Is buprenorphine (Subutex) effective for treating kratom withdrawal?

Buprenorphine for Kratom Withdrawal Management

Buprenorphine is effective for treating kratom withdrawal and can be safely prescribed for kratom use disorder, with similar dosing protocols to those used for traditional opioid withdrawal. 1, 2

Mechanism and Rationale

• Kratom contains compounds (mitragynine and 7-hydroxymitragynine) that act as partial mu-opioid receptor agonists, producing opioid-like effects and withdrawal symptoms when discontinued 2
• Buprenorphine, as a partial opioid agonist, effectively reduces withdrawal symptoms from kratom with less severe side effects than other options 3, 1
• Buprenorphine has demonstrated effectiveness in treating kratom dependence in multiple case studies, with successful long-term maintenance and reduced kratom use 1, 4

Assessment and Administration Protocol

• Confirm active withdrawal symptoms before administering buprenorphine to avoid precipitating withdrawal 5
• Assess withdrawal severity using the Clinical Opiate Withdrawal Scale (COWS) 5
• For kratom withdrawal, buprenorphine can be safely initiated as early as 8 hours after last kratom use 1
• Initial dosing recommendations:
  • For moderate to severe withdrawal (COWS >8): 4-8 mg sublingual buprenorphine 5
  • Reassess after 30-60 minutes and adjust as needed 5
  • For mild withdrawal (COWS <8): Defer buprenorphine and reassess in 1-2 hours 5

Maintenance Dosing

• Maintenance doses for kratom use disorder are similar to those used for opioid use disorder 1, 4
• Typical stabilization doses range from 8-16 mg daily, though some patients may require up to 24 mg daily for adequate symptom control 1, 4
• In a case series of 28 patients with kratom use disorder:
  • Most patients (23/28) stabilized on 8-16 mg of buprenorphine/naloxone 4
  • No correlation was found between daily kratom dose and required stabilization dose of buprenorphine 4
  • 82% of patients had negative tests for mitragynine by 8-12 weeks of treatment 4

Prescribing Considerations

• Providers with X-waivers can prescribe buprenorphine/naloxone for 3-7 days or until follow-up 5, 3
• Non-waivered providers can administer (but not prescribe) buprenorphine for up to 72 hours while arranging referral 5, 3
• Consider buprenorphine/naloxone formulation for outpatient use to reduce diversion potential 1
• Monitor treatment with urine drug screens for kratom alkaloids when available 1

Special Considerations and Cautions

• Some patients may experience prolonged withdrawal symptoms despite buprenorphine treatment 1
• Polysubstance use with kratom dependence may require higher levels of care and potentially higher doses of buprenorphine 1
• Patients with co-occurring pain may benefit from multiple daily doses or higher total daily doses 1
• Both in-clinic and telehealth-guided home induction protocols have been successfully used for kratom use disorder 6

Long-term Management

• Long-term buprenorphine maintenance has shown success in treating kratom use disorder, with patients remaining in treatment for an average of 11 months in one case series 4
• Extended-release buprenorphine formulations have also been used successfully for tapering after achieving kratom abstinence 7
• Discontinuing buprenorphine therapy prematurely can precipitate withdrawal and increase risk of relapse to kratom use 3

Buprenorphine represents the most effective evidence-based approach for managing kratom withdrawal and dependence, leveraging the same pharmacological principles that make it effective for traditional opioid use disorders.