Association Between State Kratom Policy Status and Kratom‑Involved Overdose Deaths in the United States, 2020–2024: Analysis of the State Unintentional Drug Overdose Reporting System (SUDORS)

BACKGROUND: Kratom laws vary widely across U.S. states, from Schedule I control to regulation or no policy. Limited evidence links these environments to kratom detection in fatal overdoses. This study examines the association between state kratom policy status and kratom-detected overdose deaths using State Unintentional Drug Overdose Reporting System (SUDORS) data. METHODS: A retrospective ecological analysis using 2020-2024 SUDORS data from 45 jurisdictions reporting kratom detections. Jurisdiction-year observations were classified as controlled, regulated, or lacking statewide policy. Negative binomial regression with jurisdiction and year fixed effects and an offset for total overdose deaths estimated incidence rate ratios (IRRs). Standard errors were clustered by jurisdiction. Opioid-stimulant co-involvement was included as a covariate. Quasi-Poisson fixed-effects model assessed robustness. RESULTS: Compared with Schedule I controlled-substance states, kratom detection rates were significantly higher in regulated states (IRR 3.27; 95% CI 1.78-6.02) and in states without statewide policy (IRR 4.19; 95% CI 2.94-5.98). Quasi-Poisson estimates were similar. CONCLUSIONS: Kratom detection in fatal overdoses was more common in regulated and non-regulated states than in controlled-substance states. State policy context may influence kratom availability and detection. Ongoing monitoring and policy evaluation are needed.