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Wang C, Walker AE. 
“Fatal Mitragynine-Associated Toxicity in Canada: A Case Report and Review of the Literature”. 
Acad Forensic Pathol. 2018;8(2):340-346.
Mitragynine is amongst the more than 40 natural indole alkaloids derived from the Mitragyna speciosa, or kratom tree, also referred to as ketum. The compound is unique in that it exhibits dose-dependent clinical outcomes with stimulant effects at lower doses but sedative effects at higher concentrations. It is indigenous to Southeast Asia, where the local population has had extensive experiences utilizing the substance for its medicinal as well as recreational effects. Mitragynine is advertised as an herbal remedy and is readily accessible via the Internet, resulting in its expansive distribution throughout the world. The addictive potential of this substance is quickly becoming recognized and mitragynine has been implicated in multidrug toxicity deaths. We present a case of the first reported mitragynine-associated fatality in Canada where an independently fatal mitragynine concentration was detected in the postmortem femoral venous blood and the source drug was likely obtained as a powder from Indonesia.
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Jun 14, 2018 19:37
Do Not Take Super High Dose Kratom Powder with High Dose Opioids and Medium Dose Benzodiazepines when You're Really Sick #

In a surprise to no one, it turns out that it can be fatal to combine super high doses of kratom powder along with high dose oxycodone and medium dose lorazepam. It's probably extra dangerous if you are really sick and have chronic breathing and heart problems.

The decedent in this case was a 56 year old woman with several serious health conditions, including COPD and heart valve issues. The authors do not know exactly what or how much she took, but had femoral venous blood concentrations of oxycodone (0.19 0.01 mg/L) and lorazepam (63 5 ng/L) and 2500 ng/mL of mitragynine. This 2500ng/mL mitragynine concentration is the highest reported in a published medical case report.

Their analytical lab reported the oxycodone level by itself was 0.02mg/L lower than their listed fatal level.

During the post mortem analysis, the authors also found evidence of respiratory infections.
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