What is the drug of choice for managing kratom (Mitragyna speciosa) withdrawal?

Management of Kratom Withdrawal

Buprenorphine is the drug of choice for managing kratom withdrawal, as it effectively alleviates withdrawal symptoms while providing a pathway to medication for addiction treatment (MAT). 1

Understanding Kratom Withdrawal

Kratom (Mitragyna speciosa) contains alkaloids that act as partial agonists at mu- and delta-opioid receptors, producing opioid-like effects and dependence. Chronic use leads to tolerance and withdrawal symptoms upon cessation, similar to opioid withdrawal.

First-Line Treatment Options

Buprenorphine/Buprenorphine-Naloxone

• Primary recommendation: Buprenorphine effectively manages kratom withdrawal symptoms while initiating treatment for the underlying substance use disorder 1, 2
• Dosing considerations:
  • Start with standard buprenorphine induction protocols (typically 2-4mg initially)
  • Titrate based on withdrawal symptom control
  • Maintenance dosages may vary significantly between patients 2
• Administration methods:
  • Traditional observed induction in clinical settings
  • Home induction with telehealth support has shown success in case reports 2

Supportive Medications for Symptom Management

• α2-adrenergic agonists (clonidine, lofexidine):

  • Effective for autonomic symptoms (hypertension, tachycardia, sweating) 1
  • Can be used as adjuncts to buprenorphine or as alternatives when buprenorphine is contraindicated

• Antiemetics:

  • For management of nausea and vomiting associated with withdrawal 1

• Short-acting opioids:

  • For severe abdominal pain during acute withdrawal phase 1
  • Morphine is preferred for opioid-naïve patients, titrated to symptoms

Assessment and Monitoring

• Use standardized withdrawal assessment tools to evaluate symptom severity
• Monitor for:
  • Vital sign abnormalities (hypertension, tachycardia)
  • Gastrointestinal symptoms (nausea, vomiting, diarrhea)
  • Pain and discomfort
  • Sleep disturbances
  • Psychological symptoms (anxiety, agitation)

Special Considerations

• Higher risk of severe withdrawal in heavy users (≥3 glasses of kratom per day) 1
• Polysubstance use is common and may complicate withdrawal management 3
• Potential drug interactions through CYP450, P-glycoprotein, and UGT enzyme modulation 3
• Kratom withdrawal may be complicated by underlying conditions being self-treated (pain, anxiety, depression) 4

Clinical Pearls

• Patients often use kratom to self-manage opioid withdrawal or treat pain, anxiety, and depression 4, 5
• Despite not being classified as an opioid, kratom produces opioid-like withdrawal requiring similar management approaches 6
• Long-term maintenance therapy with buprenorphine may be necessary to prevent relapse 6
• Kratom remains legal at the federal level in the US but is classified as a "drug of concern" by the DEA 2
• Lack of disclosure by patients and limited testing options present challenges for healthcare providers 5

Treatment Protocol

1. Initial assessment: Evaluate withdrawal severity, kratom use history, and comorbidities
2. Buprenorphine induction: Follow standard protocols for opioid withdrawal
3. Adjunctive therapies: Add α2-agonists, antiemetics as needed for breakthrough symptoms
4. Maintenance therapy: Continue buprenorphine with regular follow-up
5. Address underlying issues: Treat pain, anxiety, or depression that may have led to kratom use

Successful management of kratom withdrawal requires recognition of its opioid-like properties and implementation of evidence-based approaches similar to those used for conventional opioid withdrawal.