Thirty-six people in the United States have died after using kratom, a largely unregulated drug sold in shops around Denver, according to the federal government. A young man in Boulder may be among them.
Jay Knaus, 25, died in his room this year after ingesting what his sister believes was a typical dose of the substance. The Boulder coroner directly linked his death to kratom's active component. And his sister wants action.
"How many deaths are there going to be before you do anything about it?" asked Julie Knaus.
The death is one of the reasons that the city of Denver has placed new restrictions on the drug, which also is the subject of a new federal warning.
In response, city officials will require labels saying that the product is not for human consumption. They'll also move to shut down kratom bars that serve the drug on site.
However, the city won't use its power to ban the sale of the product.
"What we’re seeing is products being sold without any information about dosage. In some cases, very little labeling at all. It really leaves a lot of safety concerns," said Danica Lee, director of public health inspections for the city.
Jay Knaus was a student at Metro State University.
"Jay was a very healthy, athletic, popular guy. Everyone loved him," said Julie, his twin sister.
A family member discovered Jay unresponsive in bed at the family home in Longmont this February. They had no idea what was wrong with him, Knaus said, and they wouldn't have an explanation for six more weeks.
"I was looking in trash cans, all over his room, anything for an answer. We all had no idea how and why," she said.
When it finally arrived, an autopsy from the Boulder County Coroner's Office listed the cause of death as accidental "mitragynine intoxication." Mitragynine is a key active compound in kratom. Knaus' body contained a "lethal level" of the substance, the autopsy reported.
"It was definitely a product we weren’t even aware he was taking," Knaus said.
Jay Knaus also was found to have suffered pulmonary edema -- fluid in the lungs -- and that he had inhaled vomit, all related to mitragynine poisoning, according to the autopsy. The toxicology report found no other substances besides caffeine and drugs that are commonly used in medical treatment and rescue attempts, such as naloxone.
The family had to look at Jay Knaus' bank statements for hints at what had happened.
"We believe he started the spring of 2016, but then he stopped because he had side effects like itchy skin, hair loss, irritability. We didn’t know this was the product," said Julie Knaus, who works as a physical therapist aide in California.
While many people use kratom as an alternative to heroin and other opiates, Jay Knaus had no history with those drugs, according to his sister. She believes he was attracted to kratom because he saw it as a health product.
"It was mostly marketed as a health supplement. It's marketed as a good source of extra energy -- helps you focus," Knaus said.
Kratom is derived from a tropical tree leaf. Its fans liken it to coffee, and it’s informally used to treat chronic pain and to replace other substances, especially opiate painkillers or heroin. A typical cup might cost $1.50 to $3.
Some users say that it saved their lives from hard drugs, and they point to the prevalence of alcohol-related deaths.
Bank records reviewed by the family show that Jay Knaus stopped buying it in the summer of 2016. He apparently started again late in January, making three purchases in the last week of his life. The purchases were of moderate size, his sister said.
His last purchase came from a Denver business, Julie Knaus said, but she declined to name the business.
The death reflects broader concerns.
In a statement issued last week, FDA Commissioner Scott Gottlieb warned that the administration was "aware of reports of 36 deaths associated with the use of kratom-containing products." It's unclear whether that figure includes Jay Knaus.
Chris McCurdy, a professor of medicinal chemistry at the University of Florida and leading expert on kratom, told Denverite that it's "a total 'buyer beware' marketplace at this point."
The drug has been used in Thailand and Malaysia "for centuries with no related deaths" reported, he wrote in an email. "However, in the USA this has obviously been a different story."
A lack of regulation of dietary supplements is part of the problem, he continued. "This, unfortunately, means that it is impossible to tell what one is purchasing when they believe they are purchasing kratom," he wrote.
It's particularly concerning that kratom may be mixed with other substances, McCurdy added. A study found kratom-related deaths tended to involve other drugs too.
The Knaus family has consulted with medical experts who said that the level of mitragynine in Jay's body was not atypical for kratom use, according to Julie Knaus.
What will Denver do next?
Denver's new rule will require a label on each kratom package in large font, reading:
The city briefly went further than that, issuing a total ban on sales last fall. At the time, Denver was responding to the federal Drug Enforcement Administration, which had proposed a ban and suggested that kratom was an "imminent hazard" to public health.
However, the DEA reversed course. It withdrew its proposal to make the substance illegal and called for more research. One researcher said the change was "shocking." And Denver followed suit, withdrawing its ban in October 2016.
Julie Knaus says that a different government decision could have saved her brother's life. "I know if it was scheduled in September 2016 as a drug, he would not have died," she said. Now, she wants Denver and other governments to go further. Instead of warnings, she wants a ban.
"Putting a label on every single package -- I think that’s a step in the right direction," she said. But she wants it to be restricted as a prescribed medicine, she said.
Lee, the Denver health official, said that instituting a total ban would be a difficult legal move, especially as higher levels of government haven't banned the sale of the product either.
"At this point in time, we don’t feel it’s appropriate to implement a complete ban, given the fact that there are other uses (of kratom) and the state health department isn’t taking any action," Lee said.
A local ban "would be using broad authority, and we would definitely have to make sure we’re taking a defensible position. This is what we feel comfortable with at this time."
