Mitragyna speciosa use in the northern states of Malaysia: A cross-sectional study

Abstract

The consumption of Mitragyna speciosa (MS) for its psychoactive effects is widely reported amongst people in the villages in Thailand and Malaysia even though its use is illegal.
This study examined the pattern of MS use, its reported effects and explored its potential to cause dependence.
We used both convenience and snowball-sampling methods to recruit participants in a border town between two northern states in Malaysia. Face-to-face interviews were conducted with the use of a structured questionnaire on 562 respondents who gave oral consent to participate in the study.
The response rate was 91%. The majority of the respondents (88%) reported daily use of MS. The main mode of using MS was by drinking the MS extract as tea (90%). The mean age of starting MS use was 28.3 (SD=8.1) years. A variety of reasons were given for using MS including for social and recreational needs, stamina and physical endurance, pain relief and improved sexual performance. Despite its reported usefulness in weaning off opiate addiction, 460 (87%) admitted they were not able to stop using MS. Only education level had a statistically significant association with the ability to stop or not stop the use of MS (χ(2)=31.0, df=1, p<0.001). Significantly higher proportions of those with a lower education level (38%) were able to stop using MS compared to respondents with a higher education level.
Our study provides important information on the pattern of MS use, its effects and its potential to cause addiction, as there has been growing interest in MS as evidenced by the number of advertisements for its sale on the Internet. Future study is required to explore its psychological and social impact on users.

Full text

Journal
of
Ethnopharmacology
141 (2012) 446–
450
Contents
lists
available
at
SciVerse
ScienceDirect
Journal
of
Ethnopharmacology
jo
ur
nal
homep
age
:
www.elsevier.com/locate/jethpharm
Mitragyna
speciosa
use
in
the
northern
states
of
Malaysia:
A
cross-sectional
study
Kamarudin
Ahmad, Zoriah
Aziz∗
Department
of
Pharmacy,
Faculty
of
Medicine,
University
of
Malaya,
Kuala
Lumpur,
Malaysia
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
13
December
2011
Received
in
revised
form
27
February
2012
Accepted
4
March
2012
Available online 14 March 2012
Keywords:
Central
nervous
system
Drugs
of
abuse
Pain
Alkaloids
Sedatives
Ketum
a
b
s
t
r
a
c
t
Ethnopharmacological
relevance:
The
consumption
of
Mitragyna
speciosa
(MS)
for
its
psychoactive
effects
is
widely
reported
amongst
people
in
the
villages
in
Thailand
and
Malaysia
even
though
its
use
is
illegal.
Aim
of
the
study:
This
study
examined
the
pattern
of
MS
use,
its
reported
effects
and
explored
its
potential
to
cause
dependence.
Materials
and
methods:
We
used
both
convenience
and
snowball-sampling
methods
to
recruit
participants
in
a
border
town
between
two
northern
states
in
Malaysia.
Face-to-face
interviews
were
conducted
with
the
use
of
a
structured
questionnaire
on
562
respondents
who
gave
oral
consent
to
participate
in
the
study.
Results:
The
response
rate
was
91%.
The
majority
of
the
respondents
(88%)
reported
daily
use
of
MS.
The
main
mode
of
using
MS
was
by
drinking
the
MS
extract
as
tea
(90%).
The
mean
age
of
starting
MS
use
was
28.3
(SD
=
8.1)
years.
A
variety
of
reasons
were
given
for
using
MS
including
for
social
and
recreational
needs,
stamina
and
physical
endurance,
pain
relief
and
improved
sexual
performance.
Despite
its
reported
usefulness
in
weaning
off
opiate
addiction,
460
(87%)
admitted
they
were
not
able
to
stop
using
MS.
Only
education
level
had
a
statistically
significant
association
with
the
ability
to
stop
or
not
stop
the
use
of
MS
(2=
31.0,
df
=
1,
p
<
0.001).
Significantly
higher
proportions
of
those
with
a
lower
education
level
(38%)
were
able
to
stop
using
MS
compared
to
respondents
with
a
higher
education
level.
Conclusions:
Our
study
provides
important
information
on
the
pattern
of
MS
use,
its
effects
and
its
potential
to
cause
addiction,
as
there
has
been
growing
interest
in
MS
as
evidenced
by
the
number
of
advertisements
for
its
sale
on
the
Internet.
Future
study
is
required
to
explore
its
psychological
and
social
impact
on
users.
© 2012 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Mitragyna
speciosa
belongs
to
the
Rubiaceae
family,
grows
well
in
swampy
areas,
and
is
native
to
countries
in
South-East
Asia.
It
grows
wild
mainly
in
Thailand,
Malaysia,
Indonesia
and
Papua
New
Guinea
and
it
is
cultivated
mostly
for
its
leaves.
The
leaves
are
either
prepared
as
a
drink,
chewed
when
freshly
picked,
or
smoked
when
dried.
In
Thailand,
MS
is
commonly
known
as
“Kratom”
while
in
Malaysia
as
“Biak-biak”
or
“Ketum”.
Currently,
out
of
more
than
40
alkaloids
identified
in
MS
(Shellard,
1974),
four
alkaloids
namely
mitragynine,
7-hydroxymitragynine,
corynantheidine
and
speciociliatine
appear
to
act
on
opioid
receptor
(Takayama
et
al.,
2002).
Mitragynine,
which
accounts
for
about
66%
of
the
total
alka-
loids,
is
the
dominant
alkaloid
and
is
exclusive
to
MS
(Shellard,
1974;
Ponglux
et
al.,
1994).
It
does
not
appear
to
have
psychedelic
activity
(Matsumoto
et
al.,
1997)
although
it
has
a
chemical
∗Corresponding
author.
Tel.:
+60
3
79674707;
fax:
+60
3
79674964.
E-mail
address:
zoriah@um.edu.my
(Z.
Aziz).
structure
resembling
a
psychedelic
rather
than
an
opiate
(Jansen
and
Prast,
1988a).
Burkill
(1935)
first
recorded
the
use
of
MS
in
Malaya
(present
day
Peninsula
Malaysia)
as
a
wound
poultice,
cure
for
fever
and
a
sub-
stitute
for
opium,
when
opium
was
not
available
or
not
affordable.
Traditionally
MS
has
been
used
to
wean
addicts
off
heroin
addiction,
to
treat
diarrhoea,
to
improve
blood
circulation
and
to
treat
diabetes
(Chan
et
al.,
2005).
However,
there
are
also
reports
that
the
leaves
are
mainly
used
as
a
stimulant
to
enable
labourers
to
endure
phys-
ical
fatigue
(Jansen
and
Prast,
1988b).
The
first
case
of
addiction
to
MS
was
first
reported
in
1957
and
a
case
series
of
addiction
was
pub-
lished
in
1975
(Thuan,
1957;
Suwanlert,
1975).
Typical
withdrawal
symptoms
reported
include
hostility,
aggression,
excessive
tearing,
inability
to
work,
aching
of
muscles,
bones,
and
jerky
limb
move-
ments;
whereas
long-term
use
has
been
associated
with
anorexia,
weight
loss,
and
insomnia
(Suwanlert,
1975).
In
Malaysia,
MS
is
widely
available
in
the
northern
states
of
Malaysia
namely
Kedah
and
Perlis
that
share
a
common
border
with
Thailand
and
it
is
widely
sold
as
drinks
and
teas
(Chan
et
al.,
2005).
The
drinks
are
easily
available
in
the
villages
and
are
cheap.
In
2003,
the
Malaysian
government
listed
Mitragynine,
the
major
alkaloid
0378-8741/$
–
see
front
matter ©
2012 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.jep.2012.03.009

K.
Ahmad,
Z.
Aziz
/
Journal
of
Ethnopharmacology
141 (2012) 446–
450 447
of
MS
in
the
First
Schedule
and
the
Third
Schedule
of
Psychotropic
substances
in
the
Poisons
Act,
1952.
Under
this
Act
a
person
found
to
possess
or
sell
MS
leaves
or
other
MS
preparations
such
as
drinks
and
teas
containing
mitragynine
may
be
fined
a
maximum
penalty
of
RM
10,000
(USD
3300)
a
four-year
jail
sentence
or
both
(Poisons
Act,
1952).
With
the
introduction
of
this
restriction,
the
authorities
have
destroyed
many
trees
which
could
mean
a
loss
in
the
world’s
biodiversity
as
the
species
is
found
only
in
very
few
countries
(Chan
et
al.,
2005).
MS
is
now
believed
to
have
the
potential
to
be
used
as
a
medicinal
product
because
of
its
antinociceptive
properties,
which
have
been
reported
to
be
somewhat
better
than
opiates
in
animal
studies
(Matsumoto
et
al.,
2005).
The
effects
of
MS
have
been
widely
debated.
There
are
contra-
dictory
reports
regarding
the
psychoactive
properties
of
MS.
There
are
reports
claiming
it
to
be
both
a
narcotic
and
a
stimulant;
two
effects
which
are
generally
regarded
as
opposite.
The
pharmaco-
logical
bases
underlying
these
effects
(stimulants
and
narcotics)
are
still
unclear.
It
has
been
demonstrated
that
mitragynine
and
7-hydroxymitragynine,
the
two
active
constituents
of
MS
have
antinociceptive
properties
and
that
they
act
through
␮-
and
␦-
supraspinal
opioid
receptors
(Matsumoto
et
al.,
1996a,b).
On
the
other
hand,
there
are
many
anecdotal
descriptions
of
the
stimulant
effects
of
MS,
but
the
evidence
from
the
scientific
literature
is
still
lacking.
It
would
seem
that
MS
is
a
unique
plant
and
identifying
the
mechanism
of
its
action
is
important
to
improve
the
understanding
of
its
psychoactive
properties
and
hence
resolve
the
contradictions.
Compared
to
Khat,
a
plant
that
also
has
psychoactive
effects,
little
is
known
about
the
epidemiology
of
MS
use.
Stefan
and
Mathew
(2005)
estimated
that
worldwide
about
ten
million
people
use
Khat
on
a
daily
basis
while
there
is
few
published
infor-
mation
on
the
prevalence
of
MS
use.
A
cross
sectional
national
survey
conducted
among
youths
in
Malaysia
found
that
of
all
drugs
abused,
0.5%
involved
the
use
of
MS
and
it
is
mainly
abused
in
the
northern
states
of
Peninsula
Malaysia
(Nazar
Mohamed
et
al.,
2008).
It
appears
that
MS
remains
a
substance
associated
with
the
rural
areas.
The
present
study
therefore
aimed
to
describe
the
use
of
MS
including
patterns
of
use
and
its
effects
and
to
explore
its
addic-
tive
potential
among
a
representative
population
sample
of
users
in
Kedah
and
Perlis.
The
need
to
document
the
use
of
MS,
its
effects
and
abuse
potential
is
important
because
over
the
past
decade
there
has
been
growing
interest
in
MS
as
evidenced
by
the
number
of
advertisements
for
its
sale
on
the
Internet
(Schmidt
et
al.,
2011).
Given
its
increasing
popularity
on
the
Internet,
it
is
possible
that
abuse
of
MS
could
spread
worldwide.
2.
Materials
and
methods
2.1.
Study
design
and
sampling
The
study
was
conducted
between
June
and
September
2010
in
the
border
towns
of
Kedah
and
Perlis
in
the
northern
states
of
Malaysia.
Sampling
was
based
on
a
convenience
and
snowball
sam-
pling
method.
Adults
who
had
used
MS
at
least
once
during
the
past
12
months
were
recruited.
We
trained
Privileged
Access
Interview-
ers
(PAIs)
to
conduct
the
interviews.
The
rationale
for
using
a
PAI
approach
is
that
engaging
users
from
a
similar
social
and
cultural
background
as
the
target
sample
increases
the
recruitment
of
par-
ticipants
(Elliott
et
al.,
2002).
Previous
study
of
the
same
nature
has
shown
this
approach
to
be
effective
(Griffiths,
1998).
Two
trained
PAIs
conducted
face-to-face
interviews
using
a
structured
ques-
tionnaire.
The
responders
were
assured
of
the
voluntary
nature
of
the
survey
and
the
confidentiality
of
their
responses.
All
responders
provided
verbal
informed
consent.
2.2.
Questionnaire
Since
all
the
respondents
understood
the
national
language
of
Malaysia
(Bahasa
Malaysia),
the
questionnaire,
which
was
written
in
English,
was
translated
into
Bahasa
Malaysia.
In
order
to
check
for
equivalence
(Herdman
et
al.,
1997)
between
the
two
versions,
we
engaged
a
translator
to
translate
the
translated
Bahasa
Malaysia
questionnaire
back
to
English
to
confirm
that
the
meaning
was
sim-
ilar
to
the
original.
The
process
of
translating
was
repeated
until
the
back
translation
questionnaire
was
almost
identical
to
the
original.
Demographic
data
collected
included
age,
occupation,
mari-
tal
status
and
level
of
education.
Other
information
collected
was
information
on
drug
use
history,
route
of
MS
administration,
effects
of
MS
use,
and
any
potential
problems
experienced
associated
with
MS
use.
We
explored
the
likelihood
that
MS
could
cause
dependence
by
adapting
ten
questions
from
Drug
Abuse
Screen-
ing
Test-10
(DAST-10)
(McCabe
et
al.,
2006).
We
retained
all
the
wordings
of
DAST-10,
except
that
we
changed
the
word
“drugs”
to
“Ketum”
(the
local
name
for
MS)
as
we
were
focusing
on
the
use
of
MS.
We
excluded
DAST-10
scoring
for
measuring
addictive
tenden-
cies
because
it
was
not
our
aim
to
measure
the
possible
abuse
of
MS;
rather
we
sought
to
provide
preliminary
data
on
the
possibility
of
dependence
on
MS.
The
first
draft
of
the
questionnaire
was
pre-tested
on
40
respon-
dents.
We
used
information
from
the
pilot
study
to
modify
the
questionnaire
and
the
data
were
not
included
in
the
final
analysis.
2.3.
Data
analysis
The
data
was
analysed
using
SPSS
version
17.
Descriptive
statis-
tics
such
as
percentages
and
means
were
used
to
describe
the
sample
on
the
various
variables.
Differences
between
groups
were
assessed
either
with
an
independent
t-test
or
2test.
To
measure
the
internal
consistency
of
DAST-10,
Cronbach’s
␣
coefficient
was
calculated.
A
probability
of
p
<
0.05
was
considered
statistically
sig-
nificant.
3.
Results
A
total
of
530
respondents
out
of
562
subjects
approached
(91%
response
rate)
agreed
to
participate
in
the
study.
Except
for
two
females,
all
the
respondents
were
adult
males.
The
demographic
characteristics
of
the
samples
are
as
shown
in
Table
1.
Almost
all
the
respondents
were
Malay.
About
94%
of
the
respondents
used
MS
on
a
daily
basis.
A
Chi-squared
test
for
independence
was
used
to
determine
whether
daily
use
was
associated
with
other
demographic
variables
and
showed
that
there
was
no
association
between
daily
use
with
any
of
the
demographic
variables
exam-
ined;
marital
status,
education
level,
occupation
and
age
groups.
The
majority
of
the
respondents
(96%)
did
not
use
other
sub-
stances
of
abuse.
However,
22
respondents
(4.2%)
used
MS
together
with
marijuana,
amphetamine,
heroin
or
cough
syrup.
3.1.
Usage
patterns
The
mean
duration
of
MS
use
was
4.6
(SD
=
3.8)
years
while
the
mean
age
of
starting
MS
was
28.3
(SD
=
8.1)
years.
MS
was
mainly
used
in
a
form
of
a
drink
(90%),
while
other
methods
of
consumption
including,
chewing,
smoking
and
adding
the
leaves
to
food
consti-
tuted
the
other
10%.
The
mean
effects
of
MS
were
reported
to
last
3.5
(SD
=
2.6)
h.
The
majority
of
the
respondents
obtained
the
MS
from
trees
grown
in
the
village
and
a
small
percentage
(13%)
bought
MS
from
either
coffee
shops
or
restaurants
in
their
village.
The
frequency
of
MS
use
ranged
from
one
to
ten
times
daily.
Two
thirds
of
the
respondents
took
MS
one
to
three
times
daily,
with
about
a
quarter

448 K.
Ahmad,
Z.
Aziz
/
Journal
of
Ethnopharmacology
141 (2012) 446–
450
Table
1
Demographic
characteristics
of
the
study
group.
Daily
user
Non-daily
user
Total
Number
Percent
Number
Percent
Number
Percent
Gender
Male
494
93.6
34
6.4
528
99.6
Female 2 100.0
0 0.0
2 0.4
Marital
status
Married 344
94.0
22
6.0
366
69.1
Single
139
92.1
12
7.9
151
28.5
Divorced
13
100.0
0
0.0
13
2.5
Ethnicity
Malay 488 93.5
34 6.5
522 98.5
Chinese 5 100.0
0 0.0
5 0.9
Indian 3
100.0
0
0.0
3
0.6
Education
level
Primary
and
lower
secondary 49
89.1
6
10.9
55
10.4
Upper
secondary
and
tertiary
education
447
94.1
28
5.9
475
85.8
Occupation
Technician
and
associate
professional
15
100.0
0
0.0
15
2.8
Service
and
sale
worker
165
95.9
7
4.1
172
32.5
Skilled
agriculture,
forestry
and
fishery
workers
168
92.8
13
7.2
181
34.2
Labourers 122 92.4
10 7.6
132
24.9
Unemployed
26
86.7
4
13.3
30
5.7
taking
MS
four
to
six
times
a
day.
Very
few
respondents
(2%)
took
MS
more
than
seven
to
10
times
a
day.
Another
group
of
respon-
dents
(6%)
used
MS
only
when
required
for
minor
ailments
such
as
diarrhoea
and
fever.
3.2.
Reasons
for
use
Many
respondents
gave
more
than
one
reason
for
using
MS.
It
was
mainly
used
for
stamina
and
endurance,
social
and
recre-
ational
use,
and
improving
sexual
performance.
MS
was
also
used
to
help
with
sleeping
and
to
reduce
withdrawal
symptoms
and
for
its
euphoric
effects.
The
use
for
medicinal
purposes
which
included
use
for
alleviating
pain,
treating
diarrhoea,
fever
and
also
for
dia-
betes
and
hypertension
constitutes
about
one
third
of
the
total
use
of
MS.
3.3.
Effects
of
Mitragyna
speciosa
and
effects
experienced
on
stopping
its
use
Table
2
shows
a
variety
of
effects
were
reported
with
the
use
of
MS.
Slightly
more
than
a
quarter
of
the
effects
reported
con-
cerned
feeling
energised
and
increased
alertness.
Another
quarter
of
the
effects
reported
involved
euphoric
effects
such
as
feelings
of
relaxation
and
contentment.
There
were
also
reports
of
hyper-
pigmentation
(10%)
particularly
on
the
face.
Other
effects
reported
included
improved
sexual
performance,
vomiting,
feeling
sedated
and,
feeling
hot
and
sweaty.
All
the
effects
lasted
between
an
hour
and
6
h.
The
users
reported
experiencing
some
unpleasant
effects
on
stopping
MS
use.
The
most
common
effects
reported
were
feeling
tired,
excessive
tearing
and
jerky
movement
of
limbs.
Effects
such
as
hostility
and
aggression
were
less
commonly
reported.
3.4.
Dependence
on
Mitragyna
speciosa
Table
3
shows
that
the
majority
of
the
respondents
(87%)
were
unable
to
stop
using
MS
when
they
wanted
to.
A
very
high
per-
centage
of
users
(94%)
did
not
feel
guilty
about
their
use
of
MS.
Nevertheless,
about
60%
of
the
respondents
reported
that
their
fam-
ily
did
not
agree
with
their
MS
use.
However,
a
very
high
percentage
(99%)
claimed
that
they
did
not
neglect
their
family
while
using
MS.
3.5.
The
association
between
socio-demographic
variables
and
the
ability
to
stop
MS
use
A
Pearson
Chi-square
test
conducted
to
examine
whether
there
was
a
relationship
between
the
socio-demographic
variables
(gen-
der,
race,
marital
status
and
education
levels)
and
the
ability
to
stop
using
MS
revealed
that
only
education
level
was
significantly
asso-
ciated
with
the
ability
to
stop
using
MS
(2=
31.0,
df
=
1,
p
<
0.001).
A
significantly
lower
proportion
of
those
with
upper
secondary
education
and
tertiary
education
(10%)
were
able
to
stop
using
MS
compared
to
those
from
the
primary
and
lower
secondary
education
(38%).
4.
Discussion
This
study
aimed
to
describe
the
use
of
MS
among
users
in
the
northern
states
of
Malaysia.
The
majority
of
MS
users
primarily
use
Table
2
Effects
of
MS
and
effects
experienced
on
stopping
MS
use.
N(%)
Effects
reported
(total
responses
=
3627)
Energised
and
increased
alertness
1002
27.6
Euphoria,
feeling
relax
and
contented
947
26.1
Light
headed
102
2.8
Sedated
21
0.6
Hot
and
sweaty
492
13.6
Improve
sexual
performance
449
12.4
Hallucination/induce
fantasy
151
4.2
Pigmentation
458
12.6
Others
(e.g.
vomiting,
increase
appetite
and,
bitter
taste)
5
0.1
Effects
experienced
on
stopping
MS
use
(total
responses
=
1321)
Hostility 6
0.5
Aggression
12
0.9
Excessive
tearing
396
30.0
Inability
to
work
51
3.9
Aching
of
muscles
and
bones
91
6.9
Jerky
movement
of
limbs 166
12.6
Loss
of
appetite
17
1.3
Weight
loss
17
1.3
Insomnia
59
4.5
Malaise
434
32.9
No
effects 64
4.8
Restlessness 8
0.6
N.B.:
respondents
could
give
more
than
one
response.

K.
Ahmad,
Z.
Aziz
/
Journal
of
Ethnopharmacology
141 (2012) 446–
450 449
Table
3
Dependence
on
Mitragyna
speciosa
(with
modified
DAST-10).
Questions
N
(%)
Yes
No
Have
you
used
Ketum
other
than
for
medical
purposes?
435
(82.1)
95
(17.9)
Do
you
abuse
more
than
one
drug
at
a
time?
24
(4.5)
506
(95.5)
Are
you
always
able
to
stop
using
Ketum
when
you
want
to? 70 (13.2)
460 (86.8)
Have
you
had
a
“blackout”
or
“flashbacks”
as
a
result
of
Ketum
use? 12 (13.2)
518
(86.8)
Do
you
ever
feel
bad
or
guilty
about
Ketum
use? 31
(5.8)
499
(94.2)
Does
your
spouse
(or
parents)
ever
complain
about
your
involvement
with
Ketum?
311
(58.7)
219
(41.3)
Have
you
neglected
your
family
because
of
your
use
of
Ketum?
7
(1.3)
523
(98.7)
Have
you
engaged
in
illegal
activities
in
order
to
obtain
Ketum?
6
(1.1)
524
(98.9)
Have
you
ever
experienced
withdrawal
symptoms
(felt
sick)
when
you
stop
taking
Ketum? 416 (78.5)
114 (21.5)
Have
you
had
a
medical
problem
as
a
result
of
your
Ketum
use
(e.g.
memory
loss,
hepatitis,
convulsions,
bleeding,
etc.)? 6 (1.1)
524 (98.9)
MS
to
increase
physical
endurance
for
sustained
work
and
most
of
them
were
unable
to
stop
using
it.
Our
sample
consisted
mainly
of
male
respondents
and
had
only
two
female
respondents.
The
low
number
of
female
respon-
dents
was
expected
as
MS
is
not
commonly
used
among
females
(Suwanlert,
1975;
Tanguay,
2011).
The
under-representation
of
females
also
reflects
the
general
reluctance
of
women
to
partici-
pate
in
surveys
of
this
nature
(Moore
et
al.,
2010;
Vicknasingam
et
al.,
2010).
Additionally,
MS
is
mainly
used
in
rural
areas
in
which
culturally,
society
would
frown
upon
its
use
by
females
(Suwanlert,
1975).
The
majority
of
the
users
were
using
MS
on
a
daily
basis.
This
is
not
surprising
as
MS
is
freely
available
because
of
the
plentiful
supply
in
villages
and
surrounding
areas.
Subjects
may
also
simply
buy
MS
from
local
coffee
shops,
since
it
is
being
sold
openly
despite
being
illegal.
The
measure
chosen
by
the
Government
to
control
MS
use
by
banning
mitragynine-containing
products
can
be
considered
to
be
ineffective,
since
cultivation
of
the
trees
is
still
widespread.
It
is
also
important
to
note
the
different
methods
of
using
the
leaves
between
the
Thai
and
Malaysian
users.
It
appears
that
in
Thailand
the
leaves
are
commonly
chewed
or
the
leaves
are
ground
before
being
swallowed
with
a
glass
of
warm
water
or
other
hot
beverages
like
coffee
or
tea
(Suwanlert,
1975;
Assanangkornchai
et
al.,
2007)
while
in
our
study
in
Malaysian
users,
the
leaves
are
mostly
boiled
and
drunk
as
tea.
It
would
be
interesting
to
find
out
from
clinical
pharmacokinetic
studies
whether
the
effects
of
MS
are
different
with
the
various
modes
of
consumption.
Our
findings
are
in
agreement
with
at
least
two
Thai
studies
(Suwanlert,
1975)
which
show
that
MS
is
mainly
used
by
labour-
ers
who
work
long
hours
in
the
sun.
However,
a
small
proportion
of
respondents
use
MS
to
help
them
with
sleeping.
It
seems
that
MS
has
both
stimulant
and
sedative
effects.
Currently,
the
stimu-
lating
effect
of
MS
has
only
been
reported
in
humans
(Jansen
and
Prast,
1988b).
Apryani
et
al.
(2010)
and
Reanmongkol
et
al.
(2007)
reported
that
mitragynine
has
no
central
stimulant
effects
in
ani-
mal
models.
In
a
mouse
model
of
depression,
MS
was
shown
to
have
antidepressive
effects
and
no
stimulating
effects
like
amphetamine
(Farah
Idayu
et
al.,
2011).
In
addition
to
increasing
stamina,
MS
was
also
used
for
reducing
pain,
which
was
also
reported
in
two
other
studies
(Assanangkornchai
et
al.,
2007;
Vicknasingam
et
al.,
2010).
Several
studies
in
animals
have
shown
MS
to
have
antinoci-
ceptive
effects
(Matsumoto
et
al.,
1996a,b,
2004;
Thongpradichote
et
al.,
1998;
Matsumoto,
2006)
which
involve
both
the
adrenergic
and
serotonergic
systems
(Matsumoto
et
al.,
1996b,
1997).
These
animal
data
may
perhaps
provide
some
evidence
that
MS
could
be
useful
for
pain
in
humans.
However,
without
any
proper
clin-
ical
studies,
it
is
still
too
early
to
acknowledge
the
therapeutic
potential
of
MS
for
pain
relief.
Our
findings
are
similar
to
a
Thai
Study
(Assanangkornchai
et
al.,
2007)
in
that
a
small
minority
of
responders
reported
the
use
of
MS
for
diabetes
and
hyper-
tension.
Currently,
the
data
from
this
study
and
other
studies
(Assanangkornchai
et
al.,
2007)
are
insufficient
to
support
the
claims
for
these
benefits.
In
contrast
to
the
findings
of
Suwanlert
(1975)
and
Assanangkornchai
et
al.
(2007);
our
data
showed
that
MS
was
also
used
to
improve
sexual
performance
by
prolonging
coitus.
It
could
be
possible
that
MS
exerts
its
effects
on
the
vas
deferens
as
one
animal
study
showed
that
MS
relaxes
the
smooth
muscles
of
the
vas
deferens
(Horie
et
al.,
2005).
Despite
the
vast
information
on
the
effects
of
MS,
little
is
known
on
its
side-effects
and
toxicological
properties.
Side-effects
reported
such
as
light
headedness,
vomiting
and
hyperpigmen-
tation
are
similar
to
other
studies
and
are
reported
to
be
mild
(Marcan,
1929;
Grewal,
1932;
Suwanlert,
1975;
Assanangkornchai
et
al.,
2007).
Only
one
study
reported
serious
cases
of
psychosis
associated
with
the
use
of
MS
(Suwanlert,
1975).
A
high
pro-
portion
of
respondents
experienced
withdrawal
symptoms
on
stopping
MS
use.
Typical
effects
experienced
were
mainly
malaise,
excessive
tearing,
and
jerky
movement
of
limbs,
which
are
not
life
threatening
and
these
effects
were
similar
to
a
Thai
study
(Assanangkornchai
et
al.,
2007).
Responders
with
higher
education
levels
were
less
able
to
stop
using
MS
compared
to
those
with
lower
education
levels.
Our
results
are
inconsistent
with
the
general
belief
that
people
with
lower
education
levels
might
have
a
tendency
to
problem-prone
behaviour
and
thus
likely
to
be
involved
in
substances
of
abuse
(Battin-Pearson
et
al.,
2000;
Fergusson
et
al.,
2003;
Townsend
et
al.,
2006).
The
probable
explanation
for
this
observation
is
that
most
of
those
with
lower
education
levels
tend
to
be
unskilled
labourers
and
they
use
MS
mainly
to
enable
them
to
endure
hard
physi-
cal
work,
while
those
with
higher
education
levels
use
MS
for
its
euphoric
effects.
DAST-10
is
a
brief
screening
instrument
used
to
assess
possi-
ble
abuse
of
drugs
(McCabe
et
al.,
2006).
Since
MS
has
not
been
established
as
a
drug
of
abuse,
we
did
not
attempt
to
use
DAST-
10
to
screen
for
possible
abuse
to
MS.
Instead
we
used
DAST-10
for
its
relevant
questions
that
help
to
describe
qualitatively
the
social
impact
of
MS
on
MS
users.
Despite
the
reported
use
of
MS
to
manage
withdrawal
from
other
substances
of
abuse,
many
respon-
dents
reported
difficulty
in
withdrawing
from
MS,
which
indicate
a
possible
dependence
associated
with
its
use.
A
further
qualita-
tive
study
may
therefore
be
useful
to
explore
the
psychological
and
social
impacts
of
its
use.
We
used
convenience
and
snowball
sampling
methods
in
recruiting
respondents
and
this
may
limit
the
generalisability
of
our
findings
to
other
cultural
settings
as
our
respondents
were
mostly
of
the
Malay
race.
It
is
known
that
the
main
disadvantage
of
snowball
sampling
method
is
that
participants
tend
to
recruit
fur-
ther
participants
through
their
own
social
networks,
which
might
limit
the
heterogeneity
of
the
sample
(Faugier
and
Sargeant,
1997).
Nevertheless,
we
believe
that
snowball
sampling
was
the
most
appropriate
method
in
identifying
hidden
population
of
MS
users
and
it
was
cost
effective
(Lopes
et
al.,
1996;
Faugier
and
Sargeant,

450 K.
Ahmad,
Z.
Aziz
/
Journal
of
Ethnopharmacology
141 (2012) 446–
450
1997).
Additionally,
it
is
also
generally
known
that
MS
can
be
con-
sidered
as
a
medicinal
plant
culturally
associated
more
with
the
Malays
(Ong
and
Nordiana,
1999).
5.
Conclusions
The
overall
picture
was
that
most
users
were
using
Mitragyna
speciosa
in
a
moderate
way
in
terms
of
frequency
for
its
stimulat-
ing
effects
and
drinking
the
extract
was
usually
a
social
activity.
The
majority
of
users
reported
one
or
more
desirable
effects
from
MS
consumption.
There
was
large
number
of
users
who
reported
their
inability
to
stop
using
it
and
closed
to
80%
of
the
respon-
dent
reported
undesirable
effects
which
included
excessive
tearing,
malaise
and
jerky
movements
of
the
limbs
on
stopping
MS
use.
These
users
may
need
some
help
and
support
in
controlling
their
MS
use.
Further
research
would
therefore
be
useful
to
explore
the
psychological
and
social
impacts
of
the
MS
use.
Sources
of
funding
Funding
for
this
study
was
provided
by
University
of
Malaya
(PS450/2010A).
Acknowledgements
We
thank
Chong
Nyuk
Jet
and
Siti
Fauziah
Abu
from
the
Phar-
macy
Department,
University
of
Malaya
for
helping
to
collect
data
for
the
pilot
study.
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