Should patients using Kratom (Mitragyna speciosa) be placed on buprenorphine (partial opioid agonist) maintenance?

Management of Kratom Use Disorder with Buprenorphine Maintenance

Patients using kratom should be placed on buprenorphine maintenance therapy when they demonstrate signs of kratom dependence and withdrawal, as buprenorphine has been shown to be an effective treatment option for kratom use disorder with favorable outcomes.

Understanding Kratom Use Disorder

Kratom (Mitragyna speciosa) contains alkaloids with partial mu-opioid receptor agonist and antagonist effects at kappa and delta-opioid receptors. This pharmacological profile leads to:

• Opioid-like effects and dependence potential
• Withdrawal symptoms similar to opioid withdrawal
• Risk of addiction with chronic use

Evidence for Buprenorphine Treatment in Kratom Use Disorder

Multiple case series have demonstrated the effectiveness of buprenorphine for treating kratom dependence:

• A 2022 study of 28 patients with kratom use disorder showed that 82% had negative test results for mitragynine at 12 weeks of buprenorphine/naloxone treatment 1
• Patients remained in treatment for an average of 11 months, suggesting good retention rates 1
• A 2021 survey of addiction medicine specialists found that 89.5% of experts who treated kratom use disorder utilized buprenorphine 2
• Case reports consistently show successful management of kratom withdrawal and dependence with buprenorphine/naloxone 3, 4, 5

Buprenorphine Induction Protocol for Kratom Users

1. Assessment for withdrawal: Ensure patient is in mild-to-moderate withdrawal before induction (similar to opioid withdrawal assessment)

2. Initial dosing:

   • Begin with 4-8 mg sublingual buprenorphine/naloxone based on severity of withdrawal 6
   • Can initiate as early as 8 hours after last kratom use 3
   • Reassess after 30-60 minutes 6

3. Stabilization:

   • Most patients stabilize on doses between 8-16 mg daily 1
   • Some patients may require up to 24 mg daily, particularly those with prolonged withdrawal symptoms or co-occurring pain 3
   • No correlation has been found between daily kratom dose and required buprenorphine stabilization dose 1

Maintenance Considerations

• Duration: Long-term maintenance is appropriate, with case series showing successful treatment extending beyond 11 months 1
• Divided dosing: For patients with inadequate pain control, consider dividing the daily buprenorphine dose and administering every 6-8 hours (4-16 mg divided into 8-hour doses) 6, 7
• Monitoring: Regular urine drug screens for kratom alkaloids are recommended to assess treatment adherence 3

Special Considerations

• Polysubstance use: Patients using multiple substances may require higher levels of care and potentially higher doses of buprenorphine/naloxone 3
• Pain management: For patients using kratom for pain management, buprenorphine can address both the dependence and underlying pain 5
• Alternative approach: If buprenorphine maintenance is ineffective despite dose optimization, consider transitioning to methadone maintenance 6

Potential Pitfalls

• Underestimating withdrawal severity from kratom
• Failing to monitor for continued kratom use through appropriate testing
• Not addressing underlying pain that may have driven initial kratom use
• Inadequate dosing of buprenorphine for patients with significant kratom dependence

By following this evidence-based approach, clinicians can effectively manage kratom dependence with buprenorphine maintenance therapy, addressing both the substance use disorder and often the underlying pain that drove initial kratom use.