What is the recommended treatment for kratom withdrawal?

Treatment of Kratom Withdrawal

Buprenorphine is the recommended first-line treatment for kratom withdrawal due to its effectiveness in managing opioid-like withdrawal symptoms and its ability to initiate medication for addiction treatment (MAT).

Understanding Kratom Withdrawal

Kratom (Mitragyna speciosa) is a botanical product with opioid-like effects at higher doses that can lead to dependence and withdrawal. According to the Mayo Clinic Proceedings, kratom has both opioid and stimulant-like properties, and chronic use can lead to a withdrawal syndrome if taking more than 5 to 15 g per day 1.

Withdrawal symptoms typically include:

• Anxiety
• Restlessness
• Tremor
• Sweating
• Cravings
• Gastrointestinal upset
• Irritability
• Fatigue/low energy 2

Assessment of Withdrawal Severity

Before initiating treatment:

1. Use a standardized scoring system (such as COWS - Clinical Opiate Withdrawal Scale) to assess withdrawal severity
2. Look for objective signs of withdrawal:
   • Tachypnea
   • Tremor
   • Sweating
   • Restlessness
   • Gastrointestinal symptoms 1

Treatment Algorithm

For Moderate to Severe Withdrawal (COWS > 8):

1. First-line: Buprenorphine/naloxone

   • Initial dose: 4-8 mg SL based on withdrawal severity
   • Reassess after 30-60 minutes
   • Target dose: 16 mg SL daily for most patients
   • Prescribe for 3-7 days until follow-up appointment 1, 3

2. Alternative if buprenorphine unavailable:

   • Dihydrocodeine in a reducing regimen with lofexidine has proven effective 4
   • Morphine can be used at bolus doses of 2 mg IV, titrated to effect 5

For Mild Withdrawal (COWS < 8):

1. Non-opioid supportive treatments:

   • α2-adrenergic agonists (clonidine or lofexidine) for symptomatic relief
   • Antiemetics for nausea/vomiting
   • Benzodiazepines for anxiety and muscle cramps
   • Loperamide for diarrhea 1

2. Nonpharmacologic supportive measures:

   • Minimize environmental stimuli
   • Promote adequate rest and sleep
   • Ensure sufficient caloric intake 1

Special Considerations

1. Home vs. Inpatient Management:

   • Telehealth followed by unobserved buprenorphine-naloxone home induction may be appropriate for patients with:
     • No comorbid substance use
     • Stable living situation
     • No history of severe withdrawal 3
   • Consider inpatient management for:
     • High-dose kratom use (>35g/day)
     • Polysubstance use
     • Previous severe withdrawal episodes
     • Medical comorbidities

2. Duration of Treatment:

   • Kratom withdrawal is typically shorter and more benign than traditional opioid withdrawal 4
   • Most patients can be managed with a 3-7 day buprenorphine taper
   • Some may require longer-term maintenance therapy, especially those with chronic use 6, 3

3. Monitoring:

   • Assess for drug interactions, as kratom inhibits CYP2D6, CYP3A, and P-glycoprotein 7
   • Monitor for signs of precipitated withdrawal if initiating buprenorphine

Follow-up Care

1. Provide overdose prevention education and take-home naloxone kit
2. Screen for hepatitis C and HIV
3. Offer reproductive health counseling if applicable
4. Arrange follow-up appointment within 3-7 days
5. Consider referral to addiction treatment services for ongoing care 1

Caution

The Mayo Clinic Proceedings explicitly recommends discontinuing kratom use and does not recommend its use as a supplement due to its opioid-like properties, withdrawal potential, and neurologic effects including seizures 1.