What medications should be given to a patient experiencing anxiety and body aches after kratom use, with electrocardiogram (EKG) findings of sinus rhythm, normal heart rate, and no ST segment abnormalities?

Management of Kratom Withdrawal Symptoms in the Emergency Department

For a patient experiencing anxiety and body aches after kratom discontinuation, benzodiazepines are the most appropriate first-line treatment, specifically diazepam 5-10 mg orally for symptom relief. 1

Assessment of Kratom Withdrawal

The patient presents with classic symptoms of kratom withdrawal:

• Anxiety and body aches occurring approximately 24 hours after last use 2
• Normal EKG findings without concerning abnormalities (sinus rhythm, normal QT interval, no ST segment abnormalities) 3

Treatment Approach

First-line Medication

• Diazepam 5-10 mg orally for immediate relief of anxiety and physical withdrawal symptoms 1
  • Benzodiazepines are indicated for the management of anxiety disorders and acute withdrawal symptoms 1
  • Dosing should start at 5 mg and can be increased to 10 mg based on symptom severity 1

Supportive Care

• Acetaminophen 650 mg orally every 6 hours as needed for body aches 4
• Consider oral hydration if the patient appears dehydrated 5
• Monitor vital signs, particularly for tachycardia or hypertension that may accompany withdrawal 5

Monitoring During Treatment

• Observe for at least 4-6 hours after administration of benzodiazepines to ensure symptom improvement 5
• Repeat EKG if new cardiac symptoms develop, as kratom has been associated with QT prolongation in some cases 6
• Monitor for excessive sedation or respiratory depression with benzodiazepine administration 5

Discharge Planning

• Provide a short course (3-5 days) of diazepam with tapering doses to manage ongoing withdrawal symptoms 1
• Warn against abrupt discontinuation of benzodiazepines to prevent rebound symptoms 1
• Consider referral to addiction medicine or psychiatry for follow-up, as kratom use may be self-medication for underlying anxiety or depression 2, 7

Important Considerations and Cautions

• Avoid beta-blockers for anxiety symptoms, as they may be contraindicated in the setting of substance withdrawal (similar to cocaine-induced states) 5
• Be aware that kratom withdrawal shares similarities with opioid withdrawal but is typically less severe 2
• Consider that the patient may have been using kratom to self-manage underlying anxiety or depression that will need addressing 2, 7
• Monitor for potential serotonin syndrome if the patient is taking other serotonergic medications 8

Special Cardiac Considerations

• Although the patient's EKG is currently normal, kratom has been associated with cardiac complications including QT prolongation in dose-dependent manner 6
• The absence of ST-segment abnormalities and normal QT interval (420 ms) suggests low immediate cardiac risk 3
• If cardiac symptoms develop, calcium channel blockers would be preferred over beta-blockers for management 5