What is the recommended approach for transitioning a patient from kratom to Suboxone (buprenorphine)?

Transitioning from Kratom to Suboxone

Buprenorphine/naloxone (Suboxone) is an effective treatment for kratom use disorder, with induction safely initiated as early as 8 hours after last kratom use, using standard opioid use disorder protocols with typical maintenance doses of 8-16 mg daily. 1, 2

Understanding Kratom's Pharmacology

• Kratom's active compounds (mitragynine and 7-hydroxymitragynine) act as partial mu-opioid receptor agonists with kappa- and delta-opioid receptor antagonist effects, producing opioid-like withdrawal symptoms upon cessation 2, 3
• Kratom dependence produces withdrawal symptoms similar to traditional opioid withdrawal, making buprenorphine/naloxone an appropriate pharmacological intervention 1, 4

Induction Protocol

Timing of First Dose

• Initiate buprenorphine/naloxone 8 hours after last kratom use - this is significantly shorter than the typical 12-24 hour wait required for traditional opioids, as kratom's partial agonist properties reduce the risk of precipitated withdrawal 1, 5
• Monitor for objective withdrawal signs before first dose, though the risk of precipitated withdrawal appears lower than with full opioid agonists 1

Starting Dose Selection

• Begin with 2-8 mg on Day 1, with most patients requiring 4-6 mg initially 1, 2, 3
• The induction dose does NOT correlate with the patient's daily kratom consumption (patients using 92 g/day of kratom were successfully inducted on doses ranging from 1-20 mg) 2
• Home induction is feasible and safe for motivated patients who cannot access inpatient care 5

Dose Escalation

• Increase to 8-16 mg by Day 2-3 based on withdrawal symptoms and Clinical Opiate Withdrawal Scale (COWS) scores 6, 1, 3
• The FDA-approved induction protocol uses 8 mg buprenorphine on Day 1 and 16 mg on Day 2, then switches to buprenorphine/naloxone combination from Day 3 onward 6
• Adjust in 2-4 mg increments until withdrawal symptoms are suppressed 6

Maintenance Treatment

Target Maintenance Dose

• Stabilize patients on 8-16 mg daily - this is the same range used for traditional opioid use disorder 6, 2
• 82% of patients maintained on buprenorphine/naloxone had negative urine tests for mitragynine (kratom alkaloid) at 8 and 12 weeks of treatment 2
• The recommended FDA target dose is 16 mg/day, though doses as low as 12 mg may be effective in some patients 6

Special Considerations for Higher Doses

• Consider divided dosing (every 6-8 hours) or doses up to 24 mg daily for patients with:
  • Prolonged withdrawal symptoms despite standard dosing 1
  • Co-occurring chronic pain 1
  • Polysubstance use disorders requiring higher levels of care 1

Duration of Treatment

• Plan for long-term maintenance treatment (average 11 months in case series, with patients remaining in treatment 5-22 months) rather than rapid taper 2
• Brief treatment with rapid tapers is associated with high relapse rates 7
• 71% of patients remained in treatment long-term when maintained on buprenorphine/naloxone 2

Monitoring Requirements

Urine Drug Testing

• Obtain specialized urine testing for kratom alkaloids (mitragynine) - standard opioid panels will NOT detect kratom use 1, 2
• Test at baseline, then at 4,8, and 12 weeks to monitor treatment response 2
• Facilities treating kratom dependence should have kratom-specific testing available as best practice 1

Clinical Monitoring

• Use COWS scores to guide dose adjustments during induction (scores typically peak around 14 in kratom withdrawal) 3
• Monitor for persistent withdrawal symptoms that may require dose adjustment or split dosing 1
• Assess for polysubstance use, which may complicate treatment and require higher doses 1

Critical Clinical Pearls

Withdrawal Timeline

• Kratom withdrawal symptoms can be prolonged and may persist despite adequate buprenorphine/naloxone dosing, requiring patience and dose optimization 1
• Some patients report improved mood and sleep patterns after initiating buprenorphine/naloxone beyond just withdrawal relief 5

Formulation Selection

• Use buprenorphine/naloxone (Suboxone) rather than buprenorphine alone (Subutex) for maintenance treatment due to the abuse-deterrent properties of the naloxone component 7, 6
• Subutex may be used for initial induction if preferred, then switch to Suboxone from Day 3 onward 6

Outpatient vs Inpatient Setting

• Most kratom-dependent patients can be successfully treated in outpatient office-based opioid treatment (OBOT) settings with home induction 5, 2
• Inpatient medically managed withdrawal may be appropriate for patients with severe dependence, polysubstance use, or those preferring short-term detoxification rather than maintenance 3

Tapering Considerations

• Patients can be successfully tapered off buprenorphine/naloxone after stabilization if they prefer not to remain on long-term maintenance, though this approach may carry higher relapse risk 3
• When tapering is planned, reduce by approximately 20-30% per week 6