Would a client using Kratom (a synthetic opiate) benefit from Medication-Assisted Treatment (MAT)?

Kratom Users Should Be Offered Medication-Assisted Treatment (MAT)

Clients using kratom should be offered MAT, specifically buprenorphine, as kratom acts as an opioid receptor agonist with documented potential for dependence and withdrawal that responds to standard opioid use disorder treatment. 1

Understanding Kratom as an Opioid Substance

First, it's critical to clarify that kratom is not a synthetic opiate—it is a plant-derived substance containing alkaloids (mitragynine and 7-hydroxymitragynine) that act on mu, delta, and kappa opioid receptors. 2 These compounds function as atypical opioids with pharmacologic effects similar to traditional opioids, though with additional activity on adrenergic, serotonergic, and dopaminergic pathways. 2

• Kratom's active alkaloids produce opioid-like effects including analgesia and euphoria, with animal studies suggesting potency comparable to or exceeding morphine. 3
• An estimated 2.1 million US residents used kratom in 2020, with up to 20% reporting symptoms consistent with kratom use disorder. 1
• Users frequently take kratom for self-medication of pain, opioid withdrawal symptoms, and as an opioid substitute. 1, 2

Evidence for MAT in Kratom Use Disorder

Buprenorphine is the recommended first-line treatment for kratom use disorder and kratom withdrawal. 1 This recommendation is based on:

• Daily, high-dose kratom use results in opioid-like withdrawal symptoms upon cessation that are best treated with buprenorphine. 1
• The American Society of Addiction Medicine identifies MAT as the gold standard for opioid use disorder, combining medications with behavioral therapies. 4
• For patients with opioid use disorder (which includes kratom-related opioid receptor agonist dependence), treatment with buprenorphine/naloxone is essential if the clinician is DEA-waivered, or referral to addiction treatment should be arranged. 5

Clinical Assessment Algorithm

When evaluating a kratom user for MAT:

1. Screen for kratom use disorder using DSM-5 criteria for opioid use disorder, recognizing that kratom produces physical and psychological dependence with classic opioid withdrawal symptoms. 1, 2

2. Assess dosing patterns and adverse effects: Higher kratom doses are associated with significantly greater odds of addiction (OR = 3.56) and withdrawal (OR = 5.88). 6

3. Evaluate for polysubstance use: Kratom toxicity and death cases almost universally involve other psychoactive substances, and polydrug use is prominently reported among kratom users. 1, 6

4. Screen for co-occurring conditions: Many users take kratom for pain, psychiatric symptoms, or to manage withdrawal from other opioids. 2, 6

MAT Implementation for Kratom Users

Offer buprenorphine/naloxone using standard opioid use disorder protocols:

• Physicians can obtain a DEA waiver through SAMHSA-approved training to prescribe buprenorphine in office-based settings. 5
• Clinicians without a waiver should arrange referral to a substance use disorder treatment specialist or SAMHSA-certified opioid treatment program. 5
• Standard buprenorphine induction protocols apply, as kratom produces opioid receptor-mediated dependence. 1

Combine pharmacotherapy with behavioral interventions:

• Evidence-based approaches include cognitive-behavioral therapy (CBT), contingency management, and motivational enhancement therapy. 4
• Combined pharmacotherapy with CBT shows greater efficacy than pharmacotherapy alone. 4

Critical Safety Considerations

Do not dismiss patients from practice due to kratom use disorder—this represents patient abandonment and a missed opportunity for life-saving intervention. 5 Instead:

• Kratom has been associated with serious adverse effects including liver toxicity, seizures, and death, particularly with polysubstance use. 2
• Kratom may potentiate toxicity of co-administered medications through modulation of cytochrome P450, P-glycoprotein, and UGT enzymes. 2
• The FDA has warned against kratom use and recommended discontinuation when possible, particularly in perioperative settings due to opioid agonist properties and withdrawal potential. 5

Harm Reduction Approach

For patients not ready to engage in MAT:

• Offer naloxone for overdose prevention, as recommended for all patients with opioid use disorder. 5
• Provide harm reduction services including safe use education and referral to appropriate programs. 4
• Avoid focusing solely on abstinence; harm reduction approaches have moderate evidence supporting their importance. 4
• Continue to offer MAT at subsequent visits, as identification of substance use disorder represents an ongoing opportunity for intervention. 5