High doses are considered to be greater than 310 grams/week.

Do not use if pregnant, nursing, or being treated for depression.

Higher doses and long term use can lead to hypertension, reduced protein levels, blood cell abnormalities, liver damage, muscle weakness, shortness of breath, visual impairment, dizziness and dry and scaly skin.

Alcohol consumption increases the toxicity of the pharmacological constituents.

Can cause drowsiness. If this happens, lower your dosage or discontinue taking kava.

It is not recommended for those who intend on driving or where quick reaction time is required

May worsen Parkinson's disease and should not be used by individuals with Parkinson's disease.

Do not take if you are on any other prescription medication.

Do not allow children to take kava kava.

Some doctors have cautioned against use when driving.

Ask a healthcare professional before use if you have or have had liver problems, frequently use alcoholic beverages, or are taking any medication. Stop use and see a doctor if you develop symptoms that may signal liver problems (e.g., unexplained fatigue, abdominal pain, loss of appetite, fever, vomiting, dark urine, pale stools, yellow eyes or skin).

Increases "off" periods in Parkinson patients taking levodopa and can cause a semicomatose state when given concomitantly with alprazolam.
- Drugs 2001;61(15):2163-75 -- Interactions between herbal medicines and prescribed drugs: a systematic review. -- Izzo AA, Ernst E.

Four lactones in kava have been found to have significant analgesic and anesthetic effects via non-opiate pathways. In vitro kava has been found to block norepinephrine uptake. The most common side effect, usually seen only with long-term, heavy usage of the herb, is a scaly skin rash called "kava dermopathy." It has also been know to potentiate other medications such as barbiturates and Xanax.
- Altern Med Rev 1998 Dec;3(6):458-60 -- Piper methysticum (kava kava).

Animal studies show that kava lactones alter neuronal excitation through direct interactions with voltage-dependent ion channels, giving rise to kava's muscle relaxant, anaesthetic, anxiolytic and anticonvulsive properties. Several isolated cases of psychotic and severe dystonic reactions following kava use suggest that kava also has psychoactive properties, yet there is no conclusive evidence that kava interferes with normal cognitive processes. 

There may be risk-factors for severe motor and psychiatric responses to kava use, although these are not well-understood. Given the increasingly widespread use of kava, further investigation is necessary to gain an understanding of its immediate neuropsychiatric effects and long-term cognitive effects.
- Aust N Z J Psychiatry 2002 Oct;36(5):657-62 -- The neurobehavioural effects of kava. -- Cairney S, Maruff P, Clough AR.

Its biological effects, due to a mixture of compounds called kavalactones, are reported to include sedative, anxiolytic, antistress, analgesic, local anaesthetic, anticonvulsant and neuroprotective properties. Until recently, the adverse effects attributed to kava use were considered mild or negligible, except for the occurrence of a skin lesion. This disorder, called kava dermopathy, occurs only with prolonged use of large amounts of kava and is reversible on reduced intake or cessation. 

In the past few years, about 35 cases of severe liver toxicity associated with kava intake have been reported in Europe and the US.
- CNS Drugs 2002;16(11):731-43 -- Therapeutic potential of kava in the treatment of anxiety disorders. -- Singh YN, Singh NN.

Kava kava may potentiate the effects of antiepileptic medications, increasing their sedative and cognitive effects.
- 2001 Dec;2(6):524-532 -- Herbal Medicines and Epilepsy: The Potential for Benefit and Adverse Effects. -- Spinella M.

Kava when used with alprazolam has resulted in coma.
- Arch Intern Med 1998 Nov 9;158(20):2200-11 -- Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. -- Miller LG.

Incidences of hepatotoxicity and nephrotoxicity may be augmented by acetaminophen when concomitantly used with the potentially hepatotoxic herbs Echinacea and kava, and with herbs containing salicylate (willow, meadowsweet), respectively.
- J Clin Pharm Ther 2002 Dec;27(6):391-401 -- Herbal medication: potential for adverse interactions with analgesic drugs. -- Abebe W.

The concomitant use of opioid analgesics with the sedative herbal supplements, valerian, kava and chamomile, may lead to increased central nervous system (CNS) depression.
- J Clin Pharm Ther 2002 Dec;27(6):391-401 -- Herbal medication: potential for adverse interactions with analgesic drugs. -- Abebe W.

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