Evaluating health information provided to kratom consumers by good manufacturing practice-qualified vendors

Abstract

Background
“Kratom” commonly refers to the botanical Mitragyna speciosa, native to Southeast Asia, which is increasingly used globally for its unique pharmacological effects. Motives for using the whole plant material or kratom-derived products include self-management of pain, mental health disorders, symptoms related to substance use disorders, and/or to increase energy. In the United States, kratom products have varying alkaloid content, potencies, and marketing profiles. There is little regulatory oversight over kratom, as it is currently not approved as a dietary supplement by the Food and Drug Administration. This results in substantial variability in labeling of kratom products and the product information provided to consumers.

Methods
In January 2023, we evaluated the American Kratom Association’s Good Manufacturing Practices (GMP) qualified vendors’ websites (n = 42) using the well-established and validated DISCERN instrument to examine the quality of health information provided to consumers. DISCERN contains 15 five-point Likert-scale questions on specific criteria, with the highest possible score being 75, indicating that all the DISCERN criteria have been fulfilled by the website (i.e., the highest quality information is provided to consumers).

Results
The mean DISCERN score for all evaluated online kratom vendors was 32.72 (SD = 6.69; score range 18.00–43.76). Overall, vendors scored higher on DISCERN questions assessing the website’s reliability, as vendors typically provided clear information for consumers about product availability, purchasing, shipping, etc. On average, vendors scored poorly on the DISCERN section pertaining to the quality of the health information provided. Information on kratom’s potential risks and benefits was particularly insufficient.

Conclusions
Consumers require high quality information in order to make informed decisions concerning use, which entails disclosure of known risks and potential benefits. The online kratom vendors evaluated in this study should consider enhancing the quality of health information provided, especially information regarding kratom’s risks and benefits. Further, consumers should be made aware of current knowledge gaps related to kratom’s effects. Clinicians must also be aware of the lack of evidence-based information available to their patients who use kratom or are interested in using kratom products, in order to facilitate educational discussions with them.

Full text

Hilletal.
Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
https://doi.org/10.1186/s13011-023-00531-4
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Substance Abuse Treatment,
Prevention, and Policy
Evaluating health information provided
tokratom consumers bygood manufacturing
practice-qualied vendors
Katherine Hill1*, Stephen Gibson2,3, Oliver Grundmann4,5, Kirsten E. Smith6, Jonathan Ballard7,8,9 and
Corneliu N. Stanciu3,8,9
Abstract
Background “Kratom” commonly refers to the botanical Mitragyna speciosa, native to Southeast Asia, which is
increasingly used globally for its unique pharmacological effects. Motives for using the whole plant material or
kratom-derived products include self-management of pain, mental health disorders, symptoms related to substance
use disorders, and/or to increase energy. In the United States, kratom products have varying alkaloid content, poten-
cies, and marketing profiles. There is little regulatory oversight over kratom, as it is currently not approved as a dietary
supplement by the Food and Drug Administration. This results in substantial variability in labeling of kratom products
and the product information provided to consumers.
Methods In January 2023, we evaluated the American Kratom Association’s Good Manufacturing Practices (GMP)
qualified vendors’ websites (n = 42) using the well-established and validated DISCERN instrument to examine the
quality of health information provided to consumers. DISCERN contains 15 five-point Likert-scale questions on spe-
cific criteria, with the highest possible score being 75, indicating that all the DISCERN criteria have been fulfilled by the
website (i.e., the highest quality information is provided to consumers).
Results The mean DISCERN score for all evaluated online kratom vendors was 32.72 (SD = 6.69; score range 18.00–
43.76). Overall, vendors scored higher on DISCERN questions assessing the website’s reliability, as vendors typically
provided clear information for consumers about product availability, purchasing, shipping, etc. On average, vendors
scored poorly on the DISCERN section pertaining to the quality of the health information provided. Information on
kratom’s potential risks and benefits was particularly insufficient.
Conclusions Consumers require high quality information in order to make informed decisions concerning use,
which entails disclosure of known risks and potential benefits. The online kratom vendors evaluated in this study
should consider enhancing the quality of health information provided, especially information regarding kratom’s risks
and benefits. Further, consumers should be made aware of current knowledge gaps related to kratom’s effects. Clini-
cians must also be aware of the lack of evidence-based information available to their patients who use kratom or are
interested in using kratom products, in order to facilitate educational discussions with them.
Keywords Kratom, DISCERN, Herbal, Mitragyna speciosa, Healthcare, Website evaluation
*Correspondence:
Katherine Hill
k.hill@yale.edu
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 2 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Background
In recent years there has been a steady increase in inter-
est, importation, and use of kratom (Mitragyna speciosa
Korth.) leaf products in the United States (US) [1, 2]. Var-
ious epidemiological studies estimate the lifetime kratom
use among the adult American population to range
between 0.9 and 6.1% [3, 4]. Motivations for use include
“self-management” of symptoms related to chronic pain,
fatigue, substance use disorders, and psychiatric condi-
tions along with attenuating opioid-withdrawal [1, 5–7].
Use of kratom as a short- or long-term substitute for opi-
oids, stimulants, and alcohol has also been described [2,
8]. Despite the numerous perceived therapeutic benefits
reported by those who use kratom, there are no clinical
safety/tolerability studies, human abuse potential studies,
or randomized clinical trials investigating kratom’s risks
or efficacy for any clinical indication [9, 10]. Moreover,
the current state of the literature does not permit any
robust, or generalizable, conclusions to be drawn con-
cerning kratom’s role as a harm reduction tool [11].
Kratom has a long history of use in its indigenous habi-
tat of Southeast Asia, where the majority of consumption
occurs via chewing or brewing of the leaves as a tea, and
to a lesser extent smoking. Unlike the traditional modes
of kratom use, unregulated products marketed in the US
are diverse in terms of alkaloid content and composition
(rather than the varied, but natural alkaloid composition
in fresh leaves), and hence differ in potency [12]. Dosing
and product formulation also differs in that many prod-
ucts are not fresh, but rather derived from dried leaves
in the form of raw powder, capsules, and concentrated
extracts formulated into tablets, liquids, and other prep-
arations. ese products are readily available for pur-
chase in gas stations, specialized convenience stores, and
from online vendors. One study performed during the
COVID-19 pandemic found that 72.7% of people pur-
chased kratom online [13].
Contrasting the benefits reported by consumers, some
state and local governments as well as the US Food and
Drug Administration (FDA) are concerned about poten-
tial harms associated with kratom [12]. ese concerns
stem primarily from the quality of products available in
the US, which have unknown purity (e.g., potential adul-
terants and contaminants) and the potential harms result-
ing from co-ingestions—specifically alkaloid interactions
with prescribed pharmaceuticals, illicit substances,
over-the-counter medications, and other products mar-
keted as supplements [14]. As such, kratom is currently
unregulated in the US and not approved by the FDA as
a dietary supplement. us, the sale of kratom products
has little regulatory oversight and consumers have been
largely uninformed about what they are actually taking
when using a “kratom product” [15].
However, the American Kratom Association (AKA)
is an industry-associated advocacy group that lobbies
for consumers’ right to use kratom. ey have been
working at the state-level to reverse or prevent prohi-
bitions, and to introduce Kratom Consumer Protec-
tion Act (KCPA) legislation for state-level regulation
of commercial kratom sales. rough this act, kratom
regulations get introduced on age restrictions, product
labeling, lab testing requirements, fines, and the sale of
kratom. Some states, such as Alabama, Rhode Island,
and Vermont, have statewide kratom bans, while other
states have specific counties, municipalities, or cities
with kratom bans, such as San Diego, California [16].
To address these bans, and prevent future ones, the
AKA lobbies for policy makers to adopt state specific
versions of a KCPA [17].
In addition to this, the AKA has recently undertaken
efforts to provide guidance for improved quality of
products. One such endeavor comes through the Good
Manufacturing Practices (GMP) Standards Program,
which are guidelines for vendors and manufacturers
to follow [18]. Vendors registered with the AKA must
adhere to all GMP regulations and pass a third-party
audit. These requirements pertain to standard operat-
ing procedures, record keeping, adverse event report-
ing systems, product labeling, product recalls, market
practice, and state regulations. Maintenance of regis-
tration also requires annual audit. This process may
ensure some quality control over the products pro-
vided to consumers from GMP-certified vendors, but
it is not a guarantee. Most who use kratom regularly
(daily or > 4 times weekly) appear to purchase primar-
ily online, even with some in-person purchasing or
changes in vendors over time [2, 19]. Consumers pur-
chasing online must ultimately make decisions about
available kratom products based on the information
available through online sources, including vendors
who should be best positioned to describe the exact
products they are selling. However, avenues for access-
ing credible, data-driven information in a manner
which the average consumer can understand remain
limited.
A 2021 study by Ng etal. evaluated the quality of con-
sumer health information available on the websites of
51 kratom vendors who sold products in Canada. e
authors concluded that kratom consumers were not
provided with critical information needed for informed
decision-making concerning use, particularly of the
risks and the impact on their health [15]. Indeed, 40 of
the evaluated sites were rated by the authors as having
a “poor” quality of information. Here, we utilized the
same assessment methods, but instead focused only on
vendors registered with the AKA’s GMP program.
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Page 3 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Methods
Eligibility criteria
Eligible vendor websites were selected based on the
AKA’s list of GMP-qualified vendors as of January 19,
2023 [18]. Only vendors who had an active website
domain with information about their kratom product(s)
were included in our analysis. us, one vendor, Kratom
Kaps, was excluded from our analysis.
Data extraction andwebsite quality assessment
All eligible vendor websites were examined by K.H. and
the following information was ascertained: URL, kratom
products sold, non-kratom products sold, the presence of
a disclaimer, and whether the site required age confirma-
tion for entry. Accuracy of the information extracted was
confirmed by multiple authors.
e DISCERN instrument, a validated tool for the
evaluation of written consumer health information, was
devised in the late 1990’s by a multidisciplinary team in
the United Kingdom [20]. DISCERN has been used to
evaluate written health information in print and online
[21]. e instrument contains 16 questions, designed to
assess whether consumers are provided quality health
information that is supported by relevant evidence [22].
e first 15 questions of DISCERN represent individual
criteria related to a specific aspect of the quality of the
written consumer health information, while the final
question represents a global score of the publication. Sec-
tion1 (questions 1–8) permits a thorough examination of
the vendor’s website reliability using questions regarding
its aims, relevancy, sources of information or support,
and potential bias. Section2 (questions 9–15) evaluates
the quality of the consumer health information on topics
such as descriptions of treatment mechanism, risks, and
benefits. Section3 contains the final evaluation (question
16), which evaluates shortcomings. All questions of the
DISCERN instrument take the form of a five-point Lik-
ert scale, with the highest possible score of 75. Higher
DISCERN scores indicate that the health information
provided to consumers is of greater reliability and qual-
ity. To assure that evaluators use DISCERN consistently,
the instrument provides what the DISCERN creators call
“hints” for each question, which prompt the evaluator to
look for and assess certain key indicators for each ques-
tion’s given criteria.
In order to compare our current study findings to the
previous study completed by Ng etal., we followed their
methods with few modifications [15]. As such, K.H.,
C.S., and S.G. individually piloted the DISCERN instru-
ment on three websites and met to discuss their scoring
methods to help standardize application of DISCERN.
After discussion of discrepancies, K.H., C.S., and S.G.
independently applied the DISCERN instrument over
a three-day period (January 20 to January 22, 2023) to
ensure websites would not change substantially during
active evaluation. K.H., C.S., and S.G. then met to dis-
cuss and reconcile any differences > 2 points on the Lik-
ert scale (e.g., one author evaluated the website as a 1 for
question 4 while another author evaluated it as a 4). After
differences were reviewed, all three evaluators’ scores for
questions 1 through 15 were averaged and summed, to
calculate a DISCERN score between 15 and 75. Stand-
ard deviations were calculated for each question and the
overall DISCERN score. All analyses were conducted in
Microsoft Excel.
Results
General characteristics ofeligible websites
A total of 42 eligible websites were evaluated (Table1).
Across vendors, there were a variety of kratom products
sold, including powder, capsules, tea, gummies, shots,
chewable tablets, and more. Some websites (17/42) sold
other products such as kava, cannabidiol, apparel, and
digital scales, while the majority of vendors exclusively
sold kratom products. Most websites (38/42) contained
some form of disclaimer about kratom consumption on
the website, often in a separate tab or at the bottom of the
web page. Only 9 out of 42 vendors prompted consumers
to confirm their age prior to entering the website, with
18 years of age being the most common age for entry
(8/42).
DISCERN instrument ratings: total score
Table2 presents the mean scores for each website across
raters following the DISCERN criteria, alongside the
standard deviation of scores between the researchers
and across the websites for each criterion. e overall
DISCERN score for each site is also provided. e high-
est DISCERN score was 43.76 and the lowest was 18.00,
whereas the total mean score was 32.72 (SD = 6.69) out of
a maximum of 75.00.
DISCERN instrument ratings: sect.1
For the specific criteria composing the total score, sec-
tion1 of the DISCERN instrument focuses on the reli-
ability of the consumer health information. Question 1
and 2 evaluate the aims and achievement of the aims of
the website. Vendor websites who scored a 4 or 5 on these
questions generally were easy to navigate, presented their
status as a vendor obviously, and provided clear infor-
mation on the origin and manufacturing of their kratom
product(s). Most (64.29%) websites scored a 4 or higher
on question 1, with the total mean score of 3.98 out of 5
across all websites (SD = 0.67).
For question 3, regarding relevancy, vendors scored
higher on the Likert scale if they provided answers to
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Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 1 Characteristics of eligible AKA GMP qualified vendors
Company Name URL Kratom Products Other Products Disclaimer Age for Entry
1836 Kratom https:// www. 1836k ratom.
com/ Powdered tea leaf, capsules,
liquid extracts None Yes No
Austin Organic Village https:// austi norga nicvi llage.
online/ Powder, capsules, extracts,
blends, leaves None Yes Yes, 21 +
Authentic Kratom https:// www. authe ntick
ratom. com/ Crushed leaf, powder,
extract, capsules Face mask, Incense Yes Yes, 18 +
Buy Kratom Bulk USA https:// buykr atomb ulkusa.
com/ Powder, capsules None Yes No
Chief Kratom https:// chief kratom. com/ Extracts None Yes No
Choice Botanicals https:// choic ekrat om. com/ Powder, capsules, extracts THC, rolling paper No Yes, 18 +
Christopher’s Organic
Botanicals https:// chris tophe rsorg anicb
otani cals. com/ Tea powder, tea, capsules,
crushed leaf, extracts None Yes No
Crisp Kratom https:// crisp kratom. com/ Gummies, capsules, powder None Yes Yes, 18 +
First Coast Tea https:// www. first coast teaco.
com/ Tea Essential oils, kava, herbal
soaps, coffee, teas, botani-
cals, apparel, posters, edible
film pouches
No No
Golden Rule Botanicals https:// golde nrule botan icals.
com/ Tea, blends CBD, shilajit, kava, subscrip-
tion boxes, teas, apparel,
cups, edible film pouches
Yes No
Happy Hippo https:// happy hippo. com/ Extracts, capsules, powder,
taffy chews Apparel, cups Yes No
Harvest Kratom https:// harve stkra tom. com/ Extracts, gummies, powder,
capsules None Yes No
Hush Kratom https:// hushk ratom. com/ Extracts, gummies, softgels,
capsules, enhanced powder None Yes No
K Chill https:// www.k- chill. com/ Powder, instant coffee,
capsules, extract capsules,
extract shots, tinctures
None Yes No
Kats Botanicals https:// katsb otani cals. com/ Powder, capsules, extracts,
blends, gummies Guidebook Yes No
King Kratom https:// kingk ratom. com/ Extracts, powder, capsules None Yes No
Kosta Kratom https:// www. kosta kratom.
com/ Powder, shots, capsules None Yes No
Kraken Kratom https:// krake nkrat om. com/ Powder, blends, leaf, tea
bags, capsules, shots,
honey sticks, chewable tea
tablets, gummies, extracts,
enhanced powders, softgels
Kava, empty capsules, digital
scales, cups, apparel, tea
accessories, book
No No
Kratom Divine https:// krato mdivi ne. com/ Powder, capsules, liquids None Yes No
Kratom krates https:// krato mkrat es. com/ Powder, capsules, extracts,
gummies None Yes No
Kratom Now https:// krato mnow. com/ Powder, gummies, extracts None Yes Yes, 18 +
Kratom Source USA https:// krato msour ceusa.
com/ Powder, capsules None Yes No
Kratom Spot https:// krato mspot. com/ Powder, leaves, capsules,
extracts, shots Empty capsules, capsule fill-
ing machine, tea accessories,
apparel
Yes No
Kryptic Kratom http:// krypt ickra tom. com/ Shots, tinctures, extract
capsules None Yes No
Laughing Lion Herbs https:// www. laugh ingli
onher bs. com/ Shots, powder, capsules Kava Yes No
Left Coast Kratom https:// left- coast- kratom.
com/ Capsules, powder, gummies,
extracts, shots Tea accessories, hand sani-
tizer, bottle, digital scales,
empty capsules, book
No No
MIT 45 https:// mit45. com/ Extracts, capsules, powdered
leaf None Yes No
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Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
anticipatory consumer questions. e authors assumed
what a kratom novice’s potential questions might be,
and whether the site had information to address such
unknowns. Specifically, we evaluated information about
methods of kratom consumption, when to use kratom,
and at what dosage. e mean score was 2.71 out of 5
(SD = 0.76) for question 3.
Questions 4 and 5 evaluate aspects of the information
provided to consumers. e majority of websites (85.71%;
36 out of 42) scored 2 or lower on question 4, as they pro-
vided little reference to the sources of the information or
claims made on their sites. us, the total mean score of
question 4 was 1.75 (SD = 0.70). Question 5 results were
similar across the study sample, with a mean of 1.64
(SD = 0.50). When evaluating whether the websites were
balanced or unbiased, the researchers scored websites
that presented kratom information in a neutral manner
that included both pros and cons of kratom use (e.g., a
product may provide the desired workout boost but may
also give you a twitchy feeling). However, most websites
tended toward providing information that highlighted or
emphasized positives of kratom, without equal discus-
sion of risks, resulting in question 6 having a total mean
score of 2.06 (SD = 0.58). Similarly, most websites did not
provide additional resources nor address the uncertain-
ties of kratom, such as the current gaps in knowledge
about possible side effects. As such, the total mean score
for question 7 was 2.09 (SD = 0.70) and for question 8
was 2.02 (SD = 0.64).
DISCERN instrument ratings: sect.2
Section2 of the DISCERN instrument allows researchers
to examine the quality of health information provided to
consumers, starting with evaluating whether the mate-
rial describes how treatments work. e researchers
searched for information regarding kratom’s mechanism
and pharmacology. Websites that described how mitrag-
ynine and 7-hydroxymitragynine alkaloids act on opioid
receptors, or some variation of this in lay terms, tended
Table 1 (continued)
Company Name URL Kratom Products Other Products Disclaimer Age for Entry
New Dawn Kratom https:// newda wnkra tom.
com/ Powder None Yes No
NuWave Botanicals https:// nuwav ebota nicals.
com/ Powder, capsules, chewable
tablets, shots, soda None Ye s Yes, 18 +
Oasis Kratom Products https:// oasis kratom. com/ Powder, gummies, capsules,
crushed leaf, extracts Kava, botanicals Yes No
Optimized Plant Mediated
Solutions https:// opmkr atom. com/ Capsules, extracts Kava Yes No
Organic Kratom USA https:// organ ickra tomusa.
com/ Powder, blends, capsules,
extracts CBD Yes No
Phytoextractum https:// www. phyto extra
ctum. com/ Capsules, extracts, chewable
tablets, crushed leaf, powder Mushrooms, kava, CBD,
kombucha, maca, botanicals,
digital scales, essential oils,
empty capsules, coffee,
books, smudge sticks,
tumeric, tea, hand sanitizer
Yes No
Premium EXP Kratom https:// enjoy exper ience
kratom. com/ about- us/ Powder, shots, tabs, capsules,
E gel None Yes No
PurKratom https:// www. purkr atom.
com/ Powder, capsules, shots,
gummies Ginger and tumeric gum-
mies, tumeric capsules Yes Yes, 21 +
Remarkable Herbs https:// remar kable herbs.
com/ Powder Kava, specialty herbs Yes No
SK https:// soapk orner. com/ Powder, capsules, blends,
shots Hemp, kava, CBD, MCT oil Yes No
Super Speciosa Raw Leaf https:// super speci osa. com/ Powder, capsules, tea bags,
chewable tablets, gummies None Yes No
The Golden Monk https:// golde nmonk. com/ Capsules, powder None Yes No
Tusk Ultra Premium Kratom https:// tuskk ratom. com/ Powder, extracts, liquids,
capsules, gummies None Yes Yes, 18 +
Viable Solutions https:// viabl ekrat om. com/ Capsules, powder, extracts,
liquids, tinctures None Yes Yes, 18 +
Whole Herbs https:// whole herbs kratom.
com/ Powder, capsules None Yes No
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Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 2 DISCERN instrument ratings
SECTION 1: Is the publication reliable?
Vendor Website 1. Are
the aims
clear?
2. Does it
achieve its
aims?
3. Is it relevant? 4. Is it clear
what sources of
information were
used to compile
the publication
(other than
the author or
producer)?
5. Is it clear when
the information
used or reported
in the publication
was produced?
6. Is it balanced
and unbiased? 7. Does it provide
details of
additional sources
of support and
information?
8. Does it refer
to areas of
uncertainty?
1836 Kratom https:// www. 1836k
ratom. com/ 4.67 4.67 3.67 2.00 1.67 3.67 3.33 3.00
Austin Organic
Village https:// austi norga
nicvi llage. online/ 4.67 4.67 3.00 3.67 2.67 2.00 3.00 2.00
Authentic Kratom https:// www. authe
ntick ratom. com/ 4.33 4.33 4.33 2.00 2.00 2.00 2.67 1.67
Buy Kratom Bulk
USA https:// buykr atomb
ulkusa. com/ 3.67 3.67 2.67 1.67 2.00 1.33 2.33 1.67
Chief Kratom https:// chief kratom.
com/ 2.67 2.67 2.00 1.00 1.00 1.33 1.67 2.67
Choice Botanicals https:// choic ekrat
om. com/ 3.67 3.67 2.00 1.00 2.00 1.00 1.33 1.00
Christopher’s
Organic Botanicals https:// chris tophe
rsorg anicb otani cals.
com/
4.67 4.67 3.00 2.00 1.67 1.67 2.33 2.00
Crisp Kratom https:// crisp kratom.
com/ 3.00 2.00 2.00 1.67 1.67 1.67 1.67 2.00
First Coast Tea https:// www. first
coast teaco. com/ 2.00 1.67 1.00 1.00 1.00 2.00 1.33 1.00
Golden Rule
Botanicals https:// golde nrule
botan icals. com/ 3.33 3.00 1.67 1.33 1.33 1.67 1.00 1.67
Happy Hippo https:// happy hippo.
com/ 4.67 4.67 3.67 1.33 2.00 2.00 2.33 1.67
Harvest Kratom https:// harve stkra
tom. com/ 4.00 3.67 1.67 1.00 1.00 1.67 1.00 1.33
Hush Kratom https:// hushk ratom.
com/ 3.33 3.00 1.67 1.33 1.00 1.67 1.00 1.67
K Chill https:// www.k- chill.
com/ 3.33 3.33 2.00 1.67 1.67 2.00 2.33 1.33
Kats Botanicals https:// katsb otani
cals. com/ 4.67 4.67 3.33 2.00 2.00 2.00 2.33 1.67
King Kratom https:// kingk ratom.
com/ 3.00 3.00 2.33 1.33 1.00 1.00 1.00 2.00
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Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 2 (continued)
SECTION 1: Is the publication reliable?
Vendor Website 1. Are
the aims
clear?
2. Does it
achieve its
aims?
3. Is it relevant? 4. Is it clear
what sources of
information were
used to compile
the publication
(other than
the author or
producer)?
5. Is it clear when
the information
used or reported
in the publication
was produced?
6. Is it balanced
and unbiased? 7. Does it provide
details of
additional sources
of support and
information?
8. Does it refer
to areas of
uncertainty?
Kosta Kratom https:// www. kosta
kratom. com/ 3.33 3.00 1.67 1.00 1.00 1.33 1.33 1.67
Kraken Kratom https:// krake nkrat
om. com/ 4.33 4.33 3.33 2.00 1.67 2.67 2.33 3.67
Kratom Divine https:// krato mdivi
ne. com/ 4.67 4.33 3.67 2.00 1.67 1.67 2.67 3.00
Kratom kaps - - - - - - - - -
Kratom krates https:// krato mkrat
es. com/ 3.67 3.67 1.67 1.00 1.00 1.67 1.33 2.00
Kratom Now https:// krato mnow.
com/ 4.67 4.67 2.67 1.67 1.33 2.67 2.33 2.00
Kratom Source USA https:// krato msour
ceusa. com/ 4.00 4.00 2.67 1.33 1.33 1.67 2.00 1.67
Kratom Spot https:// krato mspot.
com/ 4.67 4.33 3.00 2.00 2.00 2.33 2.67 2.00
Kryptic Kratom http:// krypt ickra
tom. com/ 3.00 3.00 1.67 1.33 1.33 1.33 1.00 1.33
Laughing Lion
Herbs https:// www. laugh
ingli onher bs. com/ 4.67 4.33 4.33 2.00 1.67 3.00 2.00 3.00
Left Coast Kratom https:// left- coast-
kratom. com/ 4.00 4.00 2.67 2.33 2.00 2.33 2.00 1.33
MIT 45 https:// mit45. com/ 3.67 3.67 3.00 1.33 1.67 2.00 2.00 1.67
New Dawn Kratom https:// newda wnkra
tom. com/ 4.33 4.33 3.33 3.00 2.33 3.00 3.33 3.00
NuWave Botanicals https:// nuwav ebota
nicals. com/ 3.67 3.33 2.67 1.33 1.67 2.00 2.00 1.67
Oasis Kratom
Products https:// oasis kratom.
com/ 4.33 4.33 3.00 1.67 2.00 2.33 3.00 3.00
Optimized Plant
Mediated Solutions https:// opmkr atom.
com/ 4.33 4.33 3.00 2.00 1.00 2.33 2.00 3.33
Organic Kratom
USA https:// organ ickra
tomusa. com/ 4.00 3.67 2.67 2.00 2.00 1.67 2.67 2.00
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Page 8 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 2 (continued)
SECTION 1: Is the publication reliable?
Vendor Website 1. Are
the aims
clear?
2. Does it
achieve its
aims?
3. Is it relevant? 4. Is it clear
what sources of
information were
used to compile
the publication
(other than
the author or
producer)?
5. Is it clear when
the information
used or reported
in the publication
was produced?
6. Is it balanced
and unbiased? 7. Does it provide
details of
additional sources
of support and
information?
8. Does it refer
to areas of
uncertainty?
Phytoextractum https:// www. phyto
extra ctum. com/ 4.00 3.67 2.67 2.00 2.00 2.67 2.67 1.33
Premium EXP
Kratom https:// enjoy exper
ience kratom. com/
about- us/
4.00 4.00 2.33 1.00 1.33 1.33 1.00 1.33
PurKratom https:// www. purkr
atom. com/ 4.67 4.67 4.00 1.67 1.33 2.67 2.00 2.67
Remarkable Herbs https:// remar kable
herbs. com/ 3.00 2.67 2.67 1.33 1.00 2.00 1.33 2.00
SK https:// soapk orner.
com/ 4.33 4.33 2.67 1.67 1.67 3.00 2.33 2.33
Super Speciosa Raw
Leaf https:// super speci
osa. com/ 4.67 4.67 3.33 2.67 2.00 2.33 2.67 2.00
The Golden Monk https:// golde
nmonk. com/ 4.67 4.67 2.67 1.33 1.00 2.67 2.33 2.00
Tusk Ultra Premium
Kratom https:// tuskk ratom.
com/ 4.33 4.00 2.67 2.33 2.33 2.33 3.00 2.33
Viable Solutions https:// viabl ekrat
om. com/ 4.67 4.67 2.67 4.33 3.00 2.33 3.33 1.67
Whole Herbs https:// whole herbs
kratom. com/ 4.00 4.00 3.33 1.33 2.00 2.33 1.67 2.67
Total Mean Score 3.98 3.86 2.71 1.75 1.64 2.06 2.09 2.02
Total Standard
Deviation 0.67 0.77 0.76 0.70 0.50 0.58 0.70 0.64
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Page 9 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 2 (continued)
SECTION 2: How good is the quality of information on treatment choices? SECTION 3: Overall rating?
Vendor 9. Does it
describe how
each treatment
works?
10. Does
it describe
the benets
of each
treatment?
11. Does it
describe the
risks of each
treatment?
12. Does it
describe what
would happen
if no treatment
is used?
13. Does it
describe how
the treatment
choices aect
overall quality
of life?
14. Is it clear
that there may
be more than
one possible
treatment
choice?
15. Does
it provide
support
for shared
decision-
making?
16. Based on
the answers
to all of
the above
questions, rate
the overall
quality of the
publication
as a source of
information
about
treatment
choices
Standard
Deviation of
Overall Score
(Q16)
DISCERN
Score (Sum of
Q1-Q15)
1836 Kratom 3.00 3.00 2.33 1.33 2.00 2.00 3.00 3.33 1.15 43.33
Austin Organic
Village 3.33 3.67 2.00 1.00 1.00 1.00 2.67 2.67 0.58 40.33
Authentic
Kratom 3.67 3.00 2.00 1.00 1.67 1.67 2.00 2.67 0.58 38.33
Buy Kratom Bulk
USA 2.00 1.67 1.33 1.00 1.33 1.00 1.33 1.67 0.58 28.67
Chief Kratom 1.33 1.00 2.33 1.00 1.00 1.00 2.67 2.00 0.00 25.33
Choice Botani-
cals 2.33 2.33 1.00 1.00 1.67 1.00 1.33 1.67 0.58 26.33
Christopher’s
Organic Botani-
cals
3.67 3.00 2.00 1.00 1.00 1.33 2.33 2.67 0.58 36.33
Crisp Kratom 2.00 2.00 1.33 1.00 1.33 1.33 1.33 1.67 0.58 26.00
First Coast Tea 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.33 0.58 18.00
Golden Rule
Botanicals 1.00 1.00 1.33 1.00 1.33 1.00 1.67 1.67 0.58 23.33
Happy Hippo 3.33 3.67 1.33 1.00 1.67 1.33 3.00 3.00 0.00 37.67
Harvest Kratom 1.67 2.00 1.33 1.00 1.00 1.00 1.33 1.67 0.58 24.67
Hush Kratom 1.33 1.33 3.67 1.00 1.67 1.00 2.00 2.33 0.58 26.67
K Chill 1.33 1.67 1.67 1.00 1.67 2.67 1.67 2.00 1.00 29.33
Kats Botanicals 2.33 3.33 1.67 1.00 1.33 1.00 2.00 2.33 0.58 35.33
King Kratom 1.67 1.00 2.33 1.00 1.00 1.00 2.67 1.67 0.58 25.33
Kosta Kratom 1.00 1.00 1.67 1.00 1.00 1.00 1.67 1.33 0.58 22.67
Kraken Kratom 1.67 1.67 1.67 1.00 1.00 1.67 2.33 2.67 0.58 35.33
Kratom Divine 3.00 3.00 3.33 1.00 1.67 1.00 3.00 3.33 1.15 39.67
Kratom kaps - - - - - - - - - -
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Page 10 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 2 (continued)
SECTION 2: How good is the quality of information on treatment choices? SECTION 3: Overall rating?
Vendor 9. Does it
describe how
each treatment
works?
10. Does
it describe
the benets
of each
treatment?
11. Does it
describe the
risks of each
treatment?
12. Does it
describe what
would happen
if no treatment
is used?
13. Does it
describe how
the treatment
choices aect
overall quality
of life?
14. Is it clear
that there may
be more than
one possible
treatment
choice?
15. Does
it provide
support
for shared
decision-
making?
16. Based on
the answers
to all of
the above
questions, rate
the overall
quality of the
publication
as a source of
information
about
treatment
choices
Standard
Deviation of
Overall Score
(Q16)
DISCERN
Score (Sum of
Q1-Q15)
Kratom krates 1.67 1.67 1.33 1.00 1.00 1.00 1.33 1.67 0.58 25.00
Kratom Now 2.67 3.00 1.67 1.00 1.67 1.00 2.33 2.67 0.58 35.33
Kratom Source
USA 1.67 2.00 1.33 1.00 1.67 1.33 1.33 1.67 0.58 29.00
Kratom Spot 3.00 3.00 3.00 1.00 1.67 1.67 2.67 3.00 1.00 39.00
Kryptic Kratom 1.67 2.67 1.00 1.00 1.00 1.00 1.33 1.67 0.58 23.67
Laughing Lion
Herbs 3.00 3.67 3.67 1.00 1.67 2.33 3.33 3.33 1.15 43.67
Left Coast
Kratom 2.00 2.33 1.67 1.33 1.33 1.67 2.33 2.33 0.58 33.33
MIT 45 2.00 2.33 1.33 1.00 1.33 1.00 1.33 1.67 0.58 29.33
New Dawn
Kratom 2.67 3.33 3.67 1.00 1.67 1.67 2.67 3.33 0.58 43.33
NuWave Botani-
cals 3.00 3.67 2.00 1.00 1.67 1.67 2.33 2.33 0.58 33.67
Oasis Kratom
Products 2.67 2.33 1.67 1.00 1.00 1.67 3.00 3.00 0.00 37.00
Optimized Plant
Mediated Solu-
tions
1.33 1.00 3.67 1.00 1.00 1.33 3.00 2.67 0.58 34.67
Organic Kratom
USA 2.33 2.33 1.67 1.00 1.33 1.00 2.67 2.00 0.00 33.00
Phytoextractum 2.00 2.33 1.00 1.00 1.33 2.33 1.67 2.67 0.58 32.67
Premium EXP
Kratom 1.67 1.67 2.00 1.00 1.33 1.00 1.67 1.67 0.58 26.67
PurKratom 3.67 3.67 3.00 1.00 1.33 1.67 2.67 3.00 0.00 40.67
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Page 11 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
Table 2 (continued)
SECTION 2: How good is the quality of information on treatment choices? SECTION 3: Overall rating?
Vendor 9. Does it
describe how
each treatment
works?
10. Does
it describe
the benets
of each
treatment?
11. Does it
describe the
risks of each
treatment?
12. Does it
describe what
would happen
if no treatment
is used?
13. Does it
describe how
the treatment
choices aect
overall quality
of life?
14. Is it clear
that there may
be more than
one possible
treatment
choice?
15. Does
it provide
support
for shared
decision-
making?
16. Based on
the answers
to all of
the above
questions, rate
the overall
quality of the
publication
as a source of
information
about
treatment
choices
Standard
Deviation of
Overall Score
(Q16)
DISCERN
Score (Sum of
Q1-Q15)
Remarkable
Herbs 1.33 1.33 1.67 1.00 1.00 1.00 2.00 1.67 0.58 25.33
SK 3.00 2.67 2.00 1.00 1.67 1.00 2.33 2.67 1.15 36.00
Super Speciosa
Raw Leaf 3.00 3.00 2.33 1.00 1.67 1.33 2.67 3.00 1.00 39.33
The Golden
Monk 2.33 2.00 2.00 1.00 1.67 1.33 2.67 2.33 0.58 34.33
Tusk Ultra Pre-
mium Kratom 2.67 4.00 3.67 1.00 1.67 1.00 3.67 3.00 1.00 41.00
Viable Solutions 1.67 2.00 1.67 1.00 1.33 1.00 2.67 2.67 0.58 38.00
Whole Herbs 3.00 2.67 3.00 1.00 2.00 1.67 3.00 3.00 1.00 37.67
Total Mean
Score 2.25 2.36 2.03 1.02 1.39 1.33 2.23 2.35 0.61 32.72
Total Standard
Deviation 0.79 0.89 0.82 0.07 0.31 0.43 0.67 0.62 0.31 6.69
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Page 12 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
to score higher [23]. In total, the mean score for question
9 was 2.25 (SD = 0.79).
Questions 10 and 11 evaluate the descriptions of the
potential risks and benefits of using the advertised prod-
uct. In the case of the AKA GMP qualified vendors, the
total mean score for question 10 was 2.36 (SD = 0.89),
which represents that websites often lacked sufficient
information on the benefits of kratom use. Question
11 had a total mean score of 2.03 (SD = 0.82), as many
sites did not fully describe or speculate about some of
the better-known risks of kratom use. For questions 12,
13, and 14, which evaluate the information on treat-
ment options, the websites tended to score poorly, with
mean scores falling just above 1 for all three questions.
Ultimately, when evaluating whether or not the vendors
provided sufficient information to facilitate shared deci-
sion-making between patients and providers (question
15), the total mean score was 2.23 (SD = 0.67), indicat-
ing that many websites either did not or only partially
provided adequate or high-quality health information to
consumers.
DISCERN instrument ratings: sect.3
Regarding the overall rating of the eligible AKA GMP
qualified vendors, the total mean score was 2.35
(SD = 0.62). is overall score falls between a 1 (serious
or extensive shortcomings) and a 3 (potentially impor-
tant but not serious shortcomings) on the DISCERN
Likert scale for question 16. More than 25% of websites
(11/42) received a score of 3 or higher, reflecting they fell
between potentially important but not serious shortcom-
ings (i.e., a 3) and minimal shortcomings (i.e., a 5).
Discussion
In contrast to the previous assessment of 51 online ven-
dors for Canadian kratom consumers, which found an
average DISCERN score of 29.61 (SD = 7.34), our study
of AKA GMP-qualified vendors found an average DIS-
CERN score of 32.72 (SD = 6.69) [15]. ough our study
provides evidence of slightly higher DISCERN scores for
the AKA GMP qualified vendors than the online Cana-
dian kratom vendors assessed by Ng etal., it is unclear
whether the AKA GMP qualification meaningfully differ-
entiates the two samples of vendor websites. For instance,
it might have been reasonable to suspect that GMP-
certified vendor websites would have scored higher, on
average, compared to previously assessed non-GMP-
certified vendor websites using the same instrument.
Although GMP-certification through the AKA may pro-
mote higher industry standards for internal accountabil-
ity and self-regulation, this does not seem to translate to
improvements in quality public-facing information that
consumers need about the kratom products they are
purchasing. e GMP-certified “branding” among online
vendors may be used to imply quality assurance practices
to consumers, but such assurances or signals do not sub-
stitute for detailed product information.
It is evident from our findings that there is consider-
able room for improvement, especially when contrasting
with online vendors for approved dietary supplements.
For instance, previous studies indicate that weight loss
agent online vendor websites scored an average of 44.80
utilizing the DISCERN instrument [24], while online ven-
dors selling supplements targeted at improving fatigue
symptoms scored an average of 47.64 [25]. While dietary
supplement products seemingly struggle to achieve a
perfect score using the DISCERN criteria, kratom web-
sites should still seek to improve when it comes to prod-
uct information and safety. Specifically, online kratom
vendors that we assessed performed poorly with respect
to criteria in Sects.2 and 3, which focus on the quality
of the health information regarding risks, benefits, and
unknown effects provided.
e implications of this exploratory assessment are
two-fold. First, it provides guidance to kratom vendors,
legislators, and regulatory bodies on elements needed as
part of future kratom policy development. Second, it pro-
vides physicians and other healthcare professionals with
an understanding of the quality of information available,
prompting more informed discussions and education for
patients who seek to, or actively use, kratom.
As stated earlier, kratom is not a federally, or state,
regulated industry which results in variation in what ven-
dors are required to include on their website. While most
vendors had some form of disclaimer related to kratom,
the exact content of this disclaimer varied (e.g., disclaim-
ers about age restrictions, disclaimers about how the
product is not intended to treat a health condition, dis-
claimers about where kratom is banned, etc.). Currently,
for FDA-approved dietary supplements, the Dietary Sup-
plement Health and Education Act (DSHEA) stipulates
that vendors can only provide structure–function claims,
which describe the intended role of the given supple-
ment. ese are typically relatively vague statements,
such as a product may improve sleep or may lessen
fatigue. Subsequently, DSHEA requires manufacturers to
clearly state, in bold, “is statement has not been evalu-
ated by the Food and Drug Administration. is product
is not intended to diagnose, treat, cure, or prevent any
disease” [26].
However, kratom is not an FDA-approved dietary sup-
plement. us, the AKA and kratom vendors in the US
are limited in what information they can legally present
to consumers – even if they wanted to – because of (a)
the substantial lack of data on kratom’s effects, and (b) the
legal limitations of the DSHEA about what information
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Page 13 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
can be provided. Further, in recent years, the FDA has
issued warning letters to kratom vendors who make
“fraudulent health claims,” “unsubstantiated claims,” or
sell “unapproved kratom products” [27–29]. e FDA
continues to monitor kratom vendors and has expressed
a desire for consumers to be provided with adequate and
accurate information. As such, vendors are unable to
promote content or discuss any potential health benefits
or risks associated with, or speculated to be associated
with, kratom without risk of being reprimanded or fined.
While it is imperative that consumers are not sold prod-
ucts under fraudulent or unsubstantiated circumstances,
there is very little that vendors can include on their web-
sites without a risk of penalty.
Recommendations tokratom vendors
In the long term, as emerging literature increasingly
examines kratom’s potential risks and benefits, kratom
consumers should have access to up-to-date informa-
tion. ere is currently insufficient research in the medi-
cal and scientific literature to substantiate such claims of
kratom’s risks and benefits. Unfortunately, the current
state of regulatory affairs and research leaves kratom
consumers without the adequate information needed to
make informed health decisions. us, in the meantime,
kratom vendors should focus on utilizing structure–func-
tion claims to describe potential kratom benefits along-
side the disclaimer statement explicated by the DSHEA.
Moreover, the vast majority of the websites examined
in this study lack hyperlinks to quality external resources
for further reading or research. Indeed, one way to
improve DISCERN scores would be for kratom vendors
to link and provide access to credible evidence-based
sources that provide unbiased and balanced information
concerning kratom (i.e., to improve on questions 4, 6, and
7). Secondly, given that kratom literature is rapidly evolv-
ing, such information should include the date it was pub-
lished or updated (i.e., to improve on question 5). While
many vendors have entire blogs dedicated to information
about kratom (e.g., different strains, consumption meth-
ods, etc.), the consumer is left sorting through blog posts
to find the desired information. is key information
would ideally be displayed in a more consolidated, easy-
to-read manner for consumers.
Additionally, to score more highly on DISCERN,
online vendors could provide consumers with a broad
level of understanding of how kratom works to elicit the
described structure–function claims that are stipulated
by DSHEA (i.e., to improve on question 9). For instance,
websites can, to the extent they are able, discuss what
is currently known – in lay terms – about mitragynine
and 7-hydroxymitragynine, two active constituents that
are known to interact with adrenergic, serotonergic,
dopaminergic, and opioid receptors [30, 31]. However, it
should be noted that (a) not all of the pharmacology of
kratom is centered on these two primary alkaloids, (b)
no human studies have been conducted to examine these
mechanisms, and (c) kratom is a complex botanical that
cannot be simplified by merely categorizing it in tradi-
tional categories such as “opioid” or “stimulant” [32, 33].
Presenting this uncertainty to consumers can also help
improve DISCERN scores (i.e., to improve on question 8).
Lastly, vendors could be clearer about potential risks and
harms that have been described by those who use kratom
on surveys, in public venues, and in case reports (i.e., to
improve on question 11). Many websites provide mini-
mal risk information for products or, more often, simply
provide a generic disclaimer at the very bottom of the
website which a consumer would only see if they scrolled
down. Included in risk or disclaimer information should
be how researchers and physicians are not aware of (a)
the exact conditions which may benefit from kratom, if
any, (b) do not fully understand what dose, frequency,
and route of administration is effective or safe, and (c)
do not know what drug-drug interactions may be riskier
than others if one engages in polyuse. is is especially
important as the method of consumption may impact the
risk of developing tolerance or addiction to kratom [19].
Study limitations
e current study faces several limitations. First, these
websites are dynamic entities, and here the authors ana-
lyzed the content over a limited time frame. Websites
may change rapidly upon new policies or vendor invest-
ment and interest. As such, the current DISCERN scores
only reflect the time period utilized in the study. Second,
while DISCERN has been shown to be a reliable and valid
instrument for evaluating consumer health data, it is still
open to user perceptions. To help mitigate this potential
bias, our team was multidisciplinary with reviewers hav-
ing varied backgrounds.
Future studies
Further research related to online kratom vendors and
consumer health information may consider a content
analysis exploring a website’s disclaimer, blog posts,
reviews from previous consumers, and more. Of particu-
lar interest may be how vendors describe the benefits of
kratom under the current FDA limitations. Additionally,
researchers may consider performing qualitative studies
related to vendor perceptions and/or consumer percep-
tions about online kratom access. Lastly, it will be impor-
tant to know the prevalence of blatant misinformation
about kratom or kratom’s effects provided to consumers
on vendor websites. However, there are many sources’
online consumers may use to find information about
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Page 14 of 15
Hilletal. Substance Abuse Treatment, Prevention, and Policy (2023) 18:21
kratom, including Reddit or Facebook, making it difficult
to ascertain exactly what information is or is not readily
available to consumers [13].
Conclusion
e health information provided to customers on kratom
vendors’ websites is poor and lacks sufficient details
regarding the benefits, risks, and uncertainties. Con-
sumers are hence not provided with critical information
required to make informed decisions about the use of
kratom. Although the DISCERN scores were better for
our study of the AKA GMP-qualified kratom vendors
compared to the previous study of Canadian kratom ven-
dors by Ng etal., there is considerable room for improve-
ment. Such improvements can, and should, be supported
by regulatory requirements and policies guided by both
the AKA and legislative bodies. Lastly, clinicians should
be keenly aware of the information available – or lack
thereof – to those who use kratom, in order to have
informed discussions through patient education.
Abbreviations
AKA American Kratom Association
FDA Food and Drug Administration
GMP Good Manufacturing Practices
KCPA Kratom Consumer Protection Act
DSHEA Dietary Supplement Health and Education Act
Acknowledgements
Not applicable.
Authors’ contributions
C.S. conceived of the present idea. K.H., C.S., S.G. performed data analysis. K.H.
and C.S. performed manuscript preparation. All authors provided feedback
and edits to the manuscript. All authors approved of the final version of the
manuscript.
Funding
This study was supported in part by the National Institute on Drug Abuse
Intramural Research Program of the NIH.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or
analyzed during the current study.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors have no relevant competing interest to declare.
Author details
1 Department of Epidemiology of Microbial Diseases, Yale School of Public
Health, New Haven, CT, USA. 2 Massachusetts College of Pharmacy and Health
Sciences, Manchester, NH, USA. 3 New Hampshire Hospital, Concord, NH, USA.
4 College of Pharmacy, Department of Medicinal Chemistry, University of Flor-
ida, Gainesville, FL, USA. 5 College of Pharmacy, Department of Pharmaceutical
Sciences, Midwestern University, Glendale, AZ, USA. 6 National Institute On
Drug Abuse Intramural Research Program, Baltimore, MD, USA. 7 New Hamp -
shire Department of Health and Human Services, Concord, NH, USA. 8 Depart-
ment of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
9 Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.
Received: 27 February 2023 Accepted: 27 March 2023
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