marked box in the waiting area. No personal identifiers were included in the questionnaire, but four demographic data questions were included [Annexure 1]. Volunteers were provided response choices to the non-demographic questions of “yes,” “no,” and “not sure.” Data were entered into Qualtrics survey software for analysis (Qualtrics Research Suite, Provo, Utah).
Analyses included descriptive statistics (frequency and percentages) and cross-tabulation with χ2 analysis for categorical variables. Statistical analyses were completed within the Qualtrics program with a significance of P < 0.05. For purposes of analysis, “no” and “not sure” responses were collapsed to create a dichotomous response (yes or no/not sure) to the non-demographic questions.
| Results|| |
A total of 400 questionnaires were completed. All questionnaires were included in data analysis regardless of the total number of questions answered. Of the 400 volunteers who responded to the questionnaire, 39% (n = 157/399) were adult males, 53% (n = 210/399) were adult females, and 8% (n = 32/399) preferred not to answer. The age of respondents was defined in six age categories, with 15% (n = 58/400) between 18 and 25 years of age, 16% (n = 65/400) between 26 and 35 years of age, 19% (n = 74/400) between 36 and 45 years of age, 18% (n = 73/400) between 46 and 55 years of age, 17% (n = 69/400) between 56 and 65 years of age, and 15% (n = 61/400) 66 years of age and older. The ages of the respondents were distributed evenly across the ranges.
When asked about their highest level of education, 5% (n = 20/400) stated some high school, whereas 18% (n = 72/400) were high school graduates, 29% (n = 116/400) chose some college, and 34.5% (n = 138/400) of respondents were college graduates. Nearly 6% (23/400) of volunteers completed a technical or trade school program, and nearly 8% (n = 31/400) had a professional degree such as PhD, MD, DDS, or JD. Volunteers were asked how often they used the Internet, for any purpose at all; 85% of the respondents (n = 338/399) claimed they used the Internet daily, 8% (n = 32/399) weekly, 1% (n = 2/399) monthly, and 7% (n = 27/399) rarely.
The volunteers were asked six questions regarding marijuana. When asked if recreational marijuana is now legal in the state of Michigan, 78% (n = 310/400) of all respondents answered yes, whereas 22% (n = 90/400) responded no/not sure. There was a statistically significant difference in age-groups, with all age-groups between 18 and 65 years choosing higher yes responses compared to respondents 66 years and older [Figure 1], Legal, P= 0.0080]. There was no difference in how volunteers responded to this question with respect to highest level of education [[Figure 2], Legal]. Of the respondents, 81% (n = 274/338) of the respondents who use the Internet daily knew that recreational marijuana was legal in Michigan.
Volunteers were asked if marijuana can interact with medications prescribed by healthcare professionals. Overall, 53% (n = 212/400) said yes, and 47% (n = 188/400) responded no/not sure. There was no difference in the response to this question based on age of the volunteer [[Figure 1], Interaction], with yes responses ranging from 45% to 54%. In contrast, significant differences in the knowledge of potential marijuana interactions with medications were observed based on the highest level of education of the respondents [[Figure 2], Interaction, P = 0.0006]. As a contrasting example, 71% (n = 22/31) of respondents who have a professional degree agreed that marijuana can interact with prescribed medications, whereas 35% (n = 8/23) of those with a technical or trade school education agreed. No differences in the response to this question was observed based on Internet use, as yes responses averaged approximately 50%.
Next, volunteers were queried regarding their opinion that marijuana can be used to help cure disease without getting the user “high.” Of 399 responses, 40% (n = 161/399) were yes, and 59% (n = 238/399) were no/not sure. There was no difference in response to this question based on the age of the respondent [[Figure 1], Cure Disease]. Yes responses were fairly evenly distributed among all age-groups. There were differences in yes responses to this question as a function of highest level of education [[Figure 2], Cure Disease, P = 0.0006], with those volunteers with some high school or a technical or trade school education having the lowest yes response rate. In line with previous questions, those volunteers who use the Internet on a daily basis had the highest yes response percentage (44%).
When next asked if some people use marijuana as a substitute for opioids and painkillers, 80% (n = 319/398) of all respondents replied yes, whereas 20% (n = 79/398) replied no/not sure. Yes responses to this question did not differ by age of the volunteer [[Figure 1], Opioid Substitute]; however, statistically significant differences were observed in responses based on the highest level of education [[Figure 2], Opioid Substitute, P = 0.0011]. Although 100% (n = 31/31) of respondents with a professional degree agreed that marijuana is used as a substitute for opioid and other painkillers, 55% (n = 11/20) of respondents with some high school education likewise agreed. Of those who used the Internet daily, 84% responded “yes” to this question.
The last of the questions, focused on marijuana, asked if THC is the chemical responsible for most of marijuana’s psychological effects. Of all volunteers, 60% (n = 241/399) responded positively and 39% (n = 158/399) responded negatively. There were no differences in responses based on volunteer age [[Figure 1], THC]. In contrast, significant differences in the knowledge of THC were observed as a function of highest level of education [[Figure 2], THC, P = 0.0045]. Although 74% (n = 23/31) of respondents with a professional degree had knowledge of THC, only 30% (n = 6/20) of respondents with some high school education had such knowledge. Of those who use the Internet daily, 65% responded yes to the question that THC is the chemical responsible for most of marijuana’s psychological effects.
The next section of the questionnaire focused on volunteer’s knowledge of kratom with eight questions. Before beginning this section, volunteers were given the following information: “Kratom is a tropical plant that is part of the coffee family. Kratom is an herbal supplement that has opioid-like properties.” Similarly to the section of the questionnaire focused on marijuana, the no and not sure responses were collapsed into one response. When asked if volunteers have heard about kratom before taking the survey, 12% (n = 47/398) responded yes and 88% (n = 351/398) responded no/not sure. Only 7% (n = 26/400) responded that it is legal to purchase, possess, and use kratom in Michigan, whereas 93% (n = 374/400) responded that it is not legal or they are not sure if it is legal.
When asked if kratom can interact with medications prescribed by healthcare professionals, 14% (n = 54/399) responded yes whereas 86% (n = 345/399) responded no/not sure. Volunteers were questioned whether kratom can be used to help cure diseases. To this question, 4% (n = 14/400) of the respondents replied yes with 96% (n = 386/400) replying no/not sure. The next question asked was whether people use kratom as a substitute for marijuana. To this question, 12% (n = 46/400) responded yes and 88% (n = 354/400) responded no/not sure.
Volunteers were questioned whether people use kratom as a substitute for opioids and painkillers. Responses included 15% (n = 60/400) as yes, and 85% (n = 340/400) as no/not sure. The last question focused on kratom was if mitragynine is one of the chemicals responsible for its purported effects. To this question, 4% (n = 14/400) of the respondents replied yes, whereas 96% (n = 386/400) of the respondents replied no/not sure. No cross-tabulation analysis of the questions focused on kratom was done as for each question the negative responses overwhelmed the positive ones.
| Discussion|| |
As prescription opioid use and opioid-related deaths continue to increase in the United States, patients are becoming more aware of plant-based alternatives as a means to eliminate the use of such drugs for pain management. Each year more states in the United States are legalizing marijuana for pain management or recreational use, and as of spring 2019, medical cannabis is legal in 34 states.[20 This may facilitate the use of marijuana for pain management in patients who have been hesitant to use a previously illegal drug. In an Internet-based survey of 16],[280 US adults],[ 41% reported a decrease or cessation of opioid use due to marijuana use. These authors concluded that a substantial number of US adults reported that they substituted marijuana for opioids. In a second survey study, it was found that American and Canadian users commonly substitute marijuana for opioids., However, using a retrospective cohort study, authors suggested that legalization of recreational cannabis did not affect compliance rates in patients treated with opioid therapy for chronic pain.
This study focused on respondent knowledge of current marijuana legality, not personal use. Of those surveyed, 78% knew that recreational marijuana was legal in their home state of Michigan, and 80% agreed that people use marijuana as a substitute for opioids and painkillers. These percentages corresponded closely to those who use the Internet daily. It is not known if the survey volunteers gained such knowledge of marijuana through the use of the Internet; however, it seems that the Internet is a potential source of information for those seeking information about the legality of certain drugs as alternatives to opioids in managing personal pain issues.
An unexpected outcome of this study was the apparent lack of knowledge regarding kratom in this particular survey population. Kratom is readily available in powder, leaf, or capsule form, and can be found on Amazon.com. However, only 12% of respondents were aware that kratom was a plant, and only 7% knew kratom could be purchased in Michigan. In a 2016 survey of 6150 kratom users, 9% used the leaves for the treatment of opioid addiction or dependence. A survey of 8049 volunteers revealed that kratom was primarily used for self-treatment of pain and withdrawal symptoms associated with prescription opioid use. Thus, kratom is available to the public as an alternative for opioids, with an abundance of information regarding its use, safety, and efficacy, as a self-medication regimen.
Strength of this cross-sectional survey was that because age was fairly evenly distributed among six categories, analyses of the effect of age on the knowledge of marijuana and kratom were obtainable. One might think that young adults of 18–25 years are more Internet savvy and might have greater knowledge of marijuana or kratom, but the analysis of data in this study did not show that to be consistent. The second strength of the survey was to utilize a population in an urban setting who may have more access to shops where legal marijuana and kratom would be available, thus increasing their exposure to the products. A weakness of the survey was that a convenience sample was used, and volunteers were not asked if they were consumers of marijuana and/or kratom, if they were chronic pain patients, or if they used opioids for pain management. Repetition of the study with inclusion of such information could provide information about the use of marijuana and/or kratom for the management of chronic or acute dental or medical pain. In addition, the use of the questionnaire with healthcare professionals is much important so that accurate information can be made available to patients seeking non-opioid alternatives to manage pain.
The results of this survey study conclude that a variable number of dental patients in an urban dental school have knowledge of the legality of marijuana and kratom in their home state. In some instances, this knowledge is correlated to age and the highest level of education. Although variable, the knowledge of potential benefits of marijuana as a substitute for opioid and other painkillers is much higher compared to the knowledge of the use of kratom for the same potential clinical benefits. As opioid use disorder increases, so does the search for opioid substitutes. It is important that both the public and healthcare professionals be made aware of potential opioid substitutes other than marijuana so that personal choices and decisions can be made with current and correct information.
Financial support and sponsorship
This study was supported by the internal grant funds from the University of Detroit Mercy School of Dentistry.
Conflicts of interest
There are no conflicts of interest.
Farzad Baghaie, Sarah Chamseddine, Shaza Awad all contributed equally to the construction of the survey, collection and analysis of survey data, initial writing of the manuscript. Michelle Wheater created the graphs, analyzed survey data, and prepared the final draft of the manuscript.
Ethical policy and Institutional Review board statement
The survey study was approved as exempt by the University of Detroit Mercy Institutional Review Board. The Protocol number is 1819–42.
Patient declaration of consent
Risks and benefits to participation were provided to potential volunteers by reading the research information sheet, which was included with the questionnaire.
Data availability statement
Data is stored on the online software Qualtrics.
| References|| |
Pcssnow.org. Opioid use disorder: What is opioid addiction? Available from: https://pcssnow.org/resource/opioid-use-disorder-opioid-addiction/. [Last accessed on 2020 Jan 06].
Pearson JL, Villanti AC It's past time to consider cannabis in vaping research. Nicotine Tob Res 2020;22:597-8.
Chadwick VL, Rohleder C, Koethe D, Leweke FM Cannabinoids and the endocannabinoid system in anxiety, depression, and dysregulation of emotion in humans. Curr Opin Psychiatry 2020;33:20-42.
Lucas P, Walsh Z Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients. Int J Drug Policy 2017;42:30-5.
Ishida JH, Wong PO, Cohen BE, Vali M, Steigerwald S, Keyhani S Substitution of marijuana for opioids in a national survey of US adults. PLoS One 2019;14:e0222577.
Governing.com. The states where doctors can recommend marijuana over opioids. Available from: https://www.governing.com/topics/health-human-services/sl-The-States-Where-Doctors-Can-Recommend-Marijuana-Over-Opioids.html. [Last accessed on 2020 Jan 06].
Governing.com. State marijuana laws. Available from: https://www.governing.com/gov-data/safety-justice/state-marijuana-laws-map-medical-recreational.html. [Last accessed on 2020 Jan 06].
Cinosi E, Martinotti G, Simonato P, Singh D, Demetrovics Z, Roman-Urrestarazu A, et al
. Following “the roots” of kratom (Mitragyna speciosa
): The evolution of an enhancer from a traditional use to increase work and productivity in southeast Asia to a recreational psychoactive drug in Western countries. Biomed Res Int 2015;2015:968786.
Kim S The pharmacology and toxicology of kratom: From traditional herb to drug of abuse. Arch Psych Nursing 2019;33: 325-8.
Han C, Schmitt J, Gilliland KM DARK classics in chemical neuroscience: kratom. ACS ChemNeurosci2019. doi: 10.1021/acschemneuro.9b00535. [Epub ahead of print]
Grundmann O Patterns of kratom use and health impact in the US—Results from an online survey. Drug Alcohol Depend 2017;176:63-70.
Smith KE, Lawson T Prevalence and motivations for kratom use in a sample of substance users enrolled in a residential treatment program. Drug Alcohol Depend 2017;180:340-8.
Diep J, Chin DT, Gupta S, Syed F, Xiong M, Cheng J Kratom, an emerging drug of abuse. A & A Prac 2018;10:192-4.
Chang-Chien GC, Odonkor CA, Amorapanth P Is kratom the new ‘legal high’ on the block?: The case of an emerging opioid receptor agonist with substance abuse potential. Pain Physician 2017;20:E195-8.
Swogger MT, Walsh Z Kratom use and mental health: A systematic review. Drug Alcohol Depend 2018:18:3134-40.
Domingo O, Roider G, Stöver A, Graw M, Musshoff F, Sachs H, et al
. Mitragynine concentrations in two fatalities. Forensic Sci Int 2017;271:e1-7.
Raffa RB, Beckett JR, Brahmbhatt VN, Ebinger TM, Fabian CA, Nixon JR, et al
. Orally active opioid compounds from a non-poppy source. J Med Chem 2013;56:4840-8.
Kraoma.com. Is kratom legal in Michigan in 2020? Available from: https://kraoma.com/kratom-michigan-legality/. [Last accessed 2020 Jan 06].
Practical Pain Manaagement.com. Navigating cannabis options for chronic pain. Available from: https://www.practicalpainmanagement.com/patient/treatments/marijuana-cannabis/navigating-cannabis-options-chronic-pain. [Last accessed 2020 Jan 06].
Vyas MB, LeBaron VT, Gilson AM The use of cannabis in response to the opioid crisis: A review of the literature. Nurs Outlook 2018;66:56-65.
Lo SY, Winston-McPherson GN, Starosta AJ, Sullivan MD, Baird GS, Hoofnagle AN, et al
. Cannabis legalization does not influence patient compliance with opioid therapy. Am J Med 2019;132:347-53.
Prnewswire.com. Survey of 6,000 kratom users shows no evidence of epidemic or abuse justifying DEA push to ban coffee-like herb. Available from: https://www.prnewswire.com/news-releases/survey-of-6000-kratom-users-shows-no-evidence-of-epidemic-or-abuse-justifying-dea-push-to-ban-coffee-like-herb-300331148.html. [Last accessed 2020 Jan 06].
[Figure 1], [Figure 2]