What is the treatment for kratom withdrawal?

Management of Kratom Withdrawal

Buprenorphine-naloxone is the first-line treatment for kratom withdrawal, administered when the patient is in active withdrawal with a total first-day dose typically of 8-16mg. 1

Assessment and Diagnosis

• Confirm kratom withdrawal using standardized assessment tools like the Clinical Opiate Withdrawal Scale (COWS)
• Common withdrawal symptoms include:
  • Psychological: depressed mood, anxiety, restlessness, irritability, feeling tense
  • Physical: myalgia, body ache, joint pain, lacrimation, running nose, yawning, insomnia, diarrhea, feverish sensation, loss of appetite, tremors, itching, poor concentration, and chills 2

Treatment Algorithm

First-Line Treatment: Buprenorphine-Naloxone

1. Initial Assessment:

   • Administer buprenorphine only when patient is in active withdrawal (COWS score >8) 1
   • Start with 2-4mg sublingually and observe for 1-2 hours 1

2. Day 1 Dosing:

   • Total first-day dose typically 8-16mg 1
   • May require additional doses based on continued withdrawal symptoms

3. Maintenance:

   • Stabilize on appropriate dose (may vary significantly between patients) 3
   • Implement gradual tapering schedule over 8-12 weeks
   • Reduce dose by 10-20% every 1-2 weeks 1

4. Monitoring:

   • Weekly during first month of tapering
   • Every 2 weeks during subsequent months
   • More frequent monitoring if withdrawal symptoms emerge 1

Alternative Treatments (When Buprenorphine is Contraindicated)

• α2-adrenergic agonists: Clonidine or lofexidine for autonomic symptoms 1
• Symptom-specific medications:
  • Antiemetics for nausea
  • Non-benzodiazepine alternatives for sleep disturbance and agitation 1

Special Considerations

• Home induction: Telehealth followed by unobserved buprenorphine-naloxone home induction may be an alternative where treatment accessibility is limited 3
• Polysubstance use: Kratom has inhibitory effects on CYP2D6, CYP3A, and P-glycoprotein, which may lead to drug interactions with co-consumed medications 4
• Contingency management: A contingency management program utilizing nonmonetary reinforcers along with buprenorphine has shown effectiveness for treating kratom use disorder 5

Monitoring and Safety

• Monitor for:
  • Excessive sedation
  • Respiratory depression
  • Altered mental status
  • Development of seizures
  • Severe agitation or psychosis
  • Signs of autonomic instability (tachycardia, hypertension)
  • Suicidal ideation 1

Pitfalls and Caveats

• Administering buprenorphine too early (before active withdrawal) can precipitate severe withdrawal symptoms due to its partial agonist properties 1
• Kratom's legal status varies by jurisdiction despite being classified as a "drug of concern" by the US Drug Enforcement Administration 3
• Patients with comorbid psychiatric disorders require coordinated care with psychiatry 1
• Concurrent tapering of multiple substances should be avoided, with a focus on addressing one substance at a time 1

Kratom withdrawal can be effectively managed with appropriate medication and supportive care, with buprenorphine-naloxone showing the most promise as a treatment option based on current evidence.