When can naltrexone be started after stopping kratom use?

When to Start Naltrexone After Stopping Kratom Use

Patients should wait a minimum of 7 to 10 days after stopping kratom before starting naltrexone to avoid precipitated withdrawal. 1

Understanding Kratom and Naltrexone Interaction

Kratom contains alkaloids that bind to and activate mu-opioid receptors similar to traditional opioids. Naltrexone is an opioid antagonist that blocks these receptors and can precipitate severe withdrawal symptoms if started too soon after stopping kratom use.

Risk of Precipitated Withdrawal

• Multiple case reports document severe precipitated withdrawal when naltrexone is administered to patients using kratom 2, 3
• The withdrawal can be severe enough to require hospitalization 1
• Symptoms include nausea, vomiting, dysphoria, sweating, tearing, rhinorrhea, abdominal cramps, anxiety, irritability, and bone/joint pain 1

Recommended Timeline for Starting Naltrexone

1. Minimum opioid-free interval: 7-10 days after last kratom use 1

   • This recommendation is based on FDA guidelines for short-acting opioids, which kratom functionally resembles

2. Prior to starting naltrexone:

   • Ensure patient shows no signs of opioid withdrawal
   • Consider performing a naloxone challenge test if there's uncertainty about adequate clearance 1

Naloxone Challenge Test Protocol

If there's any question about occult kratom dependence or inadequate clearance:

1. Intravenous method:

   • Inject 0.2 mg naloxone
   • Observe for 30 seconds for withdrawal signs
   • If no withdrawal, inject 0.6 mg naloxone
   • Observe for additional 20 minutes

2. Subcutaneous method:

   • Administer 0.8 mg naloxone
   • Observe for 20 minutes for withdrawal signs 1

3. Interpretation:

   • If withdrawal signs appear, the test is positive - DO NOT start naltrexone
   • Wait 24 hours and repeat the challenge
   • If test is negative, naltrexone may be started if no other contraindications exist 1

Alternative Treatment Options

For patients who cannot wait the full 7-10 days or are experiencing significant kratom withdrawal:

• Buprenorphine/naloxone has been successfully used to manage kratom dependence and withdrawal 4, 5, 6
  • Can be initiated as early as 8 hours after last kratom use 4
  • Maintenance dosing similar to that used for opioid use disorder 4
  • May require multiple daily doses up to 24mg for prolonged withdrawal symptoms 4

Monitoring During Treatment

• Monitor for signs of liver injury, as both kratom and naltrexone can affect liver function 1, 2
• Baseline and periodic liver function tests are recommended 1
• Urine drug screens for kratom alkaloids may be beneficial for monitoring abstinence 4

Important Precautions

• Patients should carry identification indicating they are taking naltrexone 1
• Warn patients about increased sensitivity to opioids after discontinuing naltrexone, which increases overdose risk 1
• Naltrexone is most effective when used as part of a comprehensive treatment program that includes counseling and support 1

Remember that precipitated withdrawal from kratom can be severe and potentially dangerous. Following these guidelines will help minimize risks while effectively transitioning to naltrexone therapy.