Southern California PSYCHIATRIST March 2025

Understanding Kratom: Risks, Benefits, and the Psychiatrist’s Role

by Robert Lenfestey, MD; UC Riverside Psychiatry

We live in a world where an overwhelming number of psychotropic substances are available for purchase over the internet. Often marketed as “research chemicals” or “nootropics,” these are essentially cleverly disguised drugs with mechanisms that range from opiate agonists to GABA analogues, all conveniently delivered to your doorstep with just the click of a button. For psychiatrists, the instinctive response is to condemn these substances and recommend their immediate cessation—often without fully understanding their mechanisms or effects. This approach is deeply flawed, as it overlooks the valuable clinical insight that the use of these substances can offer into the unique challenges faced by our patients. Therefore, gaining a deeper understanding of these substances, their mechanisms, and their subjective effects can play a crucial role in guiding treatment of our patients.

One such substance is Kratom (Mitragyna speciosa), a tropical tree endemic to Southeast Asian countries such as Thailand and Indonesia. For many years, its leaves have been employed in traditional medicine, mostly for their energizing and pain-relieving effects. Mitragynine and 7-hydroxymitragynine (7-OH) are the primary active constituents of Mitragyna speciosa (kratom) and have been identified as partial agonists at the μ-opioid receptor. This interaction is likely responsible for the analgesic properties of kratom, as well as its popularity among individuals seeking to manage opioid withdrawal symptoms through self-medication.

During my tenure working in an addiction psychiatry clinic at the VA, I encountered a Veteran actively engaged in chronic kratom use. This individual had a history of being prescribed long-term opioid medications for chronic pain, but was attempting to discontinue their use by utilizing kratom to mitigate withdrawal symptoms. Over time, the patient progressively increased their kratom intake, eventually consuming large quantities of the powder at intervals of approximately every two hours to avoid symptoms of withdrawal. If a dose was missed—particularly during the night when maintaining a regular schedule was challenging—the patient would frequently wake up abruptly while experiencing symptoms such as cold sweats, nausea, and several other typical opioid withdrawal manifestations, including diarrhea and rhinorrhea. While these withdrawal symptoms were admittedly less severe than those encountered when attempting to abruptly discontinue prescription opioids, they were sufficiently distressing to necessitate frequent kratom dosing, thereby establishing a new physical dependence in place of the previous one. This experience eventually culminated in the individual preparing multiple doses of kratom at their bedside to be ingested throughout the night to alleviate such withdrawal symptoms. Following treatment at the VA clinic, the patient was prescribed a scheduled dose of buprenorphine, which has alleviated his symptoms, and he has not ingested kratom since.

While one can easily find online communities singing praises of the miracle of kratom, the primary issue we psychiatrists need to be on the lookout for lies in the experience mentioned above. It is true that many have successfully used kratom to wean themselves off more debilitating opiates, but our concern is that Kratom, which is often described as a “dirty drug” in some circles, has limited research on its pharmacokinetic pathways and unclear pharmacological activity of its metabolites. Further concern lies within the source from which the kratom is obtained as it is difficult to discern whether one is getting pure kratom versus one contaminated with unregulated adulterants.

As professionals, we prefer that those attempting to discontinue opiates employ use of medications which have been extensively researched and scientifically shown to be a safe and successful way to taper off opiates, with commonly used examples being methadone or buprenorphine. However, we should strive not to demonize our patients when they come into our office and admit they are using kratom to try to attempt this feat on their own. Their hearts are in the right place, but our training provides us the insight and judgement necessary to offer them safer and more efficacious options. We must work to explain this to our patients in a way that does not sound demeaning or condescending, and ultimately gains their trust while they begin such a difficult process.

References:

Boyer EW, Babu KM, Adkins JE, McCurdy CR, Halpern JH. Self-treatment of opioid withdrawal using kratom (Mitragynia speciosa korth). Addiction. 2008 Jun;103(6):1048-50. doi: 10.1111/j.1360-0443.2008.02209.x. PMID: 18482427; PMCID: PMC3670991.

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;180:340-348. doi:10.1016/j.drugalcdep.2017.08.034

Prozialeck WC, Jivan JK, Andurkar SV. Pharmacology of kratom: an emerging botanical agent with stimulant, analgesic and opioid-like effects. J Am Osteopath Assoc. 2012;112(12):792-799.

A Private Practice Psychiatry Component at APA: It is (Well-Past) Time

by Matthew Goldenberg D.O., SCPS Private Practice Committee Chair

As I wrote in the September 2024 edition of the SCPS Newsletter, “at its origins, SCPS was founded by local psychiatrists who were primarily in private practice. As our field, and medicine as a whole has evolved, more of our colleagues practice psychiatry as employees of hospital groups, public organizations and other organizations.

However, the tradition of private practice psychiatry lives on for many SCPS members. Some are in part-time private practice and others work in their private practice full time. Others are in the early stages of contemplating starting their own practice and others are close to wrapping up a long career in private practice.

The SCPS Private Practice Committee remains the key SCPS resource and opportunity for liaison for all SCPS members and especially those interested in and/or engaged in private practice psychiatry.”

Conversely, at the time of this writing, the American Psychiatric Association (APA) does NOT have a Private Practice component. You can view the full list of APA Components and Councils here: https://www.psychiatry.org/about-apa/meet-our-organization/councils

When the new APA CEO and Medical Director (Marketa M. Wills, M.D., M.B.A., FAPA) came and spoke with SCPS in late 2024, I raised this question and concern with her directly. She was not only aware of the lack of a Private Practice Focused Component, but she also expressed a desire to create one and discussions appeared to already be underway.

A Council on Private Practice Psychiatry, would be made up of a diverse group of psychiatrists from across the country who all have expertise in the practice of private practice psychiatry and caring for patients in a private practice setting.

Possible Highlights of Responsibilities

• Consider important developments in basic knowledge, treatment, methodology, treatment systems, and related matters that impact psychiatrist’s private practice and patients under the care of private practice psychiatrists, and dissemination of that knowledge.
• Provide psychiatric leadership in maintaining and growing patient access to high quality private practice psychiatry care and on advocacy and legislative considerations that impact practice psychiatry.
• Develop and clarify the role of the private practice psychiatrist in the prevention and treatment of mental health and addictive disorders.
• Identify local, state and federal government, insurance, and health systems requirements, policies and regulations that pose special challenges for private practice psychiatrists and their patients, and advocate for appropriate changes.
• In cooperation with other appropriate APA components, enhance the quality and quantity of medical education of private practice psychiatry at all educational levels, including undergraduate, residency, fellowship, and continuing medical education
• Provide additional liaison to medical, educational, consumer-interest, and governmental organizations interested in parity and improving access to high quality private practice mental health treatment.
• Collaborate with other councils and components of APA on common issues related to the role of private practice psychiatry; for example, to improve the quality of care and risk management for patients seeking outpatient mental health treatment via in-network and out-of-network insurance benefits, to foster parity, decreased stigma, access and funding, and to foster adequate reimbursement for treatment.

As a current member of the American Psychiatric Association’s Council on Addiction Psychiatry, I have seen the important role that each Council has on our patients, our field and our practice of psychiatry. Accordingly, I took the liberty of adjusting the highlights of the Council on Addiction Psychiatry and updated them (as per above) to be appropriate for the Council on Private Practice Psychiatry.

I hope APA will take the next steps that Dr. Willis indicated that they would and form a Council on Private Practice Psychiatry.

There are so many areas that the Council on Private Practice Psychiatry could educate, advocate and advise APA and other stakeholders on, that I could fill this newsletter with articles for the next 12 months. However, some of the major areas include:

• Parity: Improving Insurance Reimbursement and Decreasing Administrative Barriers to Improve Access for In-Network Psychiatry and Out of Network
• Access to Physician Driven Care: Insuring Patients Understand the Quality of Education and Experience of Their Healthcare Provider and Protecting Physician Lead Care in outpatient mental health treatment.
• Patient and Practice Protection: Working to protect patients and the practice of private practice psychiatry from trending and unproven treatments by non-psychiatrists.

While we wait for the APA to take the next steps, I encourage you to consider joining  the SCPS Private Practice Committee… If you might be interested, please reach out to Mindi (socalpsychiatric@gmail.com) for the details.

The Private Practice Committee is a low time commitment, high yield opportunity to meet colleagues, discuss the practice of psychiatry in a safe and supportive environment and to help make sure SCPS (and hopefully in the future, APA as well) is attuned and is attending to the needs of our colleagues in private practice.

You are welcome and encouraged to come check it out at our next meeting in March 2025!

UCLA CDU Dana Center

by Amy Woods, MD

In April 2024, the Dana Foundation announced its funding of a multi-million-dollar initiative between the University of California, Los Angeles (UCLA) and Charles R. Drew University of Medicine and Science (CDU) to establish the UCLA-CDU Dana Center for Neuroscience and Society. The Center is pioneering a new methodology for community-partnered neuroscience by integrating principles from human-centered design (HCD).

The Dana Center brings together scholars from neuroscience, social sciences, education, policy, and the humanities, working alongside local clinician-scholars, community partners, and organizations in South Los Angeles to reimagine the relationship between neuroscience and the public. These collaborations inform the Center’s educational programming, academic and community fellowships, and seed grant initiatives. The Dana Center is guided by three core values:

• Prioritizing community collaboration and building genuine partnerships.
• Promoting experiential, novel, and interdisciplinary learning.
• Challenging existing hierarchies and developing new systems of knowledge production.

In October 2024, the Dana Center launched the inaugural one-year Fellowship Program, bringing together 12 fellows from diverse areas of expertise, including cognitive neuroscience, neuroethics, a professional musician, and community leaders. Throughout the fellowship, participants have engaged in weekly seminars fostering interdisciplinary dialogue and critical examination of study design. They have learned the principles of human-centered design, which emphasize inclusive question-asking and minimize traditional academic hierarchies. Additionally, fellows have explored community-partnered study design, science communication for non-neuroscientists, and the intersection of neuroscience with community organizing and activism. The program will culminate in individual fellow projects, ranging from curriculum development on neuroscience for formerly incarcerated individuals to research on ableism in neurotechnology, science communication initiatives, and community-partnered neuroscience workshops.

This year, the UCLA-CDU Dana Center awarded over $200,000 in seed grants. Funded projects include studies on the impact of adverse childhood experiences on the neurobiology of maternal-child attachment in marginalized women, as well as the creation of intergenerational birding sanctuaries and community gardens at UCLA and in South Los Angeles.

These initiatives are made possible through partnerships with community organizations, including the CDU Pipeline Program, Community Coalition, FAM-LI, Brain Research Institute, Urban Health Institute, Semel Institute, and the UC-CSU Collaborative for Neurodiversity and Learning. With the support of over 50 faculty members from UCLA and CDU, the Dana Center is advancing an innovative, community-driven approach to neuroscience and society.

Directors: Amy Woods, MD & Ashley Feinsinger, PhD

Associate Directors: Helena Hansen, MD, PhD; Denese Shervington, MD, MPH; Gina Poe, PhD

Administrative Director: Sabrina Amani, MS

Website: https://bri.ucla.edu/ucd-cns/

Information on Clozapine

The Clozapine REMS (risk evaluation and mitigation strategies) program has ended.

https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-clozapine

Welcome New SCPS Members!

We are proud to spotlight some of our newest members:

Man Cho, MD – General Member

Dr. Man Chul Cho, who has dedicated 50 years to the field of psychiatry, previously served as the medical director of the Asian Pacific Counseling Center under the Los Angeles County Department of Mental Health. As the current president of the Southern California Korean-American Psychiatric Association, beside all other psychiatric practices, he focuses on treating 4.29 riot victims and soldiers suffering from Vietnam War-related PTSD, while advocating for government compensation.

All new SCPS members are invited to provide Membership Spotlight materials.  (Providing these materials is optional.)

December Council Highlights

December minutes were approved at the February 2025 Council Meeting.  January 2025 meeting was cancelled due to the wildfires.

November 2024 Council Minutes – motion to accept

Guest Presentation by Dr. Clarence Chou about APA PAC. Congratulations to Dr. Red for getting 100% participation from SCPS assembly members. PACs are needed to get our government affairs staff in arenas where they can interact with and influence legislators on behalf of our patients. APA PAC doesn’t distinguish between political parties.

-only 3-5% of APA members contribute to PAC.

-when looking at candidates to support, we really need the input of their constituents – PAC not just looking for money, also looking for information about good candidates for us to support.

-APA uses its dollars judiciously – high rate of getting legislators elected

-Our DB can’t contribute as a DB to a Federal PAC, so we’re looking to encourage members to contribute.

-can contribute to APA PAC through APA website or at below link https://secure.ngpvan.com/MPBcPJIMm0Ovpp2cqEP3Lg2

Assembly Report – Dr. Red

Need a resident to run for Area 6 for Deputy Representative – must have 2 years left in training.

APA Conference Registration open

Committee Reports

• Stimulant Task Force
• Still in a lot of informational gathering stage. Weighing in on the extension of Ryan-Haight and telepsychiatry, monitoring changes with next presidential administration. Next meeting Jan 27th.
• Private Practice
• Pertinent working topics: stimulant shortage, change in teleprescribing rules, Medicare, access to care issues. A lot of interest from early career members.
• Diversity and Culture. Next meeting in Jan to prepare for Black History Month. Reached out to all residency programs within SCPS region for DMUR position. Working on George L. Mallory Diversity, Culture, and Social Justice Award – soliciting more applications.
• Access to Care
• New subcommittee for access to acute/subacute beds, discussed beds for patients with autism + psychosis, have attempted to liaise with medical directors of various counties RE: beds and any
• APA Representation Task Force
• Narrowing/refining process about soliciting nominations from DBs, have them considered by APA, process for Action Papers.
• RFM (Resident-Fellow) – Career day occurred Dec 8th at 9:30 at Kaiser West LA – looking at other opportunities for RFM engagement.

Government Affairs Committee (GAC) Report – Dr. Shaner

RESOLVED, that SCPS recommend to the APA Dept of Government Relations and the US DOJ Drug Enforcement Administration regarding telemedicine flexibilities and prescribing of controlled substances that:

1. There should be NO additional requirements beyond DEA registration for physicians with otherwise valid state licenses.
2. Consideration should be given to requiring additional training for non-physician prescribers, specifically in ADHD screening, diagnosis and treatment and stimulant medication risks and benefits.

RESOLVED, that the SCPS Council requests that the SCPS CSAP Board representatives inform the CSAP Board that SCPS will contribute funding to CSAP in 2025 for the purposes of securing a contract for time limited services of a previously suggested legislative consultant to forward CSAP 2025 legislative priorities, provided that:

1. The amount of the SCPS contribution to the contract is proportional to the percentage of the SCPS contribution to overall CSAP expenses,
2. The cost does not vary unreasonably from preliminary cost estimates, and
3. The CSAP Board approves the contract as required by the CSAP Procedural Code.

Other Action 1: That, consistent with an SCPS Council motion of 11/14, SCPS CSAP GAC representatives will move at the CSAP GAC meeting of 12/12 that CSAP, in coordination with other supporters, petition the U.S. Congress to investigate the role of the CSA and the DEA in reducing legitimate access to necessary medications for child and adult patients with ADHD  (passed today at CSAP)

A. Rachel Johnson, APA Gov’t Affairs, has begun some analysis post-election – keeping flexible, will adjust to situation after Jan 20th

B. SCPS efforts to support candidates for APA components and action papers with government relations connections – ongoing work of the SCPS APA Representation Task Force to optimize SCPS advocacy roles, including legislative advocacy, at the APA and APA Assembly for national issues and the Area 6. Council for state issues. The Task Force intends to consult with experts at all levels and ultimately develop a plan to help ensure that the broad range of SCPS advocacy interests, as expressed by SCPS Council, are reflected in APA and the Assembly, and that related actions are transparent and follow clear pathways. Such pathways would include those for nomination and election of representatives and disposition of action papers.

Treasurer’s Report – Dr. Wood

November Financials and Cash on Hand Report

Dr. Wood reviewed various financial metrics, year-to-date. Overall, SCPS is in good fiscal health.

President Elect Report – Dr. Rees (for Dr. Kelly)

A. Newsletter Updates were provided. Thanks to the individuals who contributed for December. Encouragement to Council Members to submit more than one article for the year. Announcement of the upcoming article assignments for January.

B. Nominating Committee: Dr. Lin presented the slate from Nominating Committee for slate for next SCPS election. Slate approved –

Emily Wood – Pesident-elect, Gillian Friedman – Treasurer-elect, SO Min Lim – Secretary, Yelena Koldobskaya – SFV Councillor, Ruqayyah Malik – ECP Dep Rep, Alexis Smith – RFM Rep, Christopher Chamanadjian – RFM Rep, Austin Nguy – DMURR, C Freeman – Assembly Rep

C. Joint SCPS/SCSCAP Meeting Sunday, Jan 26th at 11:00 am. Dr. Emily Wood and Dr. Siddarth Puri will present about the stimulant shortage Crisis. SCSCAP would like to pay honoraria to both speakers and has requested SCPS to contribute (which SCPS does not do for other presentations). Decision made that SCPS not make an exception for one presentation – could consider the question in the future whether in general we want to set aside a certain amount in the budget for honoraria for presenters at our educational presentation.

President’s Report – Dr. Rees

• AI for minutes – pros/cons, various AI platforms discussed. Council members to investigate further. Concerns such as free/cost, data security.
• Tele-Prescribing flexibilities – DEA/HHS finalized a third temporary extension for the teleprescribing of controlled medications prior to an in-person evaluation through December 31, 2025. Ryan Haight Medicare telehealth visits will be required to be seen in person no more than 6 months prior to their next telemental health appointment, with an Beginning in 2025, Medicare patients will be required to be seen in person no more than 6 months prior to their next
• Advocacy Talks – completed for Loma Linda, Arrowhead,
• APA Reception – Mon 5/19/25, 4-6pm. Palm Restaurant (prior booked venue) is closing, so won’t be able to have the reception there. Reception committee has been contacting other venues. 3 viable options, at least one has preliminary quote within our budget and is within walking distance of APA conference.
• Career Fair – Sun, Dec 8th. Great turnout, great presentations. Interestingly, many resident questions were about private practice. Suggestion from Dr. Amy Woods for consideration for future career fair – presentation about contracts and contract negotiation. Largest group of attendees were non-members and members from different district branches (10).
• New Committees/Chairs – Fellowship and Awards Committee divided to:
• f) Fellowship committee – APA distinguished awards (Larry Gross)
  g) Awards committee – installation and awards ceremony (Matt Goldenberg)
  h) Save the date 5/3/25 NCP
• ED meeting with Dr. Wills (APA CEO) – Dr. Wills was at a meeting of CEO of all the specialty medical organization. Agreement among the specialty medical organization leadership to work together, support each other going into new governmental administration.

Membership Report – Dr. Ijeaku

Membership report was approved.

Starting “Spotlight on New Members” in Newsletter to welcome new members

Adjournment – Dr. Rees 09:05

Next meeting is January 9, 2024

Information about SCPS Dues and Tax Deductibility

Your continued membership is of great value to SCPS and the California State Association of Psychiatrists (CSAP).

For 2025, 28.2% of your dues will go towards direct advocacy services. The remaining 71.8% may be written off as a business expense. Please consult your accountant regarding deductibility.

For 2024, 25% of your dues went towards direct advocacy services. The remaining 75% may be written off as a business expense. Please consult your accountant regarding deductibility.  A portion of your 2024 advocacy dues were used to make a CSAP PAC contribution.

We know that membership is a choice and we thank you for choosing to support your profession, your patients, and your colleagues.

Sincerely,

Ijeoma Ijeaku, M.D.
Chair, Membership Committee