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Kava

  • Unlike most substances reviewed at Drug Science, kava is not simply a drug, but inclusive of wider cultural understandings including practice, therefore defying a narrow definition script.

     

    To fully comprehend the question of ‘What is Kava’ we recommend you read this blog written by Dr Apo Aporosa.

     

    Kava is typically explained as either the Piper methysticum plant unique to tropical Pacific Oceania or the beverage made by steeping the crushed roots and basal stump of the kava plant in water.

  • Kava’s alternative ‘forms’ are solely reflected in subtle traditional use practice differences across Pacific Oceania. For instance, kava is typically mixed to a higher strength concentration in Vanuatu and the Pacific islands to the West when compare with Fiji and the islands to the east.

    ​

    To limit confusion regarding ‘different’ forms of kava, it is Pacific traditional knowledge and kava’s role as a cultural keystone species that is the sole authority on what amounts to, and can be defined as, kava.[i] Simply put, there is kava, as understood and informed by indigenous knowledge systems, and then there are extracts, pills, capsules, and pop-culture products containing Piper Methysticum, which are not technically considered to be kava.

     

    Extracts and pill/capsules containing Piper methysticum

    These pharmacologically manufactured pills, capsules and extracts are typically prescribed and sold as health supplements, particularly as natural alternatives to benzodiazepine and sleep aiding drugs. "The recommended daily dose for an adult is typically one to three capsules with a daily dose of 60–250 mg kavalactones for one or two months."[ii] This rate is approximately 15 times smaller than is routinely ingested in traditionally influenced kava use settings.


    It should be noted that while there are thousands of peer-reviewed and published ‘kava’ clinical trials, most all of these used tablets or extracts containing Piper methysticum in non-naturalistic settings as part of the methodology. Clinical trials that used kava in its traditionally influenced form in naturalistic spaces are extremely limited.[iii] Nevertheless, the results of studies using tablets and extracts containing Piper methysticum in non-naturalistic settings are routinely generalized or applied to individuals who consume kava in traditional settings, regardless of the monumental difference between these drugs.[iv]

    ​

    Pop-culture products containing Piper methysticum

    A wide variety of commercially manufactured products containing Piper methysticum, routinely but inappropriately marketed as kava, add to further confusion regarding kava as a cultural keystone species and traditional practice. These products include Piper methysticum infused vapes and chocolate, flavored extracts and pop-culture beverages sold both outside and inside bar-like venues (particularly in the USA). Some of those beverages resemble alcohol cocktails inclusive of a piece of pineapple and an umbrella, and shots, which in some cases, are adulterated with other drugs substances to increase psychotropic effects. Some of these adulterated Piper methysticum products carry serious health warnings.

    ​

    The sale of Piper methysticum products in spaces called kava bars contributes to mis- and disinformation, as the term ‘bar’ infers kava is an alcohol which it is not.[v] While acknowledging exceptions exist, many of these spaces are a mash-up of contemporary bar furnishings, flashing lights, loud music and occasionally traditional iconology,[vi] staffed by barkeeps who encourage the chanting of Pacific greetings.

  • Kava in its beverage form typically contains 20 kavalactones in combination with various other active ingredients, including flavokavains and alkaloids.[vii] Pharmacology reports that six of the 20 kavalactones as being responsible for its psychoactive effect.  These six lactones have each been allocated a number to aid chemotype classification, and are listed below with their chemotype number and standard abbreviation:

     

    1. demethoxy-yangonin (DMY)

    2. dihydro kavain (DHK)

    3. yangonin (YAN)

    4. kavain (KAV)

    5. dihydromethysticin (DHM)

    6. methysticin (METH).    

                                                                                                                             

    Pharmacology explains that kava acts on the brain and central nervous system by blocking the calcium ion channels, which leads to a reduction of neurotransmitter release excitation, and the potentiation of gamma-Aminobutyric acid (GABAA), through enhanced ligand binding to the GABA receptors. This creates a reduction in the neuronal re-uptake of noradrenaline responders and possibly dopamine, leading to a reversal of monoamine oxidase (MAO) B inhibition.[viii] Although this explanation would suggest there is a high level of knowledge regarding kavalactone psychopharmacology, researchers[ix] warn that kavalactone “modes of action are not fully understood”, with even less known about “the neurophysiological mechanisms associated with kavalactone metabolism”. Further confusing this knowledge gap is the psychopharmacology of Piper methysticum pharmaceuticals/nutraceuticals preparation, particularly extracts, containing selected or altered kavalactones.

  • Even at high consumption volumes (3.6 litres over 6 hours), kava’s effects are subtle, not causing marked euphoria or vestibular disturbance, hallucinations or ‘intoxication’.[x] Kava’s effect subtlety has been likened to an ‘anti-Red Bull’,[xi] inducing feelings of relaxation that facilitate clear-headed discussion and promote wellbeing.[xii]

     

    A recent study highlights kava's minimal cognitive interference. This research used a validated somatosensory neuro-diagnostic tool to evaluate six specific neurological functions—Focus, Accuracy, Temporal Order Judgement (TOJ), Timing Perception, Plasticity, and Fatigue—before, during, and after six hours of traditional kava consumption. Results were compared with a control group not consuming kava and applied to driver safety. The study found a statistically significant but minor negative impact on TOJ (p=0.007301, BF=6.193058), which relates to the brain's ability to sequence events.[xiii] Importantly, this impairment was shown to be very different to the effects of alcohol, cannabis, and other recreational substances.[xiv]  These findings align with ethnographic observations suggesting that kava, when consumed traditionally, has a small effect primarily through TOJ disruption. Moreover, this work corroborates traditional knowledge that reports kava does not hinder reasoned thinking or interpersonal connection, which are essential aspects of kava use in communities.

    ​

    The effects described here do not include those experienced when using contemporary Piper methysticum products.

  • Traditional knowledge reports kava as having a variety of medicinal uses including antifungal and antibacterial action, mild anesthetic and analgesic effects, and stress relieving and sleep promoting properties.[xv] Kava users describe its anxiolytic properties as manifesting “a pleasant, warm, and cheerful, but lazy feeling”, effects that in some cases can be felt for several days. Further, ethnographic research with combat veterans and first responders (police, fire and ambulance) reports the efficacy of kava with talanoa to reducing PTSD symptomology, work that is currently being validated in clinical trials.[xvi] 

     

    Research utilizing contemporary pills, capsules and extracts of Piper methysticum have shown positive mild anesthetic and analgesic effect, and antifungal and antibacterial action,[xvii] including its use as “as a treatment for gonorrhea in the German Pharmacopoeia prior to the discovery of penicillin."[xviii] Piper methysticum nutraceuticals have also been shown to improve sleep quality inclusive of “rapid onset of effect … [with] minimal morning after-effects”,[xix] and anxiolytic efficacy, particularly in the treatment of generalized anxiety disorder.[xx] These Piper methysticum preparation also show viability as a natural hormone replacement therapy (HRT) for women,[xxi] and more recently anti-cancer action, specifically ovarian, bladder, colon, lung cancer and leukemia.[xxii]

  • High kava use increases gamma-glutamyl transpeptidase (GGT) levels in the blood. Research is clear that “while elevated GGT and white blood cells [lymphocytes] were abnormal [to those unfamiliar with kava’s effects on the liver], this does not mean that this abnormality is of concern”.[xxiii] Additionally, high kava use over a prolonged period can cause kava dermopathy, or a drying and flaking of the skin.[xxiv] However, this subsides a week or so after use is slowed or ceased, without residual effects.

     

    Kava’s level of safety is recognised in 2000+ years of traditional knowledge and use, and a 2016 World Health Organisation’s (WHO) kava risk assessment report: “On balance, the weight-of-evidence from both a long history of use of kava beverage and from the more recent research findings indicates that it is possible for kava beverage [made with noble cultivars] to be consumed with an acceptably low level of health risk."[xxv] That same report also cited research showing kava as statistically safer than Paracetamol.[xxvi] Additionally, the 2019 Drug Harms Ranking Study[xxvii] assessed kava as the least-most harmful drug of the 22 assessed substances, with the harm to the user scored at 2, and harm to others 1 (total 3 harm-points). The harm to user score includes the GGT level rise and kava dermopathy (as discussed above) which are reversable. Kava’s safety is reflected in its regulation as a ‘food’ in some countries.[xxviii] However, the WHO (including the UN/WHO Kava CODEX Alimentarius[xxix]) ‘food’ classification and harm ranking is caveated on kava beverage made only from noble drinking cultivars of Piper methysticum and prepared using a traditionally influenced water-based method. This ‘food’ safety recognition does not extend to contemporary products, extracts and pop-culture products made from, and including, Piper methysticum.

    ​

    Several specific kava risks with now be discussed.

    ​

    Kava wash-down

    Coinciding with kava’s move away from its traditional use environment is the growing practice of washdown in which alcohol is consumed together with, or following, kava consumption.[xxx] Alcohol, even at very small quantities following, or with, kava use, is known to potentiate the effects of kava.[xxxi] There is concern that the use of ethanol by the pharmaceutical/nutraceutical industry to extract kavalactones potentially caused a chemotype disruption and was a contributing factor in European Kava Ban hepatoxicity cases.[xxxii] It is suspected that kava wash-down increases the likelihood of in-vivo chemotype disruption and liver complication. Kava wash-down is potentially dangerous, as are Piper methysticum products that contain alcohol or used it in processing.[xxxiii]

    ​

    Kava, Piper methysticum preparations and Kratom

    Research shows that over 60% of ‘kava bars’ in the USA either mix kratom (Mitragyna speciosa), or have it available to mix, with their kava or pop-culture Piper methysticum drinks. [xxxiv] Kratom is a Southeast Asian leaf with addictive, opioid-like effects, and is said to give kava a ‘euphoric hit’.[xxxv] Although the practice of mixing addictive kratom with safe kava is frequently denied, a large collection of kava bar ‘menus’ and social media posts provide a plethora of evidence of this practice. More concerning are reports in online addiction support groups from kava bar patrons who believed they had been drinking kava, only later to learn this had been adulterated with kratom and had led to dependency. The FDA advises that “kratom is not lawfully marketed in the U.S. as a drug product, a dietary supplement, or a food additive”.[xxxvi] Kava bar attendees are advised to seek clarification on kava / Piper methysticum preparation ingredients. Customers are strongly advised not to consume ‘kava shots’ or kratom Piper methysticum drinks. These are marketed under names including Phlex, Feel Free, Flayvorz, etc. and are potentially dangerous.[xxxvii]

    ​

    General kava safety comments

    Research warns, "[i]t is important to keep in mind that not all … [Piper methysticum preparations are] equal in efficacy and safety and therefore it is critical to characterize a … [Piper methysticum] product with detailed knowledge of its preparation method and chemical composition. Many factors, ranging from cultivars, parts of the plant used, preparation methods, and solvents employed for extraction, affect the composition of the final kava products." [xxxviii] Additionally, kava misinformation (see section under), practices such as Kava wash-down, kava drug interactions and unethical behaviour including adulterating Piper methysticum with kratom has led to regulatory confusion.

  • Although kava products occasionally carry warnings stating kava is to be avoided during pregnancy and breastfeeding, it is common for pregnant and breastfeeding Pacific women to consume kava both as a traditional medicine and for cultural purposes.[xxxix] However, pregnant and breastfeeding woman are advised not to use Piper methysticum pharmaceuticals/nutraceuticals or pop-culture products. People who have hepatitis or liver problems are encouraged to avoid kava and not to use Piper methysticum pharmaceuticals/nutraceuticals or pop-culture products.

  • Kava has wide traditional Pacific medicinal utility. While mostly used in its natural state (eg. kava beverage for stomach upset, leaves applied to wounds, roots boiled for specific purposes), kava is also occasionally mixed with other traditional plant medicines for wider application.[xl] Kava and contemporary Piper methysticum nutraceuticals and products should not be used together with other drugs. This will reduce interaction and minimize the potential for unjustly damaging kava's safe use reputation.  

    ​

    Kava and drug interactions

    Research warns against the use of kava together “with certain drugs such as antidepressants [Selective serotonin reuptake inhibitor (SSRI)], benzodiazepines, alcohol, and various antipsychotics",[xli] St. John’s Wort (Hypericum perforatum) and the Chinese herb Aristolochia,[xlii] Warfarin[xliii], the Parkinsons drug Levodopa and Alprazolam.[xliv]

  • Kava is not physically addictive. [xlv] As discussed earlier, typical kava consumption is reported as 3.6 litres (6.33 pints) over six hours. In some parts of the Pacific, it is common to consume this amount on a daily basis for weeks. [xlvi] Despite early European colonial assumptions that prolonged kava use led to addiction,[xlvii] research shows that even at high use volumes, kava is not physically addictive.[xlviii] Research reports that “if the label ‘addiction’ is to be applied to yaqona [kava], I would hesitantly use ‘socially addictive’ in the sense that it has been habituated to most aspects of Fijian [Vanuatu, Tongan and Samoa] socialization.” [xlix]

  • People who have hepatitis or liver problems are encouraged to avoid kava and not to use Piper methysticum pharmaceuticals / nutraceuticals or pop-culture products. Additionally, kava should not be mixed with alcohol or alcohol consumed within 12 hours of drinking kava or consuming Piper methysticum products. Further, people taking antidepressants (selective serotonin reuptake inhibitor [SSRI]), benzodiazepines, antipsychotics,  St. John’s Wort (Hypericum perforatum), the Chinese herb Aristolochia,  Warfarin, the Parkinsons drug Levodopa and Alprazolam are advised not to consume kava or Piper methysticum products.

  • Regardless of kava’s subtle effects and lack of safety concern as reflected in risk assessment reports[l] and regulation,[li] kava continues to be misunderstood, misrepresented and linked with more potent substances and their adverse social and health consequences, with this perpetuating a harmful anti-Pacific narrative about the drink and its associated culture. Common kava misinformation includes kava being an alcohol, having addictive properties and causing liver problems. These myths and reasoning behind them are discussed at length in the Journal of Drug Science, Policy and Law, 2019, Volume 5, p. 1-13. 

    ​

    A few of the lesser myths not covered in the Drug Science paper can be found here.

  • [i] Aguirre, B. V., Tualima, H., Wendland, W., Jaiya, G. S., Toki, K., Zografos, Johnsson, D., . . . Boyd, T. (2017). Protect and promote your culture: A practical guide to intellectual property for indigenous peoples and local communities. Geneva: World Intellectual Property Organization (WIPO).

    [ii] Bian, T., Corral, P., Wang, Y., Botello, J., Kingston, R., Daniels, T., . . . Xing, C. (2020). Kava as a clinical nutrient: Promises and challenges. Nutrients, 12(10), 3044. (p. 4)

    [iii]

    • Waqainabete, I. (2003). Neoropsychological effect of kava (Masters of Surgery). Fiji School of Medicine, Suva.

    • Aporosa, S. A., Atkins, M., & Brunton, R. (2020). Kava drinking in traditional settings: Towards understanding effects on cognitive function. Journal of Human Psychopharmacology: Clinical and Experimental, 35(2), e2725.

    • Aporosa, S. A., Atkins, M., & Leov, J. (2021). Decolonising quantitative methods within a Pacific research space to explore cognitive effects following kava use. Pacific Dynamics: Journal of Interdisciplinary Research, 5(1), 74-92.

    • Aporosa, S. A., Ballard, H., Pandey, R., & McCarthy, M. J. (2022). The impact of traditional kava (Piper methysticum) use on cognition: Implications for driver fitness. Journal of Ethnopharmacology, 291(115080), 1-15.

    • Aporosa, S. A., Hébert-Losier, K., & Aughton, H. (2022). Traditional kava use and body sway: A pilot investigation. Pacific Health Dialog: The Journal of Pacific Research, 21(10), 683-692.

    [iv] Aporosa, S. A. (2022). ‘Doped’ on kava: Understanding kava’s impacts on cognition and driving. Suva: Pacific Studies Press (p. 59-60; download link: https://tinyurl.com/dopedonkava)

    [v] Aporosa, S. A. (2019). De-mythologizing and re-branding of kava as the new ‘world drug’ of choice. Journal of Drug Science, Policy and Law, 5, 1-13.

    [vi] Evans, K. (2024). US kava production plans worry Pacific growers. ABC Radio Australia: Pacific Beat, March 26,. Retrieved from https://www.abc.net.au/pacific/programs/pacificbeat/us-kava-and-reax/103632412.

    [vii]

    • Bian, T., Corral, P., Wang, Y., Botello, J., Kingston, R., Daniels, T., . . . Xing, C. (2020). Kava as a clinical nutrient: Promises and challenges. Nutrients, 12(10), 3044.

    • Lebot, V., & Legendre, L. (2016). Comparison of kava (Piper methysticum Forst.) varieties by UV absorbance of acetonic extracts and high-performance thin-layer chromatography. Journal of Food Composition and Analysis, 48, 25-33.

    • Cheung, C., Baker, J., Byrne, J. M., & Perrault, K. A. (2022). Investigating volatiles as the secondary metabolome of Piper methysticum from root powder and water extracts using comprehensive two-dimensional gas chromatography. Journal of Ethnopharmacology, 294, 115346-115346.

    [viii]

    • Ligresti, A., Villano, R., Allarà, M., Ujváry, I., & Di Marzo, V. (2012). Kavalactones and the endocannabinoid system: The plant derived yangonin is a novel CB1 receptor ligand. Pharmacological Research, 66(2), 163-169. (p. 168)

    • Lim, T. K. (2016). Edible medicinal and non-medicinal plants: Volume 11, modified stems, roots, bulbs. New York: Springer. (p. 155)

    [ix] Kautu, B. B., Phillips, J., Steele, K., Mengarelli, M. S., & Nord, E. A. (2017). A behavioral survey of the effects of kavalactones on caenorhabditis elegans neuromuscular transmission. Journal of Experimental Neuroscience, 2017(11), 11790695177053841179069517705384. (p. 1,5).

    [x] Aporosa, S. A. (2022). ‘Doped’ on kava: Understanding kava’s impacts on cognition and driving. Suva: Pacific Studies Press. (p. 59-60; download link: https://tinyurl.com/dopedonkava)

    [xi] Hirsch, J. (2009). Kava 'anti-energy' drink takes root in the Southland. Los Angeles Times, Dec. 29., p. B1. Retrieved from https://www.latimes.com/archives/la-xpm-2009-dec-29-la-fi-kava29-2009dec29-story.html

    [xii]

    • Carlini, E. A. (2003). Plants and the central nervous system. Pharmacology, Biochemistry and Behavior, 75(3), 501-512. (p. 508)

    • Keltner, N. L., & Folkes, D. G. (2005). Psychotropic drugs. (4th ed.). Missouri: Elsevier Mosby. (p. 522)

    • Lewin, L. (1964). Phantastica: Narcotic and stimulating drugs, their use and abuse. London: Rutledge & Kegan Paul Ltd. (p. 223-224)

    [xiii] Aporosa, S. A., Ballard, H., Pandey, R., & McCarthy, M. J. (2022). The impact of traditional kava (Piper methysticum) use on cognition: Implications for driver fitness. Journal of Ethnopharmacology, 291(115080), 1-15.

    [xiv] Aporosa, S. A. (2022). ‘Doped’ on kava: Understanding kava’s impacts on cognition and driving. Suva: Pacific Studies Press. (p. 59-60; download link: https://tinyurl.com/dopedonkava)

    [xv]

    • Lebot, V., & Cabalion, P. (1988). Kavas of Vanuatu: Cultivars of Piper methysticum Frost (Vol. Technical Paper No.195). Noumea: South Pacific Commission. (p. 23-29).

    • Singh, N. N., Singh, S. D., & Singh, Y. N. (2004). Kava: Clinical studies and therapeutic implications. In Y. N. Singh (Ed.), Kava: From Ethnology to Pharmacology (Medicinal and Aromatic Plants - Industrial Profiles Volume 37) (pp. 140-164). Boca Raton: CRC Press. (p.146,149).

    [xvi] Aporosa, A., & Vaka, S. (2023). The therapeutic potential of traditional kava use spaces in the treatment of psychological trauma. Presented at Pasifika Medical Association Annual Conference: Te Ᾱkirāta Ōu - The New Dawn, Rarotonga, Cook Islands: Sept. 6-8 (Permanent link: https://hdl.handle.net/10289/16051)

    [xvii] Singh, Y. N. (2009). Kava: An old drug in a new world. Cultural Critique(71), 107-128.

    [xviii] Barceloux, D. G. (2012). Medical toxicology of natural substances: Foods, fungi, medicinal herbs, plants, and venomous animals. New Jersey: John Wiley & Sons. (p. 525)

    [xix] Wheatley, D. (2005). Medicinal plants for insomnia - A review of their pharmacology, efficacy and tolerability. Journal of Psychopharmacology, 19(4), 414-421. (p. 141)

    [xx] Sarris, J., Stough, C., Teschke, R., Wahid, Z. T., Bousman, C. A., Murray, G., . . . Schweitzer, I. (2013). Kava for the treatment of Generalized Anxiety Disorder RCT: Analysis of adverse reactions, liver function, addiction, and sexual effects. Phytotherapy Research, 27(11), 1723-1728.

    [xxi]

    • Braun, L., & Cohen, M. (Eds.). (2015). Herbs & natural supplements an evidence-based guide. (4 ed. Vol. 2). Chatswood, NSW, Australia: Churchill Livingstone.

    • Cagnacci, A., Arangino, S., Renzi, A., Zanni, A. L., Malmusi, S., & Volpe, A. (2003). Kava-kava administration reduces anxiety in perimenopausal women. Maturitas: The European Menopause Journal, 44(2), 103-109.

    [xxii] Lim, T. K. (2016). Edible medicinal and non-medicinal plants: Volume 11, modified stems, roots, bulbs. New York: Springer. (p. 155-158).​

    [xxiii]

    • Malani, J. (2002). Evaluation of the effects of kava on the liver. Report: March 12. Suva: Fiji School of Medicine. Suva: Fiji School of Medicine. (p.7)

    • Moulds, R. F. W., & Malani, J. (2003). Kava: Herbal panacea or liver poison? Medical Journal of Australia, 178, 451-453. (p. 452).

    • Mantesso, S. (2016). Kava could be prescribed for anxiety. ABC Australia: Pacific Beat. Dec. 22. Retrieved from http://www.abc.net.au/news/2016-12-22/kava-could-be-prescribed-for-anxiety/8142886

    [xxiv] Norton, S. A., & Ruze, P. (1994). Kava dermopathy. Journal of the American Academy of Dermatology, 31(1), 89-97.

    [xxv] Abbott, P. (2016). Kava: A review of the safety of traditional and recreational beverage consumption (Technical Report). Rome: Food and Agriculture Organization of the United Nations and World Health Organization. (p.26)

    [xxvi] Rasmussen, P. (2005). Submission on proposed reclassification of kava as a prescription medicine - Medicines Classification Committee. (June). Auckland: New Zealand Association of Medical Herbalists.

    [xxvii] Bonomo, Y., Norman, A., Biondo, S., Bruno, R., Daglish, M., Dawe, S., . . . Castle, D. (2019). The Australian drug harms ranking study. Journal of Psychopharmacology, 33(7), 759-768. (p.764).

    [xxviii]

    [xxix] WHO. (2023). Regional standard for Kava products for use as a beverage when mixed with water, CXS 336R-2020, Codex Alimentarius International Food Standards. Food and Agriculture Organization of the United Nations and World Health Organization, Rome. Retrieved from https://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCXS%2B336R-2020%252FCXS_336Re.pdf

    [xxx] Vui-Talitu, S. (2017). Kava drinkers urged not to "wash-down" with alcohol. Radio New Zealand: Dateline Pacific (online), Dec. 11. Retrieved from http://www.radionz.co.nz/international/pacific-news/345903/kava-drinkers-urged-not-to-wash-down-with-alcohol

    [xxxi]

    • Anke, J., & Ramzan, I. (2004). Pharmacokinetic and pharmacodynamic drug interactions with Kava (Piper methysticum Forst. f.). Journal of Ethnopharmacology, 93(2-3), 153-160. (p.157-8).

    • Singh, N. N., Singh, S. D., & Singh, Y. N. (2004). Kava: Clinical studies and therapeutic implications. In Y. N. Singh (Ed.), Kava: From Ethnology to Pharmacology (Medicinal and Aromatic Plants - Industrial Profiles Volume 37) (pp. 140-164). Boca Raton: CRC Press. (p.156).​

    [xxxii] Food Standards Australia New Zealand. (2004). Kava: A human health risk assessment. Technical Report Series No.30. April. Canberra, Australia & Wellington, New Zealand: Food Standards Australia New Zealand. (p.4)

    [xxxiii]

    • Bian, T., Corral, P., Wang, Y., Botello, J., Kingston, R., Daniels, T., . . . Xing, C. (2020). Kava as a clinical nutrient: Promises and challenges. Nutrients, 12(10), 3044. (p. 4).

    • Braun, L., & Cohen, M. (2010). Herbs and natural supplements: An evidence-based guide (3ed.). Chatswood, N.S.W.: Elsevier Australia. (p.636).

    • Fu, P. P., Xia, Q., Guo, L., Yu, H., & Chan, P.-C. (2008). Toxicity of kava kava. Journal of Environmental Science and Health: Environmental Carcinogenesis & Ecotoxicology Reviews, 26(1), 89-112. (p.96)

    [xxxiv]

    [xxxv]

    • McCurdy, C. R., Sharma, A., Smith, K. E., Veltri, C. A., Weiss, S. T., White, C. M., & Grundmann, O. (2024). An update on the clinical pharmacology of kratom: uses, abuse potential, and future considerations. Expert Review of Clinical Pharmacology, 17(2), 131-142.

    • Kounang, N., & LaMotte, S. (2017). Kratom has 'deadly risks,' FDA warns. CNN (online), Nov. 14. Retrieved from http://edition.cnn.com/2017/11/14/health/kratom-fda-warning/index.html

    • Coletti, A. (2024). Why kava laws choose tradition over commercialization. Gastro Obscura (online), Feb. 8. Retrieved from https://www.atlasobscura.com/articles/kava-laws

    [xxxvi] FDA. (2024). FDA and Kratom. US Drug and Food Administration (updated Feb. 22). Retrieved from https://www.fda.gov/news-events/public-health-focus/fda-and-kratom

    [xxxvii]

    • Abolins, T. M., & Cowgill, M. J. (2024). Amended complaint for Wrongful Death in the Superior Court of the State of Washington in and for Cowlitz County. No. 23 2 01183 08. July 12.

    • Chhabria, V. (2023). Romulo Torres v. Botanic Tonics, LLC.  United States District Court, 23-cv-01460-VC. Dec. 21.

    • Carney, S. (2024). Exotic plants, deadly consequences: The Feel Free story. (documentary): Pokey Bear LLC. Link: https://www.youtube.com/watch?v=SOs1U5IOMWI.

    [xxxviii] Sarris, J., Stough, C., Teschke, R., Wahid, Z. T., Bousman, C. A., Murray, G., . . . Schweitzer, I. (2013). Kava for the treatment of Generalized Anxiety Disorder RCT: Analysis of adverse reactions, liver function, addiction, and sexual effects. Phytotherapy Research, 27(11), 1723-1728.

    [xxxix] Frater, A. S. (1976). Medical aspects of yaqona. Fijian Medical Journal, 4(12), 526-530. (p. 527)

    [xl] Lebot, V., & Cabalion, P. (1988). Kavas of Vanuatu: Cultivars of Piper methysticum Frost (Vol. Technical Paper No.195). Noumea: South Pacific Commission. (p. 23-29)

    [xli] Singh, Y. N. (2004). Pharmacology and toxicology of kava and kavalactones. In Y. N. Singh (Ed.), Kava: From Ethnology to Pharmacology (Medicinal and Aromatic Plants - Industrial Profiles Volume 37) (pp. 104-139). Boca Raton: CRC Press. (p.133)

    [xlii] Braun, L., & Cohen, M. (2010). Herbs and natural supplements: An evidence-based guide (3ed.). Chatswood, N.S.W.: Elsevier Australia. (p.89, 101).

    [xliii] Fugh-Berman, A., & Ernst, E. (2001). Herb-drug interactions: Review and assessment of report reliability. British Journal of Clinical Pharmacology, 52(5), 587–595.

    [xliv] Hu, Z., Yang, X., Ho, P. C. L., Chan, S. Y., Heng, P. W. S., Chan, E., . . . S., Z. (2005). Herb-drug interactions: A literature review. Drugs, 65(9), 1239-1282. (p.1241)

    [xlv] See p.4 for literature review on the topic of kava and addiction: Aporosa, S. A. (2019). De-mythologizing and re-branding of kava as the new ‘world drug’ of choice. Journal of Drug Science, Policy and Law, 5, 1-13.

    [xlvi]

    • Aporosa, S. (2014). Yaqona (kava) and education in Fiji: Investigating ‘cultural complexities’ from a post-development perspective. Albany: Massey University, Directorate Pasifika@Massey. (p. 109-113; Permanent link: https://tinyurl.com/KavaEducation).

    • Aporosa, S. A., Ballard, H., Pandey, R., & McCarthy, M. J. (2022). The impact of traditional kava (Piper methysticum) use on cognition: Implications for driver fitness. Journal of Ethnopharmacology, 291(115080), 1-15.

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