How do I transition a patient from Kratom (7-hydroxymitragynine) to Suboxone (buprenorphine/naloxone)?

Transitioning from Kratom (7-OH) to Suboxone

Buprenorphine/naloxone is an effective treatment for kratom dependence and can be safely initiated as early as 8 hours after last kratom use, with induction doses typically ranging from 4-16 mg and maintenance doses of 8-16 mg daily. 1, 2

Timing of Induction

• Begin buprenorphine/naloxone induction 8 hours after the patient's last kratom dose 2
• Unlike traditional opioid induction, precipitated withdrawal appears less problematic with kratom due to the partial agonist properties of its alkaloids (mitragynine and 7-hydroxymitragynine) 3
• Patients may present with opioid-like withdrawal symptoms including myalgias, chills, nausea/vomiting, and anxiety that respond well to buprenorphine 4, 5

Induction Dosing Strategy

Start with 4-8 mg of buprenorphine/naloxone on day one, observing the patient's response 1:

• Most patients (18 of 28 in the largest case series) required induction doses between 8-16 mg 1
• A minority (9 of 28 patients) responded adequately to lower induction doses of 1-6 mg 1
• One patient required 20 mg for adequate symptom control 1
• There is no correlation between the patient's daily kratom dose and the required buprenorphine stabilization dose, so titrate based on withdrawal symptoms rather than attempting dose conversion 1

Maintenance Dosing

Stabilize patients on 8-16 mg daily of buprenorphine/naloxone 1, 6:

• The majority of patients (23 of 28) stabilized on maintenance doses between 8-16 mg daily 1
• For patients with persistent withdrawal symptoms or co-occurring chronic pain, consider divided dosing (every 6-8 hours) or doses up to 24 mg daily 2, 6
• Single daily dosing of 16 mg is appropriate for most patients with opioid use disorder maintenance 6

Special Considerations for Kratom Patients

Monitor for prolonged withdrawal symptoms that may persist despite adequate buprenorphine dosing 2:

• Some kratom-dependent patients report continued withdrawal symptoms even on therapeutic buprenorphine doses, likely due to kratom's effects on adrenergic, serotonergic, and dopaminergic pathways beyond opioid receptors 3
• Higher doses (up to 24 mg daily) or divided dosing may be necessary for these patients 2

Screen for polysubstance use, which is common in kratom users 2:

• Patients with concurrent substance use disorders may require higher buprenorphine doses and more intensive levels of care 2
• Many kratom users have histories of prescription opioid dependence and may be using kratom as self-treatment for opioid withdrawal 4, 5

Monitoring and Follow-up

Utilize urine drug screening for kratom alkaloids (mitragynine) to monitor treatment response 1, 2:

• In the largest case series, 68% of patients had negative mitragynine tests at 4 weeks, increasing to 82% at both 8 and 12 weeks 1
• Facilities treating kratom dependence should have kratom-specific testing available, as standard opioid screens will not detect kratom alkaloids 2

Expect good retention rates with buprenorphine maintenance 1:

• 20 of 28 patients (71%) remained in treatment, with average duration of 11 months and range of 5-22 months 1
• This retention rate is comparable to traditional opioid use disorder treatment 1

Common Pitfalls to Avoid

• Do not attempt to calculate equianalgesic conversions from kratom to buprenorphine—no reliable conversion exists, and stabilization doses do not correlate with kratom intake 1
• Do not use mixed agonist-antagonist opioids, as these should never be combined with opioid agonist therapy and could precipitate withdrawal 7
• Do not assume standard 24-hour waiting periods are necessary—kratom's pharmacology allows for earlier induction at 8 hours 2
• Do not overlook the need for higher or divided doses in patients with persistent symptoms, as kratom affects multiple neurotransmitter systems beyond opioid receptors 2, 3