A California bill that would have imposed regulations on kratom products was quietly shelved Thursday following a clash between advocacy groups focused on the burgeoning industry.

Kratom products are derived from the leaves of a tree that grows in Southeast Asia, where kratom has long been chewed and brewed into teas. As it has gained more popularity around the globe, greenish capsules, powders and extracts have popped up in vape and smoke shops in California.

Scientists are still learning about its complex effects, which can range from stimulant to sedative and stem from chemical compounds called alkaloids. The Food and Drug Administration has warned against using kratom for medical treatment and says it is “not appropriate for use as a dietary supplement.” Among the reported side effects have been seizures, vomiting and heart problems. Kratom has also been involved in a small share of overdose deaths, although most also involved other drugs, analyses have found.

A bill proposed by Assemblymember Matt Haney (D-San Francisco) would have required kratom products to be registered with the state, and to carry mandated labeling and warnings. It also would have prohibited sales to anyone under 21.

In addition, Assembly Bill 2365 would have banned products containing synthesized versions of kratom alkaloids. And it would have prohibited ones in which a specific chemical makes up more than 1% of its alkaloid content.

That chemical is 7-hydroxymitragynine, also known as 7-OH. It is typically found in the dried kratom leaf in very low concentrations, although a more common alkaloid in the plant — mitragynine — breaks down in the human body to create 7-OH as well.

Scientists have raised concerns about its effects: One study in the Journal of Medical Toxicology said 7-OH “is likely to be a major contributing factor to the addictive potential of kratom.” Another article published in Addiction Biology said 7-OH “should be considered a kratom constituent with high abuse potential.”

Kirsten Smith, an assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University, said that because 7-OH appears naturally at very low levels in the kratom leaf, products with much higher levels of 7-OH are “easily identifiable as being manipulated and man-made.”

“It’s no longer the botanical as it’s been used in nature,” Smith said, adding that she didn’t consider synthesized 7-OH products to be kratom at all.

Kratom advocacy groups were split over the California bill. It was backed by the Global Kratom Coalition, whose executive director, Matthew Lowe, argued kratom products should have an alkaloid content similar to the natural plant that has long been used. The coalition was joined by law enforcement groups in backing AB 2365.

In the opposing camp were the American Kratom Assn., which has fought bans on kratom products throughout the country and backed other state regulations, and Holistic Alternative Recovery Trust, which wants 7-OH to be explored as an alternative to opioids for pain relief.

The American Kratom Assn. contended that the regulatory structure needed for the California bill would be so costly that few companies would be able to pay the needed fees. State officials estimated it could cost over $4 million annually to regulate kratom under the bill.

AB 2365 “is promoted by one company who will benefit from the onerous provisions … to the detriment of small and mid-sized kratom manufacturers,” said Mac Haddow, its senior fellow on public policy. He argued Botanic Tonics — a beverage company listed as a supporter of the Global Kratom Coalition — had enough market presence that for them, the registration fees would not be prohibitive.

The Holistic Alternative Recovery Trust argued for a higher limit on 7-OH, saying that California should avoid being so restrictive that the products would lose therapeutic benefits.

Lowe said that the level they were pushing for — 2% of dry weight rather than 1% of the alkaloid content — was vastly higher and would threaten consumer safety. As for concerns about fees, Lowe said the focus should be “how the provisions in the bill inform and protect consumers, rather than the cost on the industry.”

“The Global Kratom Coalition is not looking to support any single vendor. We’re looking to ensure that kratom products are safe,” Lowe said. He added that the bill envisioned a tiered system for fees related to annual sales in California, which would allow lower fees for smaller companies.

AB 2365 stalled in the state Senate’s appropriations committee as lawmakers culled hundreds of bills on the so-called suspense file. The process allows legislative leaders to quietly halt bills that would have significant costs or pose challenging political dynamics, averting the need for many lawmakers to have to weigh in.

Haney said that “Californians are not safer by leaving kratom entirely unregulated in our state,” calling it “a total free-for-all.” The lawmaker said he plans to reach out to the California Department of Public Health to weigh next steps and hopes the FDA will take action, rather than leaving the matter to states.

“I have no interest in benefiting any particular player” in the kratom industry, but chose to err on the side of less potency, to the chagrin of “people who want to sell much stronger versions of kratom,” Haney said. He said if discussions continue, he would like the Department of Public Health to help define what is “synthetic.”

The public health department, which would have handled product registration under the bill, said it has not conducted any scientific assessment of the safety risks of 7-OH in kratom products.

The Global Kratom Coalition spent $15,000 on lobbying related to the bill, according to financial disclosures available as of Thursday. It also contributed $5,500 in political donations to Haney, who introduced AB 2365, and $36,400 to Atty. Gen. Rob Bonta, who supported it, according to state records.

Botanic Tonics, in turn, reported spending $90,000 on lobbying during this legislative session, including $30,000 during a period it was advocating on AB 2365. The company said other expenses were for “advice and counsel on the regulatory and legislative landscape specific to California.”

Holistic Alternative Recovery Trust reported spending $18,000 on lobbying over AB 2365. The American Kratom Assn. said it had not hired a lobbyist until the end of July and would report its spending after that point.

And the bill also drew interest from the kratom company MIT45 Inc., which reported spending $60,000 on lobbying. A company leader did not immediately clarify its position on the bill.

The National Institute on Drug Abuse says that “much is still unknown about chemical compounds related to kratom,” its health impacts and possible therapeutic uses, complicating discussions among regulators in California and across the country.

The Global Kratom Coalition has funded research on kratom at the University of Florida college of pharmacy, where researcher Christopher McCurdy and others have raised concerns about “semi-synthetic, isolated” alkaloids. Lowe said his group provided $500,000 total this year. Advancing research on kratom is part of its mission and “ensures that regulations are led by the evolving science,” he said.

McCurdy said the coalition and “many independent kratom vendors” had helped fund research there, but “no one that donates has any influence on what studies we conduct” and “they all understand that we will publish our findings without their review or consent.”

Smith said she had done consulting for the Global Kratom Coalition in the past, but that her research was funded by NIDA, not the coalition or any other groups connected to the kratom industry.

“We are in such early, early days of research” on kratom, she said.

Remember when Elmo went viral in January by asking folks on the Internet how they were doing and briefly became the unofficial therapist of X?

“The world is burning, Elmo,” an X user who goes by Not the Bee told the usually upbeat “Sesame Street” character. “No amount of tickles can fix this.”

“This world is full of pain, anger, violence, disease, power grabbing despots and poverty,” a user with the handle LiveLifeLikeSomeoneLeftTheGateOpen added in a long post. “The chasm is widening as HG Wells put it, between the ‘haves’ and ‘have nots.’”

And those were just two of the 20,000-plus replies.

Christina Vittas, Elmo’s social media manager, was bowled over by the unexpected outpouring and told The Times she was thankful that the Muppet’s simple question “opened up conversations about the serious mental health crisis in our country.”

Six months later, Elmo’s creators at Sesame Workshop have collaborated with the Harris Poll to conduct a more thorough check-in on the state of Americans’ mental health. They conducted 2,012 online interviews in May on an array of topics with a nationally representative sample of Americans ages 16 and up.

The resulting State of Well-Being Report was released this week. Among the findings:

• 27% of respondents said their mental or emotional health, or that of someone in their family, was negatively impacting their well-being. That was essentially tied with the 28% who were negatively impacted by a problem with physical health. The only issue taking a greater toll on survey participants was economic security and personal finances, a worry reported by 41%.

• Mental and emotional health were a particular burden on teens, with 54% of the 16- and 17-year-olds who took the survey saying the psychological issues had a negative impact on their overall well-being. So did 32% of parents and 41% of people who identified as LGBTQ+.

• When asked about their top concerns for their future well-being, 90% cited their and their family’s mental and emotional health as either somewhat or very important. For the sake of comparison, 89% said the same about physical health, economic security and personal finances, and having “a safe place to call home.”

• 77% of people told pollsters that to improve the well-being of future generations, the U.S. should prioritize investments in emotional and mental health. That was only slightly less than the 80% who called for more investments in economic security and slightly more than the 76% who said the country should prioritize high-quality education and learning opportunities.

• 44% of all respondents said their families were “still experiencing negative effects from the COVID19 pandemic.” That includes 57% of Black Americans and 56% of Latino Americans who took the survey. It also includes 63% of respondents who are members of Gen Z (between the ages of 18 and 27) and 57% of those who are millennials (between the ages of 28 and 43).

• When presented with a list of adjectives to describe the average American adult, only 37% selected “kind,” 35% selected “compassionate” and 33% selected “empathetic.” However, 56% said this hypothetical adult was “anxious” and 44% said they were “difficult.”

• The survey found overwhelming support for the notion that kindness is essential to the well-being of society. Fully 91% of people agreed that “kindness fosters stronger bonds between people,” making them more empathetic and supportive.

• 82% of respondents said their own mental well-being would improve if kindness were more common, and 89% said a kinder society would be better for children.

• 93% of those surveyed said they had committed at least one act of kindness in the past three months. More specifically, 57% said they had helped a friend or family member in need, 57% said they listened to someone else in a nonjudgmental way, 39% gave money to charity, 35% helped a stranger and 22% volunteered their time in support of a cause, among other activities.

• Despite this outpouring of kindness, most people said they didn’t see much of the same in others, with 55% of respondents agreeing that “being kind is not a priority to most people.” In addition, 64% agreed that “most people don’t go out of their way to help others.”

• 73% of Americans said they wished they had learned more about how to manage their emotions when they were children. So did 84% of those who are parents.

• 67% of Americans also wish their parents had been more transparent about their own struggles with mental health. That was particularly true for younger Americans, with 77% of teens, 77% of Gen Zers and 78% of millennials sharing that sentiment.

Sesame Workshop described the report as “a first-of-its-kind index” and said it will continue to check in with Americans “to keep a pulse on the well-being of Americans and their families.”

I have been a cancer doctor for 40 years and have seen our treatments evolve to embrace precision medicine and immunotherapy, which can be less harmful to patients than conventional forms of chemotherapy. And yet conventional cytotoxic chemotherapy — designed to attack and kill rapidly dividing cells — is still a mainstay of cancer treatment for millions of patients globally.

Cytotoxic drugs kill cancer cells, but they also kill normal cells, leading to a host of serious and even life-threatening side effects. Bone marrow suppression, a common side effect of chemotherapy, reduces the number of white cells needed to fight bacterial infections. Chemotherapy can destroy cells lining the bowel and around the mouth, making eating and even drinking nearly impossible.

Generally, these side effects are reversible as the normal white blood cells are replenished, but in the most severe cases, they can be fatal if, for example, bacteria from the gut escape into the bloodstream through a weakened bowel wall and white cell counts are too low to fight the infection. Sepsis in such a case could be catastrophic.

The toxic death rate, where chemotherapy is directly responsible for a patient’s death, can range from 0.5% to 3.1% but has been reported as high as 13%, depending on the intensity of the chemotherapy regimen, age and fitness of the patient and their genetic makeup.

We can reduce this terrible result with greater use of pharmacogenetics, which studies how our genes affect the way we respond to medications in terms of toxicity and effectiveness. It is becoming more possible to devise genetic tests that can indicate whether an individual would be likely to suffer very serious side effects. This would permit healthcare providers to tailor dosages to avoid the worst hazards of chemotherapy drugs and lessen the number of patients dealing with potentially deadly side effects.

One prominent example involves two related and widely used anticancer drugs, 5-fluorouracil, or 5-FU, and capecitabine (which functions like 5-FU), often used to treat colorectal, breast, stomach and pancreatic cancer.

In the United States, about 275,000 patients with cancer receive 5-FU each year. As many as 25% of those patients require hospitalization with severe side effects, and more than 1,300 patients are estimated to die each year from the drug’s toxicity.

The side effects are most severe for patients who have low levels of dihydropyrimidine dehydrogenase, an enzyme that is produced by the liver and that breaks down 5-FU in the body. This enzyme, also known as DPD, is usually caused by inherited changes in a particular gene. Currently, there are internationally accepted dosing guidelines for 5-FU, adjusted according to DPD genetic test results, ranging from avoiding the drug completely (risk of death is high) to conventional dosing.

While the genetic DPD tests are not perfect — they may miss some patients — nevertheless they have been shown to save lives, reduce the number of patients admitted to hospitals and reduce healthcare costs.

In the United Kingdom, the National Health Service now requires that all new patients receiving 5-FU or capecitabine take some form of a pharmacogenetic test, a policy change that was driven by pressure from families who lost a loved one and advocacy from professional medical societies.

In March, the U.S. Food and Drug Administration approved safety labeling changes regarding DPD deficiency for 5-FU, but that alone isn’t sufficient. It did not issue a national policy to require pharmacogenetic or related tests to detect the problem.

The National Health Service sets a sound example that the FDA could follow. Mandating a simple genetic blood test could help cancer patients get the care they need and better protect them from medical tragedies brought on by the treatment itself.

David Kerr is a professor of cancer medicine at the University of Oxford in Great Britain.