How do you manage kratom addiction?

Managing Kratom Addiction

The most effective approach for managing kratom addiction is a combination of contingency management (CM) plus community reinforcement approach (CRA), which has been shown to be superior to other psychosocial interventions for stimulant addictions. 1

Understanding Kratom Addiction

Kratom (Mitragyna speciosa) is a plant native to Southeast Asia with both stimulant effects at low doses and opioid-like effects at higher doses. An estimated 2.1 million US residents used kratom in 2020, often as a "legal high" or self-medication for pain and opioid withdrawal. Up to 20% of users develop symptoms consistent with kratom use disorder 2.

Treatment Algorithm for Kratom Addiction

First-Line Treatment Approach:

1. Psychosocial Interventions:
   • Contingency Management (CM) + Community Reinforcement Approach (CRA) - This combination has demonstrated the highest efficacy and acceptability for treating stimulant addictions both in short and long-term outcomes 1
   • CM provides rewards for drug-free urine samples
   • CRA adds psychological and social components including functional analysis, coping-skills training, and social/vocational reinforcements

Pharmacological Management:

• Buprenorphine - For moderate to severe kratom use disorder, especially when withdrawal symptoms are present 3
  • 89.5% of addiction medicine experts report using buprenorphine for kratom addiction management
  • Particularly effective for managing opioid-like withdrawal symptoms from kratom

Withdrawal Management:

• Monitor for classic kratom withdrawal symptoms including:
  • Abdominal pain
  • Restlessness
  • Anxiety
  • Insomnia
  • Muscle aches

Evidence Supporting This Approach

The combination of CM plus CRA has been shown to be superior to treatment as usual (TAU) for abstinence at:

• 12 weeks of treatment (NNT 2.1,95% CI 1.6–6.2)
• End of treatment (NNT 4.1,95% CI 2.3–21.9)
• Longest follow-up after treatment completion (NNT 3.7,95% CI 2.4–14.2) 1

This combined approach also demonstrated better retention in treatment compared to TAU at 12 weeks and at the end of treatment (OR 3.92 and 3.63, respectively, P < 0.001) 1.

Important Clinical Considerations

Addressing Stigma

Stigma remains a significant barrier to treatment for substance use disorders. Healthcare providers should:

• Recognize addiction as a chronic disease rather than a moral failing 1
• Avoid stigmatizing language and attitudes that may discourage patients from seeking help
• Provide education about the nature of addiction to patients and families

Potential Complications

• Polysubstance use - Kratom-associated deaths typically involve other substances 4
• Drug interactions - Kratom can inhibit CYP2D6, CYP3A, and P-glycoprotein, potentially causing dangerous interactions with other medications 4
• Suicide risk - Cases of severe kratom addiction have been associated with suicide attempts 5

Common Pitfalls to Avoid

1. Underestimating withdrawal severity - Kratom withdrawal can be significant and opioid-like
2. Focusing only on detoxification - Long-term management is essential for sustained recovery
3. Ignoring co-occurring mental health conditions - Depression and anxiety often co-exist with kratom addiction
4. Relying solely on pharmacotherapy - The evidence strongly supports combined psychosocial and pharmacological approaches

Long-term Management

For sustained recovery, continue with:

• Ongoing CM+CRA support
• Regular monitoring for relapse
• Treatment of co-occurring mental health conditions
• Consideration of maintenance therapy with buprenorphine for those with moderate to severe kratom use disorder 3

By implementing this evidence-based approach that combines behavioral interventions (CM+CRA) with appropriate pharmacotherapy when needed, clinicians can effectively manage kratom addiction and improve outcomes for patients struggling with this increasingly common substance use disorder.