Kamini: an underappreciated cause of opioid dependence

To the Editor: Kamini Vidrawan Ras (Kamini) is an opiate‐containing Ayurvedic preparation with multiple purported functions.1 Kamini comes in the form of handmade tablets or balls, with varying quantities of opium within the tablets ranging from 2 mg to 20 mg.2 Chemical analysis of Kamini tablets revealed a variety of opioid alkaloids and heavy metals such as lead, mercury and arsenic.2 There are reports of patients suffering significant harms from heavy metal poisoning after ingestion of Ayurvedic medicines.3 Evident risks of the use of Kamini include the development of de novo opioid use disorder, use of the preparation as an additional opioid source by current opioid users, and contribution to potential harms including overdose, particularly when combined with other opioids or drugs.

In Australia, Kamini poses a public health concern as an unregulated opiate‐containing medication available in certain Indian grocery stores.4 Australia is trying to curb the harms associated with opioid medications through real‐time prescription monitoring and various other interventions. As opioid medications are being increasingly scrutinised and rationalised, importation of Kamini into Western countries could increase.

In 2016, the Therapeutic Goods Administration prohibited the importation of Kamini, but patients are still presenting with opioid use disorder‐associated with this Ayurvedic preparation.1,2,4 The limited evidence regarding treatment and management of opioid dependence related to Kamini shows that the majority of patients can be stabilised with opioid substitution therapy, remain engaged in treatment, and cease Kamini use.1,4

Most patients (22/24) in the two largest case series on Kamini use were of Indian background and a large proportion were of Punjabi origin.1,4 Some sociological studies about Punjabi men and the cultural norms within this community state that it is appropriate to use substances to deal with stress and to increase productivity.5 Traditional views on the role of medications can be precipitating and perpetuating factors for ongoing substance use and could lead to poorer health outcomes. Treatment for patients with Kamini dependence should include culturally appropriate and specific education.