(41) Kratom Use in ADHD: A Case Highlighting Stimulant and Injectable-Buprenorphine Initiation

Background & Introduction: Kratom (Mitragyna speciosa) is a tropical evergreen tree native to Southeast Asia. Its leaves contain the primary psychoactive alkaloids mitragynine and 7-hydroxymitragynine, which have activity at μ-opioid receptors and likely α2-adrenergic receptors. At lower doses, kratom is often used for stimulant-like effects, whereas at higher doses it is used for analgesic/opioid-like effects.
The literature on treatment of kratom use disorder with buprenorphine, long-acting injectable buprenorphine, remains limited. In addition, there is relatively little published work describing kratom use specifically for attention and energy enhancement. This case highlights kratom use for perceived stimulant benefit in a patient with undiagnosed attention-deficit/hyperactivity disorder (ADHD), subsequent management with long-acting injectable buprenorphine, and the role of initiating evidence-based ADHD treatment with a prescribed stimulant as part of the recovery plan.

Case Description: We present the case of a 40-year-old man with a history of alcohol use disorder in sustained remission for 2 years, generalized anxiety disorder, necrotizing pancreatitis, hypertension, gout, and tobacco use disorder. He established care at our academic hospital’s low-barrier bridge clinic for treatment of kratom use disorder. Patient reported first time kratom use around 2019 in the form of tea to help before a busy workday. In April 2024, the patient started using a kratom-containing drink advertised to boost mood at a local gas station. These grew to replace his daily Monster energy drink. Our patient’s use escalated from 2 bottles daily up to 8-10 bottles daily (16-20 servings) and had become financially burdensome.
At his initial visit, the patient was offered buprenorphine for treatment of kratom use disorder. His standard induction started with 2 mg on day 1, with gradual uptitration to 4 mg (day 2), 8 mg (day 3), 12 mg (day 4), and 16 mg (day 5). He was ultimately titrated to 24-32 mg daily with slight improvement in cravings and expressed interest in transitioning to LAI buprenorphine. After receiving monthly injectable buprenorphine 300 mg, the patient continued to use overlapping films as needed for cravings.
Despite high doses of both injectable and sublingual buprenorphine, the patient continued to have cravings and trouble focusing with work-related tasks and family responsibilities. Kratom beverages were energizing and improved his focus. He ultimately underwent a thorough clinical evaluation and Adult ADHD Self-Report Scale (ASRS), met criteria for a diagnosis of ADHD. Methylphenidate was started at 20 mg daily, with patient reporting improvement in focus and kratom cravings. The methylphenidate dose gradually increased with parallel reduction in kratom intake. He has been continued on monthly LAI buprenorphine at 300 mg and methylphenidate 54 mg extended release daily. At his most recent visit, our patient reported an average kratom intake of about 1-3 drinks per month with a significant reduction from 8-10 bottles per day.

Conclusion & Discussion: Kratom is often discussed in the context of its opioid-like effects and associated dependence. However, this case underscores that patients may also use kratom for perceived stimulant benefits, including improved attention, energy, and functional performance. In our patient, kratom use was initially motivated by difficulty with focus and productivity, which contributed to ongoing use and escalation. Treatment with extended-release buprenorphine supported stabilization of opioid-like withdrawal symptoms and reduced harms related to kratom dependence, suggesting a potential role for long-acting injectable buprenorphine as a maintenance strategy in kratom use disorder when clinically appropriate.
Importantly, despite improvement in opioid-like symptoms, the patient’s persistent inattention and functional impairment prompted reassessment and initiation of evidence-based pharmacotherapy for ADHD after a robust diagnostic evaluation. After starting prescribed stimulant treatment, the patient reported resolution of cravings for kratom and improved day-to-day functioning, highlighting the clinical value of identifying and treating underlying, untreated ADHD as a potential driver of kratom use. This case supports routine screening for kratom use, careful assessment of the reasons for use (including self-treatment of attention symptoms), and integrated management that addresses both substance use and comorbid psychiatric conditions.

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