What are the recommendations for managing 7 hydroxymitragynine (7-HMG) use and potential withdrawal symptoms?

Management of 7-Hydroxymitragynine (7-HMG) Use and Withdrawal

For patients using 7-hydroxymitragynine (7-HMG), a slow taper of 10% per month or slower is recommended for discontinuation, with buprenorphine/naloxone as an alternative for those unable to tolerate tapering. 1

Understanding 7-Hydroxymitragynine

7-Hydroxymitragynine (7-HMG) is one of the active alkaloids found in kratom (Mitragyna speciosa), with significantly higher potency at μ-opioid receptors than mitragynine:

• 7-HMG is approximately 30 times more potent than mitragynine and 17 times more potent than morphine at μ-opioid receptors 2
• It acts as a partial μ-opioid receptor agonist and competitive antagonist at κ- and δ-opioid receptors 3
• Unlike traditional opioids, it does not strongly activate the β-arrestin-2 respiratory depression pathway 3

Assessment of Dependence and Withdrawal Risk

Before initiating management, assess:

• Duration of use (dependence risk increases after 5 or more days of continuous use) 4
• Daily dosage (higher doses correlate with more severe withdrawal)
• Concurrent use of other substances, particularly benzodiazepines or other opioids
• Previous withdrawal experiences
• Comorbid physical or psychiatric conditions

Withdrawal Symptoms

7-HMG withdrawal may present with symptoms similar to opioid withdrawal:

• Drug craving, anxiety, insomnia
• Abdominal pain, vomiting, diarrhea
• Diaphoresis, mydriasis, tremor
• Tachycardia, piloerection 4

Management Recommendations

Tapering Approach

1. Initiate a slow taper:

   • Reduce by 10% of the original dose per month 1
   • For patients struggling with taper, consider even slower reductions (5% monthly) 1
   • Each new dose should be 90% of the previous dose (not linear reductions) 1

2. Monitoring during taper:

   • Schedule frequent follow-ups (at least monthly) during the tapering process 1
   • Use standardized withdrawal assessment tools like the Withdrawal Assessment Tool version 1 (WAT-1) or the Sophia Observation withdrawal Symptoms-scale (SOS) 4
   • Monitor for withdrawal symptoms, pain control, functional status, and screen for depression, anxiety, and suicidal ideation 1

3. Pause or slow taper if patient experiences significant distress 1

Pharmacological Management

For patients experiencing significant withdrawal symptoms:

1. First-line option: Buprenorphine/naloxone

   • More effective than non-opioid management strategies 4
   • Preferred over methadone for ED management of opioid withdrawal 4
   • Caution: Ensure patient is exhibiting withdrawal symptoms before administering to avoid precipitated withdrawal 4

2. Symptomatic treatment:

   • For agitation/anxiety: Benzodiazepines (only after pain and dyspnea are effectively treated with opioids) 4
   • For nausea: Antiemetic medications as needed 4
   • For pain or respiratory distress: Bolus dose of opioid followed by continuous infusion if needed 4

Special Considerations

• Inpatient management may be preferable for patients at risk of severe withdrawal, with concurrent serious physical or psychiatric disorders, or lacking adequate support 4
• Avoid abrupt discontinuation as it increases risk of withdrawal, relapse, and potential overdose 1
• Be prepared to pause tapering if the patient experiences significant distress or withdrawal symptoms 1

Patient Education and Support

1. Educate patients about:

   • Expected withdrawal symptoms and timeline
   • Importance of adherence to tapering schedule
   • Risk of relapse if using other substances during withdrawal

2. Provide psychosocial support:

   • Consider involving family members in treatment when appropriate 4
   • Encourage engagement with mutual help groups 4
   • Consider referral for more structured psychological interventions such as motivational techniques 4

Monitoring for Complications

• Monitor for development of depression or psychosis during withdrawal, which may require specialist consultation 4
• Assess for signs of opioid use disorder that may require more intensive treatment 1
• For patients struggling with taper despite appropriate management, consider referral to addiction medicine specialists

Conclusion

Management of 7-HMG withdrawal requires a patient-centered approach with careful tapering, appropriate symptom management, and adequate psychosocial support. The goal is to minimize withdrawal symptoms while safely discontinuing use or transitioning to medication-assisted treatment when indicated.