Commonly Abused Dietary Supplements: A Clinical Review Integrative Medicine Perspective

Yoon Hang Kim, MD, MPH

Abstract

Most patients assume that if something is sold at a health food store or online as a "supplement," it must be safe. After more than two decades in integrative medicine, I can tell you this assumption gets people into trouble every week. This review covers the supplements I see most commonly abused in clinical practice—stimulants marketed for weight loss, GABAergic substances like phenibut that cause rapid dependence, and kratom with its opioid-like effects. My goal is to give fellow clinicians practical knowledge to identify these patterns and have honest conversations with patients about the real risks involved.

Keywords: dietary supplements, substance abuse, kratom, phenibut, tianeptine, stimulants, GHB

Introduction

The supplement industry in North America has grown into a $40 billion market (Mordor Intelligence, 2025), and with that growth has come a troubling increase in abuse and misuse. Poison control centers are seeing more supplement-related calls every year, affecting everyone from teenagers to seniors (Rao et al., 2017). What strikes me most is how often patients are genuinely surprised to learn that something they bought legally could cause serious harm.

Let me clarify the terminology I'll use throughout this review. "Abuse" means someone is taking a supplement specifically to get high or achieve a psychotropic effect. "Misuse" is broader—it includes taking something for purposes other than its intended use, like using laxatives for weight loss (Smith et al., 2013). Both patterns can lead to serious consequences, and both are more common than many clinicians realize (Biggs et al., 2017).

The Weight Loss and Performance Crowd: Stimulants

I'll start with stimulants because these are the ones that land people in the emergency room with chest pain and palpitations. The patients are often young, healthy, and completely blindsided that their pre-workout supplement could cause a cardiac event.

DMAA (1,3-Dimethylamylamine). This one has been officially illegal since 2013, yet I still see it showing up in supplements people order online. The FDA banned it after reports of cardiac arrests and deaths in young, otherwise healthy adults—including active-duty soldiers (Eliason et al., 2012). Manufacturers used to claim DMAA came from geranium plants, but laboratory testing never confirmed that; it's a synthetic stimulant, plain and simple (Health Canada, 2011; Archer et al., 2015). If a patient mentions they're using a pre-workout that gives them an unusually intense buzz, it's worth checking the ingredient list carefully.

Bitter Orange. When ephedra was banned in 2004, the supplement industry pivoted to bitter orange as an "ephedra-free" alternative. Here's what they didn't advertise: bitter orange contains synephrine and octopamine, which are structurally similar to the catecholamines your body makes naturally (Pawar et al., 2020). Combined with caffeine—which most of these products also contain—you're looking at real cardiovascular risk. I've seen patients present with hypertensive urgency after using these products for just a few weeks. The myocardial infarctions and strokes reported in the literature aren't theoretical; they happen (TRC Healthcare, n.d.).

Concentrated Caffeine. Most people don't think of caffeine as dangerous, and in moderate doses from coffee or tea, it isn't. But the concentrated powders and liquids sold online are a different story entirely. Here's a number that gets patients' attention: one teaspoon of pure caffeine powder contains roughly the same amount of caffeine as 32 cups of coffee (Temple et al., 2017). The lethal dose is somewhere between 10 and 14 grams—not hard to reach accidentally with a powder. The FDA restricted bulk sales in 2018 after deaths, but these products still circulate (FDA, 2018). Whenever a patient tells me they're taking caffeine powder for energy or workouts, I make sure they understand the math.

Ephedra. Even though ephedra has been banned for over 20 years, I still encounter patients who've ordered it online. The historical data is striking: before the ban, ephedra accounted for less than 1% of herbal supplement sales but was responsible for 64% of adverse reaction reports to poison control centers (Lai et al., 2021). That disproportion tells you everything. What makes ephedra particularly dangerous is that serious events—cardiac arrhythmias, strokes, sudden death—can occur even at low doses with short-term use (NCCIH, n.d.). There's no "safe" way to use it recreationally.

Laxatives: The Hidden Pattern

Laxative abuse often flies under the radar because the products are so mundane. Senna, castor oil—these are things your grandmother probably had in her medicine cabinet. But chronic misuse, particularly for weight control, can cause significant electrolyte disturbances. Hypokalemia is the main concern; severe potassium depletion can cause dangerous arrhythmias (TRC Healthcare, n.d.). The good news is that the old fears about permanent "cathartic colon" have been largely disproven by better research (Müller-Lissner et al., 2005). The bad news is that the pattern often indicates an underlying eating disorder that needs attention beyond just stopping the laxatives.

The Recreational Users: GABAergic Substances

These are the supplements that worry me most, because the patients using them often have no idea how quickly physical dependence develops—or how dangerous withdrawal can be.

GHB (Gamma-Hydroxybutyrate). GHB exists naturally in the brain in tiny amounts (Tunnicliff, 1992), which some people use to justify its safety. Don't believe it. The doses used recreationally are orders of magnitude higher than physiological levels, and the margin between a "recreational" dose and a dangerous one is razor-thin. GHB's euphoric effects made it popular at clubs and raves, and it remains tragically associated with drug-facilitated sexual assault. What really concerns me clinically is the withdrawal syndrome: patients can develop severe delirium with hallucinations and seizures that require ICU-level care (TRC Healthcare, n.d.). If someone has been using GHB regularly, they need medical supervision to stop.

Phenibut. This is the one I've been seeing more frequently in the past few years. Phenibut is a GABA analog developed in Russia decades ago for anxiety (Lapin, 2001). It was never approved in the United States, but that hasn't stopped it from being sold openly online as a "supplement" or "nootropic" (Cohen et al., 2022). The FDA has warned companies to stop, but enforcement is limited. Here's what patients need to understand: dependence can develop in days, not weeks. I've had patients tell me they took phenibut for "just a week" and then experienced seizures when they stopped (Graves et al., 2020). This is not a mild substance.

Tianeptine. If you haven't encountered tianeptine yet, you probably will soon. It's sold at gas stations and convenience stores under brand names like "Tianna" and "Zaza," marketed for mood and energy. What it actually is: an atypical antidepressant that activates opioid receptors at higher doses (Edinoff et al., 2023). People are using it to get high, and some are using it to self-treat opioid withdrawal—trading one dependence for another. Making matters worse, recent testing has found some tianeptine products adulterated with synthetic cannabinoids (Counts et al., 2025). Several states have started scheduling it after seeing fatalities and emergency department visits spike (Hershey et al., 2024).

The Opioid Alternative: Kratom

Kratom occupies a complicated space in integrative medicine. Some patients swear by it for chronic pain; others have developed serious dependence. I try to approach it with nuance rather than reflexive dismissal, but the facts need to be laid out clearly.

Kratom comes from a Southeast Asian tree, and its effects depend heavily on dose. Lower doses (1-5 grams) produce stimulation; higher doses (5-15 grams) produce opioid-like analgesia and sedation (TRC Healthcare, n.d.). This isn't metaphorical—the active alkaloids, particularly 7-hydroxymitragynine, directly activate mu-opioid receptors. In fact, 7-hydroxymitragynine is estimated to be about 10 times more potent than morphine (Griffin & Webb, 2018). That's not a comparison I make lightly.

Poison control data show a sharp increase in kratom exposures between 2014 and 2019, with older adults showing particularly severe outcomes (Graves et al., 2021). There have also been quality control disasters: a 2018 Salmonella outbreak sickened 134 people across 35 states (CDC, 2018), and lab testing has found some products intentionally spiked with higher concentrations of the most potent alkaloids (Lydecker et al., 2016).

When patients ask me about kratom, I don't tell them it's evil. I tell them it's an opioid-receptor agonist with no quality control, no standardized dosing, and real dependence potential. If they're using it to manage pain, we need to talk about why—and what safer alternatives might exist.

Commonly Abused Dietary Supplements: A Clinical Review

Practical Takeaways for Clinicians

Ask about supplements explicitly. I've learned to phrase it broadly: "Are you taking anything you buy at a health food store, online, or at a gas station—vitamins, herbs, energy products, anything like that?" The gas station question usually prompts a pause and sometimes a confession about tianeptine or kratom.

Watch for red flags in the history. Someone buying laxatives frequently may have an eating disorder. Someone with unexplained tachycardia may be using stimulant supplements they haven't mentioned. Someone in apparent opioid withdrawal who denies opioid use may be coming off kratom.

Know your drug interactions. Stimulant supplements combined with prescription stimulants or MAOIs can cause hypertensive crisis. GABAergic supplements combined with benzodiazepines or alcohol can cause respiratory depression. Kratom can trigger false-positive drug screens and interact with medications metabolized by cytochrome P450 enzymes. Some stimulants can also cause false-positive amphetamine results (Levisky et al., 2003).

Don't try to detox phenibut or GHB in the outpatient setting. These patients need medical supervision. The withdrawal syndromes can include seizures, and they can be life-threatening.

Closing Thoughts

The "natural equals safe" myth is probably the single most dangerous misconception I encounter in practice. Arsenic is natural. Hemlock is natural. Natural says nothing about safety. What matters is dose, quality, and mechanism—and for many of the supplements covered in this review, all three are problematic.

As integrative medicine practitioners, we're in a unique position. Patients come to us because they're interested in alternatives to conventional medicine. That gives us both the opportunity and the responsibility to help them distinguish between supplements that might genuinely help and those that could cause real harm. We can't do that if we're reflexively dismissive of all supplements—but we also can't do it if we're unwilling to have frank conversations about the ones that pose serious risks.

My hope is that this review gives you some practical tools for those conversations.

About Dr. Kim

Dr. Yoon Hang "John" Kim is a board-certified integrative medicine physician with over 20 years of clinical experience. He completed his integrative medicine fellowship at the University of Arizona under Dr. Andrew Weil and holds certifications in preventive medicine, medical acupuncture, and integrative/holistic medicine. Through his telemedicine practice, Dr. Kim specializes in utilizing LDN or Low Dose Naltrexone for treating autoimmune conditions, chronic pain, integrative oncology, and complex conditions including fibromyalgia, chronic fatigue, MCAS, and mold toxicity. He is the author of three books and more than 20 articles, and has helped establish integrative medicine programs at institutions nationwide.

Professional: www.yoonhangkim.com | Clinical: www.directintegrativecare.com

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