Interview with Dr. Fabian Pitter Steinmetz on Toxicology and Advocacy by Scientists for Better Drug Policy

Dr. Fabian Pitter Steinmetz is a toxicologist from Germany who in 2021 testified for the World Health Organization’s (WHO) 44th Expert Committee on Drug Dependence (ECDD). There, Dr. Steinmetz gave the case for why kratom should be kept legal. As a member for the European Coalition for Just and Effective Drug Policies (ENCOD), he is an outspoken advocate against the War on Drugs and in favor of harm reduction and drug policy reform. Audio version of this interview can be heard on Episode #62 of the Kratom Science Podcast.

Kratom Science: Thank you for doing this and thank you for your testimony at the WHO. You were a rock star in the kratom community for a few days there. Your field of science is toxicology, is that correct?

Dr. Fabian Pitter Steinmetz: Exactly. People get into toxicology from different types of backgrounds. There are some people who are trained medical doctors. There are a lot of chemists. I myself come from a background of chemical engineering, a pharmaceutical engineering background. Toxicology is a very, very wide field, but on the other hand it’s also very niche.

You were representing the European Coalition for Just and Effective Drug Policies when you spoke to the WHO. Can you tell us about that?

Yeah, ENCOD. They are one of those legalize, or drug policy reform entities in Europe. While traditionally there are a lot of national groups, this is one on the European level. The UN doesn’t meet in Vienna very often, particularly when they want to talk about drugs. So this is why ENCOD tries to give their opinion there. Actually, I am only a member less than a year. And so this was actually the first time I spoke for them. I am only an ordinary member, but I’ve kind of grown into what they call the inner circle. They said, there’s the upcoming ECDD, should we do something, particularly with regard to kratom? One model of ENCOD is the so-called “Freedom to Farm”. The basic attitude of, you should be able to grow your own medicine, particularly referring to hemp, poppy, and coca, as banned plants. Of course we want to prevent another plant getting banned, particularly if its even less dangerous than the other ones, and even there you could argue the plant materials – hemp – how dangerous is hemp? It’s an argument on its own. This is basically how I got there. I used the chance to tell the WHO that I think the drug policy is ridiculous. If they would ban kratom, it would even become more ridiculous. 

You’re in Germany now?

I work for an international science consultancy and our headquarters are close to London. I work for the office in Amsterdam, but I’m usually dwelling in the south of Germany, south of Frankfurt. I’m from Germany and I’m usually based in Germany.

I wanted to ask about the laws there. Cannabis is becoming more and more legal in the states. The right to grow is a big issue. There are cannabis companies now who are gaining more lobbying power, and they are lobbying against home grow laws in the States. Is that similar to what you’re seeing in Germany or other countries in Europe?

Compared to the US, countries are a little bit more independent than states in the US. On the other hand, this whole concept of the European community, it’s, I would say, is still kind of comparable. We have all of our little countries, and there’s a big European umbrella, and you got the USA and the individual states. Keep in mind, so far in the whole Europe, not a single country has a fully legalized cannabis market. We have the Netherlands, with tolerance for the coffee shops since the 70s, but there is no legal market. Even the cannabis you buy in Amsterdam, although they tolerate the shops and the shops pay taxes and stuff, the cannabis itself comes from the illegal market. So the growers for the cannabis shops, they go into jail if they get busted. 

And then of course we have some other tolerance models with the cannabis social clubs in certain countries, particularly in Catalonia and northern parts of Spain. And now Malta will have something like decriminalization with cannabis social clubs. I was also lucky to speak within the hearing of their parliament. A lot of activists and scientists involved there as well. I just made one little talk there about driving limits, and so on. One of their parliamentarians was talking rubbish, and I kind of interrupted him and just asked him to stop talking rubbish, which of course the activists involved really liked. 

Related to that, I was going to ask about the Netherlands. There was an article in Der Spiegel that you posted on Twitter. They referred to the cocaine gangs in the Netherlands carrying Kalashnikovs, and the quote was, “This is the story of a country that willingly surrendered to drugs”. And you said “Absolute bullshit.” I noticed “bullshit” is the same word in English and German. What basis do they claim that legal drugs are causing these types of crimes?

Those drugs aren’t legal, that’s the point. There are criminals involved. If one huge grower of thousands of plants gets into an argument with another person, you know, people get into arguments all the time. Usually people clarify this in court if they find no other solution. But if you can’t go to court because it’s illegal, then you have to use Kalashnikovs. I’m usually mocking them and saying, if we would legalize cannabis and other drugs, the likelihood of people going with Kalashnikovs going to other people and trying to kill them, or torture them, or kidnap their kids, or whatever, is as likely as – what are famous beer brands in the US? Budweiser and…?

Miller Lite.

…as likely as Budweiser and Miller Lite torturing each others’ kids. It’s that likely. That’s just the point. There is no regulated market, and therefore people have to apply this whole gangsterism. People don’t get it. 

In Germany, a few weeks ago, was our federal election. Now there will be most likely a so-called “traffic light coalition”. Basically all parties are at least for decriminalizing the market. The majority is for legalizing the market – I mean the cannabis market. And now, all the conservatives, the puritanic freaks, they kind of talk a lot of shit about what will go wrong and how evil drugs are. They kind of pretend that cannabis is intrinsically something not working in a market, and this is, you know, complete bullshit. I tried to explain that the reason there are weapons and violence is because it’s not regulated. If you explain this a couple of times, and you still see that the same journalist you were talking to a couple of weeks ago, then yeah, you might get a little bit frustrated. Then you have to pardon your French. 

In your opinion, how to bans of the substance actually harm people? It really seems like people are blaming the drug for the associated problems, when it’s really a lot of other things besides how toxic the actual substances are. How do making things illegal harm communities?

A few things about myself, just to understand my position. In my salad days, I was kind of pissed off that drugs which are much more safe than other drugs – I come from a wine area, and particularly when there are festivities when people are really, really drunk, and also the associated violence and damage and so on – I was pissed off that as a little pothead in high school I had to afraid to get busted all the time, and I didn’t like this. I became interested in it, and of course a lot into the pharmacology and toxicology, and this of course influenced what I studied later on. 

But then I actually started to see those other scientists, in Germany or worldwide, they would very often come from a social science background, sometimes even from a law background, and they actually learned much more how harmful this is, on so many levels. The first thing is, what you don’t learn in a natural science, biology, chemistry, pharmacology course is that use prevalence does not change very much if you ban a product like cannabis. There are a lot of studies about it. There’s little shifts, fifty plus people maybe smoking a little more pot, but particularly with vulnerable people, it’s not changing very much, and we have this data. We had this data for the Netherlands. Now we have the data for Europe, Canada, and a lot of US states. Harm is not an option if the use stays the same. 

Then you have to think, what’s the difference when banning it? First of all, harms based on law enforcement. There are a lot of young people – if I would have been busted at 16, 17, 18, 19, 20, I’m not sure if I would have pursued the same career. I know people from that time, who, if you are hindered from doing your high school degree, your driving license, if you are not allowed to do a certain job, or accepted in certain studies due to your police record or whatever, this is very harmful, and this can determine your further life very much. Social harm, just by the policing, I think is completely underestimated in the debate, and this is only one aspect.

Then, the drugs themselves. We currently have a big issue in Germany with, I’m not sure you’ve ever heard the term CBD weed? It’s basically extremely low THC strains. They are basically a grey area, not completely legal, but they are kind of sold everywhere, and particularly because the internet’s around. So there’s a market for this one. So these products sometimes are sprayed with synthetic cannabinoids, and I’m not talking about synthetic THC or the Delta-8 you’ve got in the US. I’m talking about JWH-018, and blah blah blah, so, synthetic substances with high potency, and also which are full agonists, where for example THC is only a partial agonist. So these are actually cannabinoids that can kill you. They are sprayed on these products, and they are sold to people. In Germany, people have died from cannabis, but because it’s adulterated or laced with those synthetic cannabinoids. We have a lot of psychotic episodes due to those substances. Also the potential for, in quotation marks, “addiction”, “cannabis use disorder” or however you want to call it, is much more if you have those synthetic cannabinoids. So this unregulated market is creating harms like this. Another harm would be five years ago there was a region where they added lead powder, or lead salt powders in cannabis to make it more heavy. Of course lead is a neurotoxin, so there were a lot of people who had been hospitalized due to that. So this lack of a regulated market is harming people. 

Then, tax money is missing. We have a drug science group called Schildower Kreis and they calculated that is €3 billion per year we are missing out by first of all putting money in the law enforcement, but then also leaving the money to the criminals, money which could be coming in via taxes. This is also money which is missing for education on the topic, or therapies, safer use education. 

With other drugs it’s more severe, but also with cannabis. People are growing it in their attics, in the cellar, in tents. And the waste, they just throw away. They don’t want to put it in the bin, because the police can identify where this is from. So they usually put the stuff somewhere in the countryside, or they throw it in the river. In the big river in Berlin, the Spree. They found a lot of bags with trims. If you think about cocaine production, then this is of course a lot more severe. If this would be a regulated market, then you could apply environmental standards. If there is an unregulated market, people will hide and throw it away where people can’t see them, and this is usually somewhere in nature. 

There are so many aspects. This is also my catch phrase. The ban is not lowering the use prevalence, but it’s potentiating all harms there are. In German, it sounds more catchy, I promise. 

No, the point is very clear. In terms of toxicology, there’s the concept that “the dose makes the poison”. There are some people who are developing some dependence problems with kratom. You’ve even stated that long-term use of extracts may lead to toxic reactions in the liver. Is the issue more about the misuse by the individual or the drug itself? In Southeast Asia where kratom grows, they don’t report any of those issues. I interviewed Dr. Darshan Singh who said these toxic events that happen here just don’t happen in Malaysia with traditional use. You also see this with cocaine vs. traditional use of coca leaves. How do you view this as a toxicologist?

Extracts always depend on a lot of factors, like temperature, type of solvent, the process in general. You are taking certain compounds out, and other compounds you leave behind. Depending on how you do the extract, you might also enrich some compounds which are more of concern. 

Just to make clear, we have the same issue with tea. I drank, already today, tea, Camellia sinensis or the typical black tea the British like to drink. So if you, for example, do an ethanol extract of this, due to the high antioxidant levels… There was actually a very recent study where they found out [test subjects] had elevated liver values, and even some associated with liver damage. 

So this is nothing atypical. We may find this with a lot of different plants. As soon as you put in high quantities – as you just said, Paracelsus, “the dose makes the poison”. So it’s easier to get doses where you don’t know if they’re safe if you’re using extracts. If you’re using natural material, it’s less likely to overdose. Although, overdose is maybe a misleading term in this context.

Do you know of any extracts used traditionally?

No, I don’t. As far as we could find, and I even talked to one of the producers of Hamilton’s Pharmacoepia, and they’ve studied this a lot, in those countries its only chewing and brewing fresh leaves as a tea. They might use some dry leaves. But as far as extracts, I think that’s relatively new.

So that’s the point. You’re definitely enriching the alkaloids, this is the main purpose, but you also may enrich other compounds. People, based on their genetics, might have different types of metabolisms. Certain people have slightly different enzymes than others, or different enzyme concentrations, and so then other metabolites appear. It is very often that a metabolite is the compound which is toxic. In kratom, the compound which is maybe responsible for opioid type of effects, you just have to imagine there is not just mitragynine, there is [7-]hydroxy-mitragynine, there are also fifty other metabolites, and then [for example] every metabolite also becomes another fifty metabolites, of course at some point it gets really deluded down. At a certain point, there’s only one molecule turning into another one, but it’s still very complex to predict. 

This is why, in toxicology for example, very often I look at a thing called history of safe use, particularly if I work with consumer goods, and not pharmaceutical drugs. For pharmaceutical drugs you very much know about what a single molecule is doing. You exactly know, when you swallow a paracetamol [aka acetaminophen] how much is absorbed, how much time, how much is bound to your blood plasma protein, how much is going into what type of tissues, what are the metabolites which are produced, under which circumstances are there toxic metabolites, the NAPQI in paracetamol for example. If you use very high levels of paracetamol, then one of your enzymes is depleting, and the other enzymes are taking over in relatively high amounts, and then there’s a substance abbreviated as NAPQI, this is for example a liver toxic compound… If you only use it at a low level, paracetamol is not a big problem, but in high levels, it’s damaging your liver. 

Those kinds of things in pharmaceuticals are studied very well and you do pharmacovigilance, but for things where there is a history of safe use, and this could be everything from black tea to chamomile tea to atypical food substances in fermented food products…Natural products, they are by definition mixtures, as nature has built them. It’s never… something isolated or 99% pure, it’s always a mixture. You cannot justify it on proper pharmacological, toxicological data apart from animal trials, and they are also quite limited. You shovel a lot of a certain quantity of a plant or plant extract into an animal, and then after a couple of weeks, you dissect and you will see if there are any histopathologies, if organs changed, if you can see for example if the liver or the kidney looks weird, or if the animal gets into any kind of other issues. These are of course very expensive tests, and they also get banned in certain industries, particularly in cosmetics, they have now been banned in Europe. 

This is why the argument for safety is very often the history of safe use. If you look, ok, this population is using this food product in this quantity for a very long time. This is actually used for a substantiation of why, at least at this level, you don’t expect that there will be adverse reactions. Of course you also look into the chemical composition. If there are any critical compounds you might also want to control them and do some additional studies. But very much is actually done with this attitude of history of safe use. This is also what I think justifies kratom, and what I also said in the talk to the ECDD, if you do specific extracts there, if certain alkaloid levels or use levels should be very high, then it might be valuable to do a proper clinical study, and also do a preclinical study before.

Another thing you said in that testimony, “If you treat kratom use as a deadly contribution in fentanyl overdose, then you must also consider a cup of coffee as a deadly contribution in a methamphetamine overdose”. In your opinion, does kratom contribute to some of those deaths where there was also fentanyl? Did it increase the strength of the fentanyl, or would they have died in some of these cases without the kratom?

This is a very theoretical kind of thing. Keep in mind, people who work in forensics, they usually work a very crappy deadline. Also even the samples are crappy, and also sometimes even literally crappy.

One scenario would be for example, if you assume for one person a certain plasma level, or actually a brain _____ level would be even more relevant, of fentanyl, would be deadly for this person in that situation – I mean, even this is usually variable. Even fentanyl, if applied correctly, is still a safe drug. No one’s bad-mouthing fentanyl. I once used a derivative form for surgery. I survived. 

In theory, it could be that if you have 7-hydroxymitragynine in a high concentration, it would maybe increase your respiratory depression and be a cause of death – this is very theoretical, because I think kratom also has some other properties which are stimulating slightly, of the respiratory path a little bit. I think there’s some scientific debate. I’m not the expert there. But in theory, it could be a contribution like this on a pharmacodynamic basis, where something active is happening, and in this case, something active which is harmful, like respiratory depression. 

Another scenario which is probably even more likely, is if you take a high amount of substances which basically are depleting your liver enzymes, other substances which are dependent on also being metabolized – for example a substance goes step by step into your system, via gastrointestinal absorption, the dose which is defined for you is based on the assumption that while stuff is getting in – particularly if you think about those slow-release pills – if stuff is getting in, the people who did those studies, they also expect that the substance is decaying – it’s getting out of your system, metabolized into an inactive substance. This process for example is inhibited by a lot of other substances. This is also a type of drug-drug interaction which can have a harmful outcome. 

I’m not sure if you’ve read about ayahuasca and monoamine oxidase inhibition?

Yes.

It’s basically something like that. What’s a good example? Bananas or old cheese. They’re not toxic at all, but if you have those MAOI inhibitors in your body, then something like an old cheese can be toxic. It’s difficult to imagine. Some smell toxic, but they usually aren’t toxic, even the ones from Switzerland.

Most cheese in America is fake cheese, so we don’t have to worry about that here.

Well, sometimes fake cheese is better than real cheese. My wife might disagree. 

You said something in your ECDD testimony that I don’t think I’ve heard before. You said kratom is traditional for pain and opioid withdrawal symptoms, and you said perhaps soon, Parkinson’s disease. What do we know about kratom and Parkinson’s disease?

This was actually based on a presentation, the one before mine. It’s an in vivo study on a Parkinson’s model. I thought it was quite a remarkable result. Later on, I’ve even seen some video testimonials. I don’t expect it to become a miracle drug. I would probably consider it similar to cannabis, in that it will help a certain percentage of people dramatically, and probably a lot of people it will not work. Studies need to be conducted to find that out. The problem is, clinical studies are very expensive, and for a substance you cannot patent, it’s a bit difficult to get that type of funding. It’s usually NGOs that take care of this kind of stuff, because big pharmaceutical companies prefer a substance that they can also file a patent on, and sue other companies who want to sell the same drug. Which you cannot do with kratom, because one big pharmaceutical company does a study and finds out it’s actually a “miracle drug” for Parkinson’s, then a lot of other companies will jump on the train and also license kratom-based Parkinson’s medication. But then only one company will have paid millions for the clinical study, and all the other companies are benefiting from it. This is why they only deal with substances which they have designed themselves chemically, which is an issue in the system. Hopefully we will see more on this. I find this really, really interesting. But maybe I should emphasize, I’m not an expert on Parkinson’s therapies. I’m not even an expert on kratom!

I sent you a study yesterday by Dr. Prozialeck from Midwestern University in Chicago, who I interviewed. He went around to head shops in the Chicago area where he bought kratom. He found contamination, and lead and nickel levels he was concerned about for somebody using over ten grams per day of this kratom, that over a period of time this might prove to be toxic. Do you have any thoughts about that?

I had a very brief look. Luckily this was open access. They found some micro-organisms. Of course you should avoid them if possible, and there are some critical ones. Let’s say most microorganisms, if they take the substance orally, usually the acids in your stomach can handle them. But of course, if you are on certain gastrointestinal drugs, kratom then might be a source particularly of some pathogenic microbes. So it’s not ideal. There are strategies to avoid them, and this is something we can talk about. 

With regard to the heavy metals, there is no safe limit. So it’s difficult to say is it okay or not? Also, some heavy metals can have some accumulation in your body and you get problems much later in life. There are certain standard limits for heavy metals within certain consumer products. In the samples we have seen, they were over such limits, but they were not traumatically over those limits. So that means for the occasional kratom user, I don’t see any particular issue. But of course if it’s a long-term therapy at high doses, quality control becomes a bit more important. 

Maybe this ought to be something for the vendors – the people who are growing and producing the materials – if they don’t do this analysis, then maybe this could be addressed by the people selling them, for example in Europe or the US. Particularly, those heavy metal tests are not very expensive. Then they could put a certificate of analysis, or also apply a specification, you know, just promise you they won’t go over 5 ppm of lead or whatever. They showed a range, most of them were negative, but some would be over standard limits, definitely. But not dramatically. But there are some experts on heavy metals exposure and so on, they might have a slightly different opinion, but I’m not really shocked that much, and it would probably not take me away from using kratom.

What can we do about it? This is where regulation comes in. I mean, the one thing is banning the plant. And the other thing is, what is the product actually? If you would just define the powder as a pharmaceutical drug, there would be certain quality management, due diligence, certificates of analysis. This whole thing is kind of missing, particularly in Europe for example, [legal psychoactive plants like kratom] are nothing. They are not a food. They are not a pharmaceutical. Luckily they are not a banned drug, I think there are a few exception countries in Europe. But it’s something in between. On the one hand they can buy them, and they don’t get into trouble if they are caught possessing them. But for example if I buy ibuprofen from a pharmacy, I buy this ibuprofen for a purpose. And the company guarantees within certain limits that I can use it for this purpose. The purpose of kratom, officially, is to have it. It’s not for use. And this is the trouble. Once some activist from the Netherlands asked me, he told me “I’ve got severe pain. I have some tilidines prescribed and I have some kratom. What should I use?”  I actually said to him, just on the perspective of, if you have an adverse reaction, and you can have an adverse reaction with kratom, you can have an adverse reaction with a drug, an adverse reaction can happen with anything, you can suddenly react allergic, and end up in hospital, and then you cannot work, and then you lose your job. And in such cases, you’d like to sue someone. The point is just, no one takes on this responsibility for kratom, but for the pill, they do. So if they put something bad in the pill, or for example they forgot to put on a certain warning, counter indication, or if something went wrong in the production process, they have to take responsibility. Same with cosmetics, with food, it’s built for this purpose, and therefore they have to take the responsibility. It’s sometimes difficult to sue a major company, but this stuff is designed to take it, and therefore the company takes responsibility for it. But kratom, at least in Europe, it comes from more or less dodgy vendors, and some even label it “Not for internal use”. They do this to legally protect them from anything I could do with the substance to harm myself. So basically, they don’t take the responsibility. So this is why I told the activist, “If you wanna be legally protected, take tilidine.” I think he decided for kratom anyway, but this is something we have to consider. The same reason why no one would take responsibility for it, this is also the same reason why certain quality control measures are not done.

 One typical thing to avoid microbiological growth – I know people in the cannabis scene might hate me for this – but one typical thing you do with spices and herbs is gamma radiation. So you put something radioactive very briefly next to it, and then it very shortly gives some radioactive rays on the product and it kills all the germs in there. It’s actually quite a safe process. The product afterwards is not radioactive, and if it’s done properly, also the chemistry has not been changed. If it’s one improperly, the chemistry has been changed but it’s still not radioactive. The other alternative would be heating it, particularly for spices and sensitive products, heating is not an option because you might lose the flavor. But this is something to get rid of microbes. 

And for heavy metals you usually just try to do good agriculture, and the process afterwards. You try to do a good manufacturing process, GMP. You have to do it on soil where there were no heavy machines before, and where it’s proper agricultural ground, not just random space in the garden where you don’t know what has been done there. And then you just check that you are below certain limits, and this is how you control heavy metals. But this type of responsibility, I don’t think that many vendors are taking currently this on, and I apologize to all who currently do this.

Another thing about how this would look in a regulated market. You said as part of your testimony, “It’s understandable to regulate extracts and isolates for therapeutic purposes under local medical laws, however it’s not justifiable to ban the plant in its traditional use form.” What would those regulations look like ideally? Are you saying maybe extracts can only be available through a prescription from a doctor?

That depends on one hand on the indication. I mentioned that there are a lot of different parameters for extracts. Of course, first of all, the source material makes a difference. But genetics, for kratom, I only know those three colors. But there are different variations. This is the first standard. What age do they have?

Quick example for a plant: what makes a huge difference is what part you take of the plant. The castor bean, ricinus communis, if you do a water extract of the plant itself, you can get deadly poison which is actually used for assassinations. But if you take the seeds and do an oil extraction, you get a very safe pharmaceutical or cosmetic oil. There’s some laxative property. Depending on what part of the plant you take, what type of extract you are doing, you can get a deadly poison, or you can get a quite safe cosmetic or pharmaceutical ingredient. 

This is a very extreme example. I don’t think something like this is happening with kratom. Even growing the plant, and what part to take, and how you do the extract, this is defined in pharmacopeias and in monographies and so on. I just wanted to explain an example of why this is the case, and why you don’t just buy whatever kratom from your local farmers, and you put it all in the same vessel, and put some alcohol in it, and then you sell the product. You want that the product is always the same. You also apply specification to it. Heavy metals is also a topic, why you would always want to have the same process. Then if you standardize a product like this, it’s actually quite expensive. If you then do preclinical studies for safety, and then later clinical studies, to show, for example, it’s working for people with Parkinson’s, and the company is also saying, hey, this is for Parkinson’s, and we also take a certain level of responsibility, this will definitely be a prescribable drug. But this does not mean that a very similar product could be, for example, sold for mild pain, and this could be an OTC, an over-the-counter drug, where you don’t need a prescription. So sometimes it’s more the indication or the attitude behind, which is the difference between a prescription or a non-prescription drug, or even a food supplement or whatever. 

We also treat coffee and other things which are drugs, we also treat them as food. Because traditionally, in the whole world, we don’t have psychoactive substance laws. Ideally, we would have a law where you deal with coffee, beer, cannabis, kratom, opium, and so on, whatever you use more or less for recreational purposes, we don’t have these laws. We just have, traditionally, food laws, cosmetic laws, pharmaceutical laws, and “Oh it’s an evil drug, ban them!” laws. I’m not aware of any major country or union of countries which has this type of law – this is why I’m mentioning prescription or OTC, maybe food supplement – already a lot of things with mild psychoactive effects are actually sold as food supplements, because there are no other laws for it. 

The American Kratom Association is trying to do, get kratom recognized as a food, because that’s the only possibility. Alcohol and tobacco can clearly be harmful but they are available everywhere to adults everywhere. With kratom it’s either it will go through this long process to become a drug – they did this here with CBD, it’s called Epidiolex, but here in the States if you have epilepsy and you want to take Epidiolex, that will cost about $35,000 a year. Whereas if you can get some pure CBD or THC, that might help, but it’s cheaper, and you don’t have to go to a doctor to get it. Here, there’s costs involved with healthcare that are beyond most people’s ability to pay. It seems like kratom should be regulated differently.

What do you think of other drugs like heroin and cocaine. It’s clear that banning them makes them more dangerous, especially with illicit fentanyl. If you’re against prohibition, and you’re for harm reduction, do you think drugs such as heroin and cocaine should be legally regulated?

Yeah.Things like kratom supplements and coffee or coca tea, they won’t count in what I say now. These can be treated as more or less food supplements, or maybe OTC drugs. Thinks like caffeine pills, in Germany they are sold also in pharmacies. Let’s say everything that can severely stimulate you, or give you a buzz, or psychedelic experiences, I would classify those substances into three different regulatory categories. 

The first one would be cannabis products, and maybe coca leaves to chew, khat leaves to chew, kratom leaves to chew. You have cannabis social clubs, then you have some chewing social clubs, where you can chew what you want? I don’t know. Maybe not for a supermarket, but a dispensary where the only thing which is needed, you need to be an adult, and they should not make advertisements, but everyone can enter there. Then they can either, in a communist type of way, grow their own in a social club type of model, or it could be commercial, within those limits. Without advertising in public media and TV and so on. I think it’s not ok. I think it’s also not ok for alcohol. By the way, for alcohol and tobacco, I see the same, basically with an age limit, with a certain level of education, some social responsibility, but basically you can join or you can buy the stuff on your own. You can also grow a certain amount for your own, but maybe you can consume socially. So you can drink together beers, you can chew together kratom, or you can smoke together pot. This is the first category.

Then, let’s jump to the third category. This is also a quite easy one. If you have a substance use disorder, I think you should be eligible to get this compound, whatever it is: if it’s heroin, fentanyl, methamphetamine, cocaine. By the way, yesterday a paper was published by myself, and a professor in Frankfurt who is kind of famous for the Frankfurter way of harm reduction, particularly for heroin users, and we suggested a cocaine e-cigarette for crack users. Not recreational crack users, but people with a problem and who have issues with cessation. They basically get a cocaine e-cigarette, instead of buying a thing of crack stones and being high for a quarter hour, they can basically vape the cocaine. Of course, they don’t get it from a dealer. They get it from a medical doctor. Therefore, they can also check for comorbidities, they can also give them something to down themselves afterwards, prescribe some benzos or cannabis or whatever, additionally. Because coming down is actually something very important if you’re abusing stimulants. Also, those e-cigarettes, you can program them or formulate them in a way that you don’t get lethal overdoses. This is just a concept which we tried to introduce with this publication.

So the third category is very much a prescription model, but very accepting. So basically, physicians aren’t there to withhold any drugs from you, they are just there for finding the best drugs for you. If you for example have a heroin use disorder, it should not be the ambition of the physician to talk you down, to use methadone if you don’t want to. So if you want to have proper heroin, get it prescribed. We have this prescription model now in Switzerland for I think 20 years, also in Germany and some other countries, to prescribe heroin, and this is a success model. A third of the people are not homeless anymore, they even find a job, they can watch out for themselves, their health improves, they stop stealing, they stop prostituting, everything which is associated with buying black market drugs because they get it prescribed. Financially this is a huge benefit, because a gram of heroin doesn’t cost that much, and you can make a lot of doses with a pure gram of heroin. But if you, for example, leave it to the people on how they can get the drugs, they will break into a jeweler, damage a hundred thousand euros, to just steal jewelry worth 10,000 euros, but because it’s stolen, they only get 1,000 euros for it, and then they can buy 10 grams of heroin, which are only worth, I don’t know, a couple of hundred bucks. This damage which is done there, society’s paying this all day long. And this is what people don’t get. Every person who has a heroin use disorder, if we give them heroin, it’s cheaper for us and they are healthier. Also I think a lot of physicians do not get this. And this is why it’s very important, particularly social scientists, they are very good at bringing this message across, and I think this message we have to really bring out there.

Getting back to your question, this is the third category, let’s say more or less a prescription model. I am completely aware that everyone is getting hooked on those substances, but I’m still talking about substances with a quite high likelihood, not really fit for purposes of a recreational market. If people still decide to smoke crack and they don’t have an addiction, I’m also of course for full decriminalization, and therefore drug checking services. Maybe the occasional crack smoker who does not develop use disorder, might then still like my proposal a little bit.

Then the second category: basically, what’s in the middle of cannabis and heroin? First of all we have to think of the substances with high use prevalence, so basically amphetamines. I would suggest rather the normal amphetamine than the methamphetamine. The effects are quite similar, but the effects are not that long, so you have less of an issue with coming down, and you get less into the scenario where you continually use. So, not sleeping over the weekend, but you still have to work, and then you continually use. This is very often how those very negative use patterns start. So the normal amphetamines, MDMA, psychedelics, ketamine, maybe some opium, shandu, old school opium vaping like in the 19th century. 

Of course [these come with] certain risks, and this is where you need an expert committee at some point, who decides what the exact regulations are. There might be some substances, for example, powder cocaine to opium, where there might be an additional educational session, and you need to sign for something, maybe even to sign for insurance or whatever. There are a lot of different things which are currently discussed, but the most important thing is that you get your substances in a one-on-one conversation. Similar to the first model, you need to be an adult to go into the shop, and the shop is not allowed to do advertisement, but while in the cannabis shop, you buy 10 grams and you smoke with your friends in a big hookah or whatever. In this other model, you don’t get a hundred ecstasys and everybody eats some. No. The idea is still, ok, do you know how much you weight? Do you take other drugs? Then I don’t recommend you to take more than 60 milligrams overall, but here are pills with 180 milligrams, they should be sufficient for the whole weekend. Don’t dose more than this, please. Please watch out for this and that. So for substances like ketamine, amphetamine, MDMA, LSD, you need to give them a little bit of education, a little bit more than for cannabis. Also, talk to them. Hey, if you use this substance, please don’t combine it with that substance. 

So this is why I distinguish between those categories, slightly, but this is basically my model, and I think every drug in either one of those categories, and even in multiple, depending on the concentration, maybe a very potent kratom extract would fit in the second category, so you still get it, but there is someone who studied either social science or did a seminar on pharmacology, they are basically giving you a 101, giving you advice, and only giving you a handful of doses, and not your month supply like with cannabis, or kratom leaves. So with kratom leaves, I clearly see them in category 1, or even in a food grade, you can argue in both scenarios.

So a three class model, that’s what I’m suggesting. 

You’re outspoken against the War on Drugs. More and more scientists are becoming outspoken, even about their own personal drug use. We have Dr. Carl Hart here in the United States. I interviewed Dr. Kirsten Smith from the National Institute on Drug Abuse who admits she used to use heroin. Is there a stigma to this in the sciences? Do you have any problems with backlash to your opinion? Do you have any colleagues with the same opinions who might be afraid to speak out?

Definitely, yeah. I think particularly Carl Hart’s move there, particularly with a focus on heroin, was very, very brave. I wouldn’t be that brave, to be honest. Telling that I was a pothead when I was a teenager, this is something I usually don’t say. This might be the first podcast where I am telling that! Some people know me, so.. 

Usually in the debate I try to be very neutral, particularly when it comes down to numbers and stats in pharmacology and toxicology and so on. I usually avoid having this personal reference, because if you say “I have used those substances”, immediately the argument comes, “Oh you only want to get it legalized so you have better access.” And if you say, “I’ve never used those substances” then people might say, “Then you don’t know how dangerous and how addictive they are!” So whatever you say, it’s wrong. It’s not benefitting the case. It’s not helping. So that’s why I usually avoid this.

But does your stance in general come with a stigma?

Yeah. I was on a conference for the germ pharmacologists and toxicologists. One who shares my opinion actually told me, “By the way, those people don’t like you. They won’t support your work. They will not include you in certain activities.” Yeah, that’s actually happening. 

There are so many people who are not aware of what “harm reduction” means. So they never heard of this terminology. We use the English phrase usually. They never heard of this. They didn’t understand the concept. 

There was the chair of this group of thousands of scientists, head of the board. I was asking him “Hey, I think we as toxicologists should play a role in drug policy and harm reduction. What about a working group there?” And he dropped me a very polite email, but still kind of saying how many other ideas they [were presented with] currently [and] said no. So he was discouraging me a little bit. Particularly in the natural sciences, people are not very outspoken about the topic. The social scientists are much better. This is also why I collaborate a lot with them. But on the other hand, this has a lot of benefit, because I am, for them, also one of the only natural scientists who is dealing with this topic. 

But yeah, it’s still a huge stigma. People think it’s bad for their career. Even putting in this cocaine e-cigarette paper on LinkedIn, I saw how many people were afraid and did not like it. I was able to see how many views it had. I know also a lot of friends who are on LinkedIn and probably have seen it, and they think more or less the same as I do about harm reduction and drug policy reform, maybe not that detailed, maybe a little bit less dramatic, but hardly anyone liked this. I think I asked on Twitter, “Hey does anyone want to like this one? I’m really disappointed!” But no one responded. But honestly, even someone on Twitter replied to me, “If I would like that I would lose my job.” I think it’s pure exaggeration. But you still see, people are kind of scared, because they are immediately associated with drug use.

I mean, when I started publicly talking about this topic, I was aware that I would never have a big management position in the pharmaceutical industry. The CEO of my company and my line manager, they understand what I’m doing, and they are overall on my side of things. My current position, they don’t mind if I talk about this. But in a lot of industry positions, I would be burned. I would be out of the discussion for climbing up the hierarchy or whatever.

So for a career, this is very bad what I am doing here.

In that context, thank you very much for doing what you are doing. Especially from our perspective, the kratom testimony was very helpful to have scientists up there speaking out. Because a lot of people aren’t really listened to. Even if they’ve had good experiences, they’re just written off as addicts. But I think it’s really important for scientists to speak up. So thank you very much.

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Dr. Steinmetz’s testimony at the WHO’s ECDD https://www.youtube.com/watch?v=QhLoxXW1db4
Follow Dr. Fabian Pitter Steinmetz https://twitter.com/docsteinmetz
Read Dr. Steinmetz’ paper on harm reduction and cocaine e-cigarettes: Steinmetz, F. P., & Stöver, H. (2021). The cocaine-e-cigarette – A theoretical concept of a harm reduction device for current users of smokable cocaine forms. Drug Science, Policy and Law. https://doi.org/10.1177/20503245211049310

Disclaimer: None of the content on KratomScience.com, Kratom Science Podcast, or Kratom Science Journal Club should be considered medical claims or medical advice.