What is the best approach to manage Kratom (Mitragyna speciosa) withdrawal in a patient with a history of substance use and potential mental health conditions?

Managing Kratom Withdrawal

Treat kratom withdrawal as an opioid withdrawal syndrome using either buprenorphine as first-line therapy or symptom-targeted medications including clonidine, lofexidine, and benzodiazepines for supportive care. 1, 2

Understanding Kratom Dependence

Kratom (Mitragyna speciosa) acts as an opioid receptor agonist through its active compounds mitragynine and 7-hydroxymitragynine, producing opioid-like dependence and withdrawal syndromes. 1, 2 The Society for Perioperative Assessment and Quality Improvement explicitly recommends discontinuation of kratom, noting it has opioid- and stimulant-like properties with withdrawal syndrome occurring when taking more than 5-15 g per day, and chronic use may lead to neurologic effects including seizures. 3

Withdrawal Presentation

Expect opioid-like withdrawal symptoms including anxiety, restlessness, tremor, sweating, cravings, muscle aches, and insomnia. 1, 4 Less commonly, patients may experience disturbing obsessive thoughts during withdrawal. 5 The withdrawal is typically short-acting and relatively benign compared to traditional opioids. 1

First-Line Treatment: Buprenorphine

Buprenorphine is the most effective treatment for kratom use disorder and withdrawal, particularly in patients with daily, high-dose use. 2 This approach treats kratom withdrawal as you would opioid withdrawal:

• Assess withdrawal severity using the Clinical Opiate Withdrawal Scale (COWS) before initiating buprenorphine. 3
• Ensure the patient is in active withdrawal (COWS >8) before administering buprenorphine to avoid precipitated withdrawal. 3
• Start with buprenorphine 4-8 mg sublingual based on withdrawal severity, with target total dose of 16 mg for most patients. 3
• Provide a 3-7 day supply or until follow-up appointment, prescribing buprenorphine/naloxone 8 mg/2 mg sublingual tablets. 3

Alternative Approach: Symptom-Targeted Management

When buprenorphine is not available or appropriate, use symptom-targeted medications in a monitored environment:

Core Medications

• Clonidine or lofexidine for autonomic symptoms (sweating, tremor, restlessness, anxiety). 1, 4 A reducing regime of lofexidine has proven effective in treating objective measures of opioid-like withdrawal. 1
• Dihydrocodeine in a tapering regimen combined with lofexidine has demonstrated effectiveness in supporting detoxification. 1
• Benzodiazepines (short-term only) for agitation, anxiety, and sleep disturbance. 6, 5 Lorazepam specifically has been used successfully for obsessive thoughts during kratom withdrawal. 5
• Hydroxyzine on a scheduled basis for anxiety and as adjunctive support. 4

Important Cautions

Avoid opioid agonist/antagonists (nalbuphine, butorphanol) as these can precipitate severe withdrawal. 3 Document the rationale for each medication dose administered. 6

Psychosocial Support

Provide brief psychosocial intervention (5-30 minutes) incorporating individualized feedback and advice on reducing or stopping kratom use, with follow-up. 6 Use motivational interviewing principles rather than confrontational approaches, as patients may feel defensive, ambivalent, or guilty about their substance use. 3

Resist the "righting reflex" of telling patients what to do; instead, help them generate their own arguments for change by understanding their personal motivations. 3

Screening for Comorbidities

Screen for concurrent mental health disorders including anxiety, depression, bipolar disorder, and PTSD, which are more common in patients with substance use disorders. 3 Monitor closely for depression or psychosis during withdrawal, which require specialized psychiatric consultation if severe. 6

Assess for polysubstance use, particularly concurrent benzodiazepine dependence, which requires its own gradual taper over 8-12 weeks with conversion to long-acting benzodiazepines. 6

Referral and Long-Term Management

Treat kratom dependence as a chronic relapsing illness requiring longitudinal care that can include medication-assisted treatment, referral to specialty addiction treatment, mutual help meetings (Narcotics Anonymous, SMART Recovery), and ongoing counseling. 3

For patients not ready for abstinence, harm reduction is an appropriate initial goal, providing options for change while working toward eventual cessation. 3