What is the best treatment for 7-OH withdrawal?

Management of 7-OH Mitragynine (Kratom) Withdrawal

Buprenorphine is recommended as the primary medication for 7-OH mitragynine (kratom) withdrawal, as it effectively alleviates withdrawal symptoms while initiating medication for addiction treatment. 1

Assessment and Monitoring

• Use standardized assessment tools (such as Clinical Opiate Withdrawal Scale) to evaluate withdrawal severity
• Monitor for common withdrawal symptoms:
  • Autonomic symptoms: hypertension, tachycardia, sweating
  • Gastrointestinal symptoms: nausea, vomiting, abdominal pain, diarrhea
  • Psychological symptoms: anxiety, irritability, insomnia, cravings
  • Musculoskeletal symptoms: muscle aches, tremors

First-Line Treatment: Buprenorphine

Administration Protocol:

1. Confirm patient is in active withdrawal (COWS score >8) before administering buprenorphine to avoid precipitated withdrawal
2. Initial dose: 4-8 mg sublingual buprenorphine based on withdrawal severity
3. Reassess after 30-60 minutes
4. Target dose: 16 mg sublingual daily for most patients
5. Prescribe for 3-7 days until follow-up appointment

Buprenorphine is superior to other treatments as it:

• Has higher efficacy than α2-agonists in controlling withdrawal symptoms
• Provides smoother transition to long-term addiction treatment
• Results in better treatment retention 2, 1

Alternative/Adjunctive Treatments

If buprenorphine is contraindicated or unavailable, consider:

α2-Adrenergic Agonists

• Clonidine or lofexidine for autonomic symptoms (hypertension, tachycardia, sweating)
• Dosing: Start with clonidine 0.1-0.2 mg orally every 4-6 hours as needed
• Monitor for hypotension 2, 1

Symptomatic Treatments

• Antiemetics for nausea/vomiting
• Loperamide for diarrhea
• Benzodiazepines for anxiety and muscle cramps (use with caution)
• NSAIDs or acetaminophen for pain 2, 1

Emerging Option: Mirtazapine

• Consider mirtazapine (15-30 mg at bedtime) as a potential "one-stop" treatment that addresses multiple withdrawal symptoms:
  • Antiemetic effects for nausea/vomiting
  • Anti-pruritic effects for itching
  • Anxiolytic effects
  • Sleep-promoting effects for insomnia
  • May reduce cravings 3

Special Considerations

High-Risk Patients

• Those consuming ≥3 glasses of kratom per day have higher risk of severe dependence and withdrawal 1
• Polysubstance users require careful assessment for concurrent withdrawal syndromes

Benzodiazepine Use

• If benzodiazepines are needed, consider symptom-triggered dosing rather than fixed-schedule dosing
• Symptom-triggered approach results in lower total medication doses and shorter treatment duration 4
• For patients with liver disease, short-acting benzodiazepines (oxazepam, lorazepam) may be preferred 2

Treatment Setting

• Mild to moderate withdrawal can often be managed in outpatient settings
• Consider inpatient treatment for:
  • Severe withdrawal symptoms
  • Comorbid medical or psychiatric conditions
  • History of withdrawal complications
  • Polysubstance dependence
  • Inadequate social support

Follow-up Care

• Arrange follow-up within 3-7 days
• Consider referral to addiction specialist for ongoing treatment
• Provide overdose prevention education and naloxone kit
• Screen for hepatitis C and HIV
• Discuss long-term treatment options for substance use disorder

By following this evidence-based approach to managing 7-OH mitragynine withdrawal, clinicians can effectively control symptoms while facilitating transition to long-term addiction treatment when appropriate.