How is Kratom withdrawal managed?

Management of Kratom Withdrawal

Kratom withdrawal should be treated with buprenorphine/naloxone using an approach similar to opioid withdrawal management, as kratom produces opioid-like dependence through its active alkaloids mitragynine and 7-hydroxymitragynine. 1, 2

Understanding Kratom Withdrawal

Kratom (Mitragyna speciosa) acts as an opioid receptor agonist, producing dependence that manifests with classic opioid-like withdrawal symptoms when use is discontinued. 3, 4 The withdrawal syndrome includes:

• Physical symptoms: Restlessness, tremor, sweating, muscle aches, increased lacrimation, rhinorrhea 3
• Psychological symptoms: Anxiety, irritability, cravings, emotional lability 1, 5
• Autonomic symptoms: Tachycardia, hypertension, diaphoresis 3

Up to 20% of US kratom users develop symptoms consistent with kratom use disorder, and daily high-dose use commonly results in withdrawal upon cessation. 2

Primary Treatment Approach: Buprenorphine/Naloxone

Buprenorphine/naloxone is the first-line pharmacological treatment for kratom withdrawal and dependence. 1, 2

Induction Protocol

• Timing: Buprenorphine/naloxone can be safely induced as early as 8 hours after last kratom use 1
• Initial dosing: Follow standard opioid use disorder induction protocols, starting with 2-4 mg sublingual and titrating based on withdrawal symptoms 1
• Maintenance dosing: Typical maintenance doses are similar to those used for opioid use disorder (8-16 mg daily) 1, 2

Special Considerations for Dosing

• Prolonged withdrawal symptoms: Some patients experience continued withdrawal symptoms despite standard buprenorphine/naloxone treatment 1
• Higher dose requirements: Multiple daily doses up to 24 mg per day may be beneficial for prolonged withdrawal symptoms and co-occurring pain 1
• Polysubstance use: Patients with concurrent substance use disorders may require higher doses and more intensive levels of care 1

Alternative Pharmacological Approaches

For patients where buprenorphine/naloxone is not available or appropriate, a short-acting opioid taper combined with symptomatic management can be effective. 3

Opioid Taper Regimen

• Dihydrocodeine: Use a reducing regime over 7-10 days to manage opioid-like withdrawal phenomena 3
• Tapering schedule: Reduce by 10-20% of the initial dose every 24-48 hours based on withdrawal symptom severity 3

Adjunctive Symptomatic Treatment

• Lofexidine or clonidine: Effective for managing autonomic hyperactivity (sweating, tachycardia, hypertension) 3
• Dosing: Lofexidine 0.2-0.4 mg every 6 hours as needed for autonomic symptoms 3

Monitoring and Assessment

Use standardized withdrawal assessment tools to objectively track symptoms and guide treatment adjustments. 5

• Clinical Opiate Withdrawal Scale (COWS): Validated tool for assessing opioid withdrawal severity that can be applied to kratom withdrawal 5
• Frequency: Assess withdrawal symptoms at least twice daily during acute withdrawal phase 5
• Urine drug screening: Facilities treating kratom dependence should have testing available for kratom alkaloid concentrations to monitor use and compliance 1

Duration and Course of Withdrawal

• Acute phase: Kratom withdrawal is relatively short and benign compared to long-acting opioids, typically lasting 5-7 days 3
• Protracted symptoms: Some patients report prolonged withdrawal symptoms lasting weeks despite pharmacological treatment 1, 5
• Long-term maintenance: Similar to opioid use disorder, long-term buprenorphine/naloxone maintenance may be necessary to prevent relapse 5

Non-Pharmacological Interventions

Supportive care and environmental modifications should accompany pharmacological treatment. 5

• Psychosocial support: Implement motivational interviewing and cognitive-behavioral approaches for relapse prevention 5
• Hydration and nutrition: Ensure adequate fluid intake and nutritional support during acute withdrawal 3
• Sleep hygiene: Address insomnia with behavioral interventions before adding sedative medications 5

Common Pitfalls to Avoid

• Underestimating withdrawal severity: Kratom withdrawal can be as severe as traditional opioid withdrawal and requires appropriate pharmacological intervention 2, 5
• Delaying buprenorphine induction: Unlike traditional opioids, buprenorphine can be started earlier (8 hours) without precipitating severe withdrawal 1
• Inadequate dosing: Using insufficient buprenorphine/naloxone doses leads to persistent withdrawal symptoms and treatment failure 1
• Ignoring polysubstance use: Concurrent alcohol, benzodiazepine, or stimulant use complicates treatment and requires comprehensive assessment 1
• Premature discontinuation: Abrupt cessation of buprenorphine/naloxone after stabilization leads to high relapse rates; plan for extended maintenance 5

Special Populations

Patients with co-occurring pain conditions may require higher buprenorphine/naloxone doses and longer treatment duration. 1 The analgesic properties of buprenorphine can address both withdrawal symptoms and underlying pain that may have motivated initial kratom use. 1