What is the recommended treatment approach for Kratom withdrawal?

Treatment of Kratom Withdrawal

Buprenorphine is the recommended first-line treatment for kratom withdrawal, with a typical starting dose of 8-16mg on the first day, followed by a gradual tapering schedule over 8-12 weeks. 1, 2

Understanding Kratom Withdrawal

Kratom (Mitragyna speciosa) contains mitragynine and 7-hydroxymitragynine, compounds that act as partial μ-opioid receptor agonists. Chronic use leads to dependence with opioid-like withdrawal symptoms upon cessation, including:

• Anxiety and restlessness
• Tremor and sweating
• Muscle aches and pain
• Insomnia
• Nausea and gastrointestinal distress
• Cravings

Pharmacological Management

First-Line Treatment:

• Buprenorphine/naloxone:
  • Initial dose: 8-16mg on day 1 1
  • Stabilization dose: Typically 8-16mg (range 4-20mg) 2
  • Taper schedule: Reduce by 10-20% every 1-2 weeks over 8-12 weeks 1

A study of 28 patients with kratom use disorder showed successful treatment with buprenorphine/naloxone, with 82% testing negative for mitragynine at 12 weeks 2.

Alternative Treatments:

When buprenorphine is contraindicated or unavailable:

• α2-adrenergic agonists:

  • Clonidine or lofexidine for autonomic symptoms 1, 3
  • Effective for managing objective withdrawal signs

• Dihydrocodeine:

  • Can be used in a reducing regimen with lofexidine 3
  • Case reports show effectiveness for kratom withdrawal

• Supportive medications:

  • Antiemetics for nausea
  • Non-sedating antihistamines (cetirizine, loratadine 10mg daily) for pruritus
  • Anticonvulsants (carbamazepine, pregabalin) to reduce withdrawal symptoms 1

Tapering Approach

If using kratom for tapering:

• Reduce dose by approximately 25% weekly 1
• Slow the taper if significant withdrawal symptoms emerge
• Complete tapering over 4-6 weeks

Monitoring Protocol

• Weekly assessment during the first month of tapering
• Every 2 weeks during subsequent months
• More frequent monitoring if withdrawal symptoms worsen 1
• Monitor for:
  • Seizures
  • Severe agitation or psychosis
  • Autonomic instability (tachycardia, hypertension)
  • Suicidal ideation

Non-Pharmacological Interventions

• Sleep hygiene education
• Relaxation techniques (progressive muscle relaxation, mindfulness)
• Cognitive behavioral strategies for anxiety management
• Regular follow-up during the tapering process 1

Special Considerations

• Avoid abrupt discontinuation to prevent severe withdrawal
• Do not substitute with benzodiazepines due to their higher dependence risk
• Consider inpatient management for patients with severe withdrawal or complications
• Patients with comorbid psychiatric disorders require coordinated care with psychiatry 1

Treatment Success Indicators

Long-term buprenorphine treatment has shown promising results, with one study reporting 20 out of 28 patients remaining in treatment for an average of 11 months, and 82% testing negative for mitragynine at 12 weeks 2.

The evidence strongly suggests that kratom withdrawal should be approached similarly to opioid withdrawal, with buprenorphine as the most effective treatment option for managing symptoms and preventing relapse.