Kratom Withdrawal Treatment
For patients experiencing kratom withdrawal, buprenorphine/naloxone is the most effective treatment, with induction possible as early as 8 hours after last kratom use and maintenance doses similar to those used for opioid use disorder (typically 8-24 mg daily). 1, 2
Understanding Kratom Withdrawal
Kratom (Mitragyna speciosa) produces opioid-like effects through its active compounds mitragynine and 7-hydroxymitragynine, which act as agonists at opioid receptors. 2, 3 Withdrawal from kratom resembles short-acting opioid withdrawal and includes:
- Gastrointestinal symptoms: Nausea, vomiting, diarrhea, abdominal cramping 4, 5
- Neuropsychiatric symptoms: Anxiety, restlessness, irritability, dysphoria, cravings 4, 5, 3
- Physical symptoms: Tremor, sweating, muscle aches, fatigue/low energy, piloerection 4, 5, 3
Critical distinction: Unlike benzodiazepine or alcohol withdrawal, kratom withdrawal is uncomfortable but rarely directly life-threatening as a sole condition. 6
First-Line Treatment: Buprenorphine/Naloxone
Induction Protocol
Buprenorphine/naloxone can be safely initiated as early as 8 hours after last kratom use, which is notably earlier than traditional opioid induction protocols. 1 This is because kratom's primary alkaloids have relatively short half-lives compared to prescription opioids.
Initial dosing approach: 6
- Wait for mild withdrawal symptoms to appear (typically 8-12 hours after last kratom use) 1
- Start with 2-4 mg sublingual buprenorphine/naloxone 6
- Repeat at 2-hour intervals if well tolerated until withdrawal symptoms resolve 6
- Typical first-day requirement: 4-8 mg total 6
- Reassess on day 2 and adjust dose as needed 6
Maintenance Dosing
Maintenance doses for kratom dependence mirror those used for opioid use disorder, typically ranging from 8-16 mg daily. 1, 2 However, some patients with prolonged withdrawal symptoms or co-occurring pain may benefit from higher doses up to 24 mg daily, administered in multiple divided doses (3-4 times daily rather than once daily). 1
Key clinical pearl: Prolonged withdrawal symptoms may persist despite buprenorphine treatment, requiring dose optimization and extended maintenance. 1
Special Considerations for Buprenorphine Use
- No X-waiver required for ED administration: Any DEA-licensed physician may administer (but not prescribe) buprenorphine in the emergency department for up to 72 hours while arranging referral for treatment. 6
- Polysubstance use: Patients with concurrent substance use disorders may require higher doses of buprenorphine/naloxone and higher levels of care. 1
- Monitoring: Facilities treating kratom dependence with buprenorphine should have urine drug screening available for kratom alkaloids to monitor treatment adherence and use patterns. 1
Alternative Treatment: Symptomatic Management
When buprenorphine is unavailable or contraindicated, symptomatic treatment follows principles similar to opioid withdrawal management:
Alpha-2 Adrenergic Agonists
Clonidine or lofexidine effectively reduce withdrawal symptoms by decreasing catecholamine release. 6 One case report demonstrated successful detoxification using lofexidine combined with a reducing regime of dihydrocodeine. 3
Adjunctive Medications
- Antiemetics (promethazine or ondansetron) for nausea and vomiting 6
- Loperamide for diarrhea 6
- Benzodiazepines (short-term only) for severe anxiety and muscle cramps 6
- NSAIDs or acetaminophen for muscle aches and pain 7
Important caveat: Symptomatic treatment alone is less effective than buprenorphine and does not address the underlying dependence, leading to higher relapse rates. 6, 5
Critical Safety Considerations
Avoid Methadone in Outpatient Settings
Do not convert patients to methadone for kratom withdrawal in outpatient settings due to complex pharmacokinetics, nonlinear morphine equivalency, multiple drug interactions, and documented high lethality, especially in those with high-dose kratom use. 6 Methadone administration for kratom withdrawal should only occur in specialized opioid treatment programs.
Polysubstance Use Assessment
Always screen for concurrent substance use, particularly other opioids, benzodiazepines, and stimulants, as these are common in kratom-using populations and significantly impact treatment planning. 1, 4 Check prescription drug monitoring programs to identify all controlled substances the patient is receiving. 7
Withdrawal Timeline
Kratom withdrawal typically begins 12-24 hours after last use (similar to short-acting opioids like heroin) and peaks within 2-3 days. 6, 5 Symptoms generally resolve within 5-7 days with appropriate treatment, though some patients report prolonged symptoms lasting weeks. 1, 5
Long-Term Management Strategy
Buprenorphine maintenance is recommended rather than rapid detoxification to prevent relapse, as kratom use disorder demonstrates similar patterns to opioid use disorder with high relapse rates after detoxification alone. 2, 5
Duration of maintenance: Similar to opioid use disorder treatment, maintenance should continue for at least 6-12 months, with individualized decisions about tapering based on stability, psychosocial support, and absence of cravings. 6, 5
Behavioral interventions: Integrate cognitive-behavioral therapy or other evidence-based psychological therapies alongside medication treatment to address underlying reasons for kratom use (often pain, anxiety, or self-medication for other conditions). 7, 4
When to Refer to Specialty Care
Immediate referral to addiction medicine or psychiatry is indicated for: 7
- Patients with unstable psychiatric comorbidities
- Co-occurring severe substance use disorders requiring higher levels of care
- Previous unsuccessful office-based treatment attempts
- Patients requiring doses above 24 mg daily buprenorphine
- Pregnant patients (kratom use during pregnancy requires specialist consultation)
Common Pitfalls to Avoid
Waiting too long to induce buprenorphine: Unlike traditional opioids, kratom's shorter half-life allows earlier induction (8 hours vs 12-24 hours). 1
Underdosing buprenorphine: Some patients require higher doses (up to 24 mg daily in divided doses) for adequate symptom control. 1
Failing to address polysubstance use: Most kratom users have concurrent substance use that must be identified and managed. 1, 4
Rapid detoxification without maintenance: This approach leads to high relapse rates; maintenance treatment is more effective. 2, 5
Dismissing withdrawal severity: While not life-threatening, kratom withdrawal causes significant distress that drives continued hazardous use if untreated. 6, 4