Background
Kratom – Mitragyna speciosa, active compound of interest is 7-Hydroxymitragynine (7-OH).
Derived from plant from southeast Asia that has been around for thousands of years, used medicinally as a stimulant and pain relief when chewing on the leaf or as a tea.
Frequently sold at gas stations, liquor stores, smoke shops.
Comes in drinks, capsules, powders
People use either kratom (whole product) or synthetic 7-OH.
Marketed as energy booster, mood enhancer, pain reliever, and treatment for opioid withdrawal
Pharmacology
Low doses (1-5 gm) acts like stimulant
Higher doses (>5 gm) acts like opioid.
Acts on multiple receptors: alpha-2 agonist, 5HT2a, mu opioid receptor partial agonist, delta opioid receptor, kappa opioid receptor (pain/stress)
CYP P450 inhibitor (mostly 2D6)
Overdose Management
Benzodiazepines for tachycardia, hypertension
Naloxone for seizures, AMS, sedation
Anti epileptics for seizures
NAc for acute hepatitis
Withdrawal Management
Similar to opioid withdrawal management: adjunctive meds including Clonidine, Hydroxyzine, NSAIDS, Acetaminophen, Ondansetron, Loperamide, Dicyclomine
Gradual taper of kratom – daily check ins necessary
Suboxone up to 24 mg/6mg may be necessary
Patients using <20 g/day : start Suboxone 4 – 8 mg daily
Patients using > 40 g/day: start at Suboxone 12-16 mg daily
References
Arhin M, Mobley J, Hamad H, Remick P. Successful Management of Kratom Use Disorder With Buprenorphine and Naloxone. Cureus. 15(6):e41146. doi:10.7759/cureus.41146
Henningfield JE, Chawarski MC, Garcia-Romeu A, et al. Kratom withdrawal: Discussions and conclusions of a scientific expert forum. Drug Alcohol Depend Rep. 2023;7:100142. doi:10.1016/j.dadr.2023.100142
Stanciu CN, Gnanasegaram SA, Ahmed S, Penders T. Kratom Withdrawal: A Systematic Review with Case Series. Journal of Psychoactive Drugs. 2019;51(1):12-18. doi:10.1080/02791072.2018.1562133
Weiss ST, Douglas HE. Treatment of Kratom Withdrawal and Dependence With Buprenorphine/Naloxone: A Case Series and Systematic Literature Review. J Addict Med. 2021;15(2):167-172. doi:10.1097/ADM.0000000000000721