Assistant Professor of Psychiatry The University of Miami, Florida
Background & Introduction: Recreational use of products containing derivatives of the kratom plant has increased recently. With its widespread availability, consumers are exposed to what they believe is a safe “herbal supplement” at an accelerating rate.
The mechanism of action of the primary kratom alkaloid, Mitragynine, is partial agonism of mu-opioid receptors (MOR). A metabolite, 7-hydroxymitragynine (7-OH), comprises only 2% of the total alkaloid content in natural kratom leaves; however, it exhibits much stronger agonism and affinity for the MOR than Mitragynine. Increasingly available are semi-synthetic products containing concentrated 7-OH. Consumers are often unaware that 7-OH products induce tolerance and withdrawal if consumed routinely, with high risk for developing opiate use disorder (OUD).
Buprenorphine is a medication for OUD (MOUD) and can be initiated by microinduction via a buprenorphine transdermal patch to bypass the withdrawal period and achieve maintenance buprenorphine dosing quicker than traditional induction. Some case reports have illustrated using buprenorphine in 7-OH OUD. However, none have showed buprenorphine microinduction for 7-OH OUD, nor have any case reports quantified dosing or timeline of patients with chronic use of 7-OH alone.
Herein, we present, to our knowledge, the first published case of a patient seeking detox from 7-OH, treated with low-dose buprenorphine induction.
Case Description: The patient is a male in his 20s with a two year history of daily 7-OH use, Cannabis use disorder, in sustained remission who presented to the Crisis Emergency Department voluntarily at the behest of his family to manage anxiety and kratom abuse. Last use of 7-OH was just prior to arrival, and reported experiencing nausea, vomiting, anxiety and irritability with past withdrawals. He was admitted to a medically managed inpatient detox unit (ASAM level of care 4) with Clinical Opiate Withdrawal Scale (COWS) monitoring and vitals every 4 hours, including COWS-driven PRN Sublingual (SL) buprenorphine 2 mg if COWS > 12.
On intake, the patient reported taking 30 mg - 50 mg of 7-OH product daily for the past 2 years. He started 7-OH after he was hired at a job that required random urine drug screening. Prior to this, he was using marijuana daily and felt like he needed to replace it with something. He first started using cannabis 6 years prior, to make his evenings more enjoyable due to loneliness, and now uses 7-OH in the same way and has not used cannabis since. He states that 7-OH is easily available at gas stations and smoke shops near his home. He has tried three times to quit 7-OH without success due to cravings and withdrawals, and now suffers from anxiety with or without 7-OH use. Additionally, he vapes tobacco products daily but denies use of other substances or alcohol. The patient meets 9 of 11 DSM-V diagnostic criteria, and was diagnosed with Severe (7-OH) OUD. He expressed motivation for recovery and was open to MOUD for which he was naive. Due to the patient’s report of severe withdrawal symptoms in the past, tolerance, and high daily doses of 7-OH, buprenorphine microinduction was indicated, with the plan to uptitrate to target cravings.
Buprenorphine microinduction was initiated on Day 1 of admission, for which the patient consented. He tolerated the induction with minimal withdrawal symptoms during the induction period. He was then titrated to a total daily dose of 12 mg of Buprenorphine and discharged on Day 5 with a 14-day supply of Suboxone (4 mg Buprenorphine - 1 mg Naloxone) TID with follow-up at the facility’s SUD Clinic. The patient successfully attended his intake appointment and reports continued control of cravings with residual symptoms of anxiety. He agreed to begin psychotherapy for management of persistent anxiety.
Conclusion & Discussion: Low-dose buprenorphine induction is a modality more commonly applied in inpatient settings to minimize opiate withdrawal and expedite the induction process. Consuming 30+ mg/day of 7-OH indicates significant opioid receptor occupancy and physiologic dependence. The risk of precipitated withdrawal is moderate-to-high if buprenorphine is started less than 24 hours after last use. Although one case report suggested successful buprenorphine challenge eight hours after last use, the dosing was not clear, and there are no evidence-based guidelines, as kratom’s potency and dosing are highly variable. In our case, the patient was using high doses of potent 7-OH daily for over two years, which theoretically increases the risk of precipitated withdrawals. While the risk may be lower than with high-potency synthetic opioids (HPOS), it is not negligible. Thus, low-dose buprenorphine induction was utilized to minimize the risk and improve treatment retention.
Our case report identifies a successful case of Buprenorphine microinduction for the treatment of Severe (7-OH) OUD. Future studies should consider prospectively evaluating the use of this modality as kratom use continues to accelerate. Further research is necessary to demonstrate to State and Federal Governments the risk that Kratom products pose to Public Health.
References:
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Disclosure(s):
Kavan Mulloy, MD: No financial relationships to disclose
Dhruti Patel, MD: No financial relationships to disclose
Learning Objectives:
Describe the pharmacologic mechanisms and addictive potential of kratom alkaloids, particularly 7-hydroxymitragynine, and their role in developing opioid use disorder.
Explain the rationale and process of low-dose buprenorphine microinduction for managing withdrawal in patients with 7-hydroxymitragynine dependence.
Discuss the clinical implications of emerging semi-synthetic kratom products and the need for further research and public health awareness.
