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Khat use in the U.S.

A public health perspective

By Ashraf A. Luqman, ACP Associate Member

From the August ACP Hospitalist, copyright © 2008 by the American College of Physicians

Hospitalists have learned to account for a plethora of customs, diets, lifestyles and herbal supplements that may influence patients’ health and well-being. But many physicians may be unaware that their patients could be chewing a shrub called khat, which produces an amphetamine-like reaction and has been linked to cardiovascular and reproductive risks, psychiatric problems and oral carcinomas.

Khat’s main active ingredient is cathinone, an illegal drug in the U.S. To achieve feelings of mild euphoria and increased energy, users chew the green leaves of the khat tree (also known as Catha edulis) and store it in the buccal mucosa for hours at a time. The chewing of khat is a common and socially acceptable practice in countries of eastern Africa (particularly Ethiopia and Somalia) and Yemen.

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Health risks

New information continues to emerge about the medical implications of khat use. Some of the studies to date include the following:

• Al-Motarreb and colleagues observed spikes in blood pressure and heart rate two to three hours after khat chewing sessions (Heart. 2002;87(3):279-80).
• Hassan and colleagues found that the increase in systolic blood pressure among khat users responded to beta-1 selective blockers but not alpha-blockers, suggesting that cathinone action may be on the beta receptors (Saudi Medical Journal. 2005; 26(4):537-41).
• Al-Motarreb and colleagues’ prospective case-control study of 100 patients with myocardial infarctions (MIs) reported that heavy khat chewing was associated with a 17- to 34-fold increase in the risk of acute MI (British Journal of Clinical Pharmacology. 2005;59(5):574-81).
• Hassan and colleagues randomly assigned patients to khat consumption or no consumption and found that users had higher clinical scores of depression than nonusers (Saudi Medical Journal. 2002;23(7):850-3).

Other studies have suggested that khat chewing may have potential carcinogenic effects on the oral mucosa, and the drug—which has been linked with constipation—has been associated with slow whole-gut transit time. Some studies have shown that khat chewing during pregnancy is associated with low birth weights, and breast milk from mothers who chew khat has been found to have traces of nor-pseudoephedrine, one of the active ingredients of Catha edulis.

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Communicating the risks

Cultural barriers can make it difficult for doctors to counsel patients about the potential risks of khat use. Khat is an acceptable and somewhat encouraged element of the social structure of the cultures in which it is prevalent. Because khat users do not recognize it as a drug, they are unlikely to report it when asked about drug use, and patients in the U.S. are especially unlikely to volunteer this information given that the drug is illegal.

In areas with a high density of patients from eastern Africa and Yemen, educational campaigns are needed to educate both providers and patients about the impact of khat on health and well-being. Many patients are unaware that khat may negatively impact their health. It is important to ask about khat use in patients from areas where its use is prevalent. However, linking khat use inquiries with questions about drugs and alcohol may alienate patients who do not associate khat use with the religiously and socially unacceptable use of drugs and alcohol. Furthermore, in patients with a history of heavy khat use, a close examination of the oral mucosa may help in early referral and treatment of malignant or premalignant lesions.

As hospitalists, we have the benefit of a captive and usually engaged audience that may have just experienced a life-threatening event necessitating hospitalization. Communicating the negative impact of khat, especially as it pertains to the reason for admission, may increase the effectiveness of the counseling. In patients not interested in quitting, advice about limiting the amount of time spent chewing may help with reducing the cardiovascular risks that appear to be related to the time spent chewing khat. Finally, in the U.S., khat use is illegal and users are usually reluctant to report khat use to their providers. Educating patients about physician-patient confidentiality may improve rapport and trust as well as our ability to effectively counsel them on many issues, including khat use.

Dr. Luqman is a hospitalist at the Mayo Clinic College of Medicine in Rochester, Minn.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated