What is the treatment for Kratom (Mitragyna speciosa) withdrawal?

Treatment of Kratom Withdrawal

The recommended treatment for Kratom withdrawal is a gradual taper using α2-adrenergic agonists such as clonidine or lofexidine for autonomic symptoms, combined with supportive medications for specific symptoms. 1

Understanding Kratom and Its Withdrawal

Kratom (Mitragyna speciosa) is a plant-based substance with opioid-like and stimulant-like properties. The FDA warns against its use, and it should be discontinued according to the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement 1. Kratom withdrawal syndrome typically occurs in individuals taking more than 5-15g per day and presents with symptoms similar to opioid withdrawal.

Withdrawal symptoms include:

• Anxiety and restlessness
• Tremor and sweating
• Gastrointestinal upset
• Irritability and fatigue
• Cravings
• Muscle aches and pain

Treatment Protocol for Kratom Withdrawal

First-Line Medications:

1. α2-Adrenergic Agonists

   • Clonidine: 0.1-0.2 mg every 4-6 hours as needed for autonomic symptoms
   • Lofexidine: Alternative to clonidine with less hypotension risk
   • Monitor blood pressure due to potential hypotension 1, 2

2. Symptom-Specific Supportive Medications:

   • For nausea/vomiting: Antiemetics like promethazine 2
   • For diarrhea: Loperamide 2
   • For muscle aches: NSAIDs or acetaminophen 1
   • For anxiety: Short-term benzodiazepines (use with caution due to respiratory depression risk) 1, 2

Tapering Approach:

For patients with significant dependence, implement a gradual taper:

• Reduce by approximately 10% of the original dose per week 1, 2
• Monitor withdrawal symptoms at each dose reduction
• Extend the taper period if withdrawal symptoms become severe

Special Considerations

For Severe Cases:

• Consider inpatient management for patients with:
  • Significant psychiatric or medical comorbidities
  • Unstable cardiac disease
  • History of severe withdrawal symptoms 1

For Patients with Opioid Use History:

• Consider buprenorphine or methadone for those with concurrent opioid use disorder
• Initial methadone dose of 30-40mg daily has been effective in preventing withdrawal 2

Monitoring and Follow-up

• Regularly assess withdrawal symptoms using the Clinical Opiate Withdrawal Scale (COWS) 2
• Monitor for:
  • Vital signs, especially blood pressure when using α2-agonists
  • Hydration status
  • Psychiatric symptoms including depression and anxiety

Evidence from Case Reports

Case reports have demonstrated successful management of kratom withdrawal using:

• Dihydrocodeine and lofexidine combination therapy 3
• Clonidine for symptom-triggered therapy 4
• Hydroxyzine for anxiety and sleep disturbances 4

Pitfalls and Caveats

• Underrecognition: Many clinicians are unfamiliar with kratom and may not screen for its use
• Polydrug use: Many kratom users have concurrent substance use that complicates withdrawal management 5
• Pregnancy considerations: Limited data exists on kratom use during pregnancy; approach with caution 6
• Regulatory uncertainty: Kratom's legal status varies by state, complicating patient disclosure 6
• Risk of relapse: Without adequate follow-up and support, relapse rates may be high 7

For optimal outcomes, combine pharmacological management with psychological support and address underlying reasons for kratom use, such as chronic pain, psychiatric symptoms, or prior substance use disorders.