Kratom Withdrawal and Detox
From a medical perspective, increasing reports of emergency room visits and hospitalizations have been tied to kratom withdrawal. Individuals typically present with symptoms including nausea, insomnia, irritability, restlessness, mood swings, diarrhea, rhinorrhea (runny nose), myalgia (muscle cramps) and arthralgia (joint pain).1
Case Studies and Research
A 43-year-old man was admitted for evaluation of a generalized convulsive seizure. The seizure occurred 20 minutes after he took kratom in combination with 100 mg modafinil, an experiment to boost the alertness he achieved from kratom alone. His medical history included being treated with hydromorphone for chronic pain related to spinal disease. As his tolerance escalated, he began subcutaneously injecting 10 mg hydromorphone per day from crushed pills. During periods when hydromorphone was unavailable, he managed opioid withdrawal with kratom purchased online. About three years prior to being admitted to the hospital for the seizure, he abruptly quit taking hydromorphone and prevented opioid withdrawal by drinking tea made from kratom four times a day, spending $15,000 a year on the drug. After discharge from the hospital, he abruptly stopped using kratom and sought the care of an addiction specialist.2
Case Study Treatment Protocol
During addiction treatment, he experienced a period of withdrawal considerably less intense but longer than that of prescription opioids. Physician-observed kratom withdrawal symptoms included rhinorrhea, insomnia, poor concentration and myalgias lasting 10 days from the last dose of kratom. To prevent relapse, an addiction specialist prescribed Suboxone (buprenorphine/naloxone), with the goal of a maintenance dosage of 16 mg per day. Used in addiction treatment, buprenorphine is an opioid medication that acts on heroin and morphine receptor targets without producing the same intense “high” or dangerous side effects.3 Naloxone has proven efficacy in reversing heroin and some other opioid overdoses.4 Rhinorrhea cleared up the first day of Suboxone therapy.2
A 37-year-old white woman with no previous history of substance abuse treatment but with a history of postpartum depression was admitted to inpatient mental health and addiction services for an “addiction to kratom.” After she realized she was taking more kratom than she intended, she attempted to reduce use on her own. This resulted in drug cravings and significant withdrawal symptoms including severe abdominal cramps, sweating, blurred vision, nausea, vomiting, diarrhea and prolonged periods of anxiety and depression. Over the course of the next 18 months, she attempted to detoxify in an outpatient setting with medication support from two outpatient providers using low dose clonidine, without success. By this time, she had lost a considerable amount of weight, stating kratom curbed her appetite. The woman also exhibited cardinal behavioral signs of addiction. She went to great lengths to hide the drug from her husband, such as having it shipped to a FedEx location. She also continued taking kratom despite detrimental physical and personal repercussions.5
Case Study Treatment Protocol
An opioid withdrawal protocol was employed using symptom-triggered clonidine at a dose of 0.1-0.2 mg every two hours based on scoring using the Clinical Opioid Withdrawal Scale (COWS). COWS is a validated scale scoring the severity of typical opioid withdrawal symptoms such as pupil dilation, diaphoresis (sweating), gastrointestinal distress, anxiety, fever, bone and joint pain, increased lacrimation (flow of tears), rhinorrhea (runny nose), tremors and yawning.5
Scheduled hydroxyzine of 50 mg by mouth was administered every six hours along with a daily 0.1 mg per clonidine patch to assist with withdrawal symptoms. By midafternoon on the day of admission, the client developed severe withdrawal symptoms that progressed rapidly, including:
- Bone pain
- Abdominal cramps and pain
- Blurred vision due to rapid pupil dilation5
An increased dosage of a maximum of 2 mg of clonidine was administered. During the next two to three days, hyperautonomic symptoms improved rapidly. Due to the client’s history of postpartum depression only partially treated with sertraline, extended-release venlafaxine was started at a dose of 37.5 mg and titrated daily up to 150 mg for depression. To avoid the use of benzodiazepines, a dose of 25 mg of oral pregabalin was prescribed every eight hours and titrated to 50 mg every eight hours prior to discharge for anxiety. The client was discharged to home with the plan of participating in a partial hospitalization program. She was provided with a prescription of 50 mg oral naltrexone as an opioid antagonist therapy, to commence no sooner than one week after discharge to avoid precipitating any additional withdrawal symptoms.5
Kratom Detox Treatment
Animal studies have yielded conflicting findings regarding which opioid antagonists can reverse the effects of kratom. The first case study suggests Suboxone is helpful in mitigating kratom withdrawal. The second case study implies a combination of high dose alpha-2 agonist therapy and hydroxyzine may provide relief from both the physical and mental symptoms of kratom withdrawal. The additional drugs given to this client were related to co-occurring mental health issues, which may have been exacerbated by kratom abuse. This client was prescribed oral naltrexone due to lack of efficacy studies regulating the use of opioid agonists for kratom addiction treatment. Naltrexone is typically used for heroin, morphine and codeine addictions to block the euphoric and sedative effects of these drugs.1,3,4,5
- Chang-Chien GC, Odonkor CA, Amorapanth P. Is Kratom the New ‘Legal High’ on the Block? The Case of an Emerging Opioid Receptor Agonist with Substance Abuse Potential. Pain Physician. 2017 Jan-Feb;20(1):E195-E198.
- Boyer EW, Babu KM, Adkins JE, McCurdy CR, Halpern JH. Self-treatment of opioid withdrawal using kratom (Mitragynia speciosa korth). Addiction. 2008;103(6):1048-1050. doi:10.1111/j.1360-0443.2008.02209.x.
- Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine Updated May 31, 2016. Accessed February 13, 2017.
- Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment/treatment/naltrexone Updated September 12, 2016. Accessed February 13, 2017.
- Galbis-Reig D. A Case Report of Kratom Addiction and Withdrawal. WMJ. 2016 Feb;115(1):49-52; quiz 53.