Should a patient taking buprenorphine/naloxone (Suboxone) abruptly discontinue kratom?

Should Kratom Be Stopped Abruptly When Taking Suboxone?

No—kratom should never be stopped abruptly when a patient is taking Suboxone (buprenorphine/naloxone), because kratom has opioid-agonist properties and abrupt discontinuation can precipitate withdrawal symptoms that require tapering to avoid. 1

Why Abrupt Discontinuation Is Dangerous

• Kratom contains mitragynine and 7-hydroxymitragynine, which are partial mu- and delta-opioid receptor agonists that produce opioid-like effects including analgesia and euphoria. 2

• The Society for Perioperative Assessment and Quality Improvement (SPAQI) explicitly states that kratom has opioid agonist properties and should be tapered due to the potential for withdrawal—not stopped abruptly. 1

• Withdrawal syndrome occurs in patients taking more than 5 to 15 grams per day, and chronic use may lead to neurologic effects including seizures. 1

• The FDA has warned against kratom use due to these serious adverse effects, but when dependence exists, safe discontinuation requires a structured approach. 1

The Correct Approach: Transition to Buprenorphine/Naloxone

Since the patient is already on Suboxone, the appropriate strategy is to use the existing buprenorphine/naloxone to manage kratom withdrawal and dependence rather than stopping kratom cold turkey.

Evidence for Buprenorphine Treatment of Kratom Dependence

• Multiple case series demonstrate that patients with kratom dependence can be effectively and safely treated with buprenorphine/naloxone, with successful control of withdrawal symptoms and long-term maintenance. 3, 4, 5, 2, 6

• Buprenorphine/naloxone induction can be initiated as early as 8 hours after the last kratom use—much shorter than the waiting period required for traditional opioids—because kratom's partial agonist properties reduce the risk of precipitated withdrawal. 3

• Maintenance dosing for kratom dependence is similar to doses used for opioid use disorder, typically in the range of 4–24 mg daily, with most patients stabilizing around 16 mg daily. 3

Practical Management Algorithm

1. Do not discontinue kratom abruptly. 1

2. Assess current kratom use:

   • Daily dose (grams per day)
   • Duration of use
   • Withdrawal symptoms when kratom is missed 3, 4

3. Optimize the existing Suboxone dose:

   • If the patient is experiencing kratom cravings or withdrawal despite being on Suboxone, the buprenorphine dose may need to be increased
   • Some patients with kratom dependence require higher doses (up to 24 mg per day) or multiple daily doses to control prolonged withdrawal symptoms and co-occurring pain 3
   • Standard maintenance is 16 mg daily, but adjust based on symptom control 3

4. Gradually taper kratom while maintaining stable Suboxone:

   • Reduce kratom by approximately 10% of the current dose per week
   • Monitor for withdrawal symptoms (autonomic hyperactivity, anxiety, insomnia, muscle aches, gastrointestinal distress)
   • Slow or pause the taper if withdrawal symptoms emerge 1

5. Use adjunctive medications for withdrawal symptoms:

   • Clonidine 0.1–0.2 mg every 6–8 hours for autonomic symptoms (sweating, tachycardia, hypertension) 7
   • Trazodone, gabapentin, or mirtazapine for insomnia and anxiety 7
   • Loperamide for diarrhea 7
   • Antiemetics (promethazine or ondansetron) for nausea 8

6. Monitor with urine drug screens:

   • Facilities treating kratom dependence with buprenorphine should have testing available for kratom alkaloids to monitor adherence and confirm abstinence 3

Special Considerations

• Polysubstance use: Patients using kratom alongside other substances may require higher levels of care and higher doses of buprenorphine/naloxone. 3

• Prolonged withdrawal: Some patients report continued withdrawal symptoms despite buprenorphine treatment, which may respond to multiple daily doses or higher total daily doses (up to 24 mg). 3

• Behavioral support: Cognitive behavioral therapy reduces dropout risk and improves functional outcomes during any substance taper. 7

• Patient education: Explain that buprenorphine/naloxone is the evidence-based treatment for kratom dependence and that the goal is safe discontinuation of kratom while maintaining therapeutic buprenorphine levels. 3, 4, 5, 2, 6

Common Pitfalls to Avoid

• Never demand abrupt kratom cessation—this ignores the opioid-agonist properties and withdrawal risk. 1

• Do not assume the current Suboxone dose is adequate—kratom-dependent patients may need dose optimization or adjustment. 3

• Avoid abandoning the patient if they struggle with kratom cessation—close observation and clinician availability are critical. 7

• Do not taper Suboxone while the patient is still using kratom—stabilize kratom abstinence first, then consider whether long-term buprenorphine maintenance or eventual taper is appropriate. 9, 7