Clinical presentation and treatment in kratom withdrawal: a narrative review of case studies
DOI:
https://doi.org/10.12775/JEHS.2026.88.69728Keywords
Mitragyna, Substance Withdrawal Syndrome, Opioid-Related Disorders, Herbal Medicine, BuprenorphineAbstract
Background. Kratom (Mitragyna speciosa) use is increasing internationally and case reports describe a range of withdrawal syndromes. Clinical guidance for recognizing and managing kratom withdrawal is limited. This narrative review of case reports synthesizes clinical features, management strategies, and outcomes among published patient cases.
Aim. To characterize the clinical features, management strategies, and outcomes reported in published cases of kratom withdrawal. Additionally, identify common patterns in presentation and treatment that may inform preliminary clinical guidance for recognition and management.
Methods. Article databases were searched for case studies related to kratom withdrawal. After screening titles/abstracts and full texts, 12 reports describing 16 individual patients were included. Data was extracted and findings were narratively synthesized across demographics/use characteristics, clinical presentation, pharmacological management, and outcomes.
Results. Reported reasons for kratom use included self-treatment of opioid use disorder, pain, and psychiatric symptoms. Presentation varied from mild autonomic and gastrointestinal symptoms to severe, atypical syndromes. Opioid-like features of mild severity relative to usual opioid use predominated. Pharmacological management most commonly involved buprenorphine/naloxone. Clonidine and benzodiazepines were common adjuncts.
Conclusions. Case-level evidence and existing literature indicates that kratom withdrawal most often presents as an opioid-like syndrome and that buprenorphine, with symptom-driven, conservative induction, was the most consistently effective treatment in reported cases. Interpretation is limited by small numbers, heterogeneous and incomplete reporting (dose/formulation/duration). Prospective, standardized reporting of exposure and outcomes and kratom-specific validation of withdrawal assessment tools are needed to inform evidence-based management.
References
1. Kerrigan S, Basiliere S. Kratom: A systematic review of toxicological issues. WIREs Forensic Science. 2022;4:e1420. https://doi.org/10.1002/wfs2.1420
2. Eastlack SC, Cornett EM, Kaye AD. Kratom—Pharmacology, Clinical Implications, and Outlook: A Comprehensive Review. Pain Ther. 2020;9:55–69. https://doi.org/10.1007/s40122-020-00151-x
3. Todd DA, Kellogg JJ, Wallace ED, Khin M, Flores-Bocanegra L, Tanna RS, et al. Chemical composition and biological effects of kratom (Mitragyna speciosa): In vitro studies with implications for efficacy and drug interactions. Sci Rep. Nature Publishing Group; 2020;10:19158. https://doi.org/10.1038/s41598-020-76119-w
4. Prevete E, Kuypers KPC, Theunissen EL, Esposito G, Ramaekers JG, Pasquini M, et al. Clinical Implications of Kratom (Mitragyna speciosa) Use: a Literature Review. CURRENT ADDICTION REPORTS. 2023;10:317–34. https://doi.org/10.1007/s40429-023-00478-3
5. Garcia-Romeu A, Cox DJ, Smith KE, Dunn KE, Griffiths RR. Kratom (Mitragyna speciosa): User demographics, use patterns, and implications for the opioid epidemic. Drug and Alcohol Dependence. 2020;208:107849. https://doi.org/10.1016/j.drugalcdep.2020.107849
6. Annuar NAK, Azlan UK, Mediani A, Tong X, Han R, Al-Olayan E, et al. An insight review on the neuropharmacological effects, mechanisms of action, pharmacokinetics and toxicity of mitragynine. Biomedicine & Pharmacotherapy. 2024;171:116134. https://doi.org/10.1016/j.biopha.2024.116134
7. Grundmann O, Hendrickson RG, Greenberg MI. Kratom: History, pharmacology, current user trends, adverse health effects and potential benefits. Disease-a-Month. 2023;69:101442. https://doi.org/10.1016/j.disamonth.2022.101442
8. Sokup B, Pippin MM. Kratom. StatPearls [Internet] [Internet]. StatPearls Publishing; 2023 [cited 2026 Feb 23]. https://www.ncbi.nlm.nih.gov/sites/books/NBK585120/. Accessed 23 Feb 2026
9. Ganasan J, Karunakaran T, Marimuthu Y, Rusmadi N, Firouz N, Jenis J, et al. Chemistry and toxicity of 7-hydroxymitragynine (7-OHMG): an updated review on the oxidized derivative of mitragynine. Phytochemistry Reviews. 2024;24:4051–64. https://doi.org/10.1007/s11101-024-10029-x
10. Foss JD, Nayak SU, Tallarida CS, Farkas DJ, Ward SJ, Rawls SM. Mitragynine, bioactive alkaloid of kratom, reduces chemotherapy-induced neuropathic pain in rats through α-adrenoceptor mechanism. Drug and Alcohol Dependence. 2020;209:107946. https://doi.org/10.1016/j.drugalcdep.2020.107946
11. Farkas DJ, Inan S, Heydari LN, Johnson CT, Zhao P, Bradshaw HB, et al. Cannabinoid mechanisms contribute to the therapeutic efficacy of the kratom alkaloid mitragynine against neuropathic, but not inflammatory pain. Life Sciences. 2023;328:121878. https://doi.org/10.1016/j.lfs.2023.121878
12. Hossain R, Sultana A, Nuinoon M, Noonong K, Tangpong J, Hossain KH, et al. A Critical Review of the Neuropharmacological Effects of Kratom: An Insight from the Functional Array of Identified Natural Compounds. Molecules. Multidisciplinary Digital Publishing Institute; 2023;28:7372. https://doi.org/10.3390/molecules28217372
13. Henningfield JE, Grundmann O, Huestis MA, Smith KE. Kratom safety and toxicology in the public health context: research needs to better inform regulation. Front Pharmacol [Internet]. Frontiers; 2024 [cited 2026 Feb 23];15. https://doi.org/10.3389/fphar.2024.1403140
14. Sivakumar D, Pascual J, Kennedy M, Clark KT, Mason JM, Walfield AL, et al. The successful use of buprenorphine to manage kratom withdrawal secondary to self-treatment of opioid withdrawal. Clin Toxicol (Phila). England; 2025;63:1018–9. https://doi.org/10.1080/15563650.2025.2552436
15. Bleifuss W, Boley S, Bardwell J, Goebel C, Wilkinson J. Severe kava withdrawal managed with phenobarbital. Am J Emerg Med. United States; 2025;96:298.e5-298.e7. https://doi.org/10.1016/j.ajem.2025.06.016
16. Kava Shots for Focus [Internet]. Botanic Tonics. [cited 2026 Feb 17]. https://botanictonics.com/products/feel-free-classic-tonic. Accessed 17 Feb 2026
17. Alghalith A, Nguyen H, Tennant R. The Complexities of Kratom: Insights on an Increasingly Frequent Clinical Encounter. Cureus. United States; 2024;16:e59650. https://doi.org/10.7759/cureus.59650
18. Abidali M, St Victor G, Mashaly S, Dahal P. Red kratom and red corvette: A case of mania induced by kratom withdrawal. Int J Psychiatry Med. United States; 2025;60:221–5. https://doi.org/10.1177/00912174241281980
19. Hong S, Zimmerman PE, Rao V, Markwalter DW. Buprenorphine-Naloxone in the Setting of Kratom Withdrawal, Opioid Use Disorder, and Stage IV Lung Adenocarcinoma. J Palliat Med. United States; 2023;26:734–6. https://doi.org/10.1089/jpm.2022.0491
20. Giancola NB, Caplan JP, McKnight CA. “A Kratom Konundrum”: Management of Kratom Withdrawal With Gabapentin in a Patient With a Left Ventricular Assist Device. J Acad Consult Liaison Psychiatry. Netherlands; 2021;62:368–9. https://doi.org/10.1016/j.psym.2020.10.004
21. Lei J, Butz A, Valentino N. Management of kratom dependence with buprenorphine/naloxone in a veteran population. Subst Abuse. Routledge; 2021;42:497–502. https://doi.org/10.1080/08897077.2021.1878086
22. Settle AG, Yang C. A Case of Severe Kratom Addiction Contributing to a Suicide Attempt. Cureus. United States; 2022;14:e29698. https://doi.org/10.7759/cureus.29698
23. Weiss ST, Douglas HE. Treatment of Kratom Withdrawal and Dependence With Buprenorphine/Naloxone: A Case Series and Systematic Literature Review. J Addict Med. Netherlands; 2021;15:167–72. https://doi.org/10.1097/ADM.0000000000000721
24. Jarka C, Gregoire K. Precipitated withdrawal with kratom use following naltrexone administration. Mental Health Clinician. American Association of Psychiatric Pharmacists; 2023;13:155–8. https://doi.org/10.9740/mhc.2023.06.155
25. Teixeira F, Ajewole O, Picior M, Roberts E. Treatment of obsessive compulsive disorder and Kratom dependence with buprenorphine and supportive care. BMJ Case Rep. England; 2025;18:e265834. https://doi.org/10.1136/bcr-2025-265834
26. Goodwin BJ, Chaudhri M, Jain A, Alahdadi T, Vohra A, Patel S, et al. Kratom Withdrawal: A Case Report and Review of Epidemiology, Incidence, and Prevalence. Prim Care Companion CNS Disord. United States; 2025;27:25cr04043. https://doi.org/10.4088/PCC.25cr04043
27. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs. Taylor & Francis; 2003;35:253–9. https://doi.org/10.1080/02791072.2003.10400007
28. Pergolizzi Jr JV, Raffa RB, Rosenblatt MH. Opioid withdrawal symptoms, a consequence of chronic opioid use and opioid use disorder: Current understanding and approaches to management. Journal of Clinical Pharmacy and Therapeutics. 2020;45:892–903. https://doi.org/10.1111/jcpt.13114
29. Jasim RK, Singh D, Gam L-H. Development and validation of ELISA for screening of Kratom (Mitragyna speciosa) habitual users using urinary AZ122 biomarker. Biotechnology and Applied Biochemistry. 2023;70:707–15. https://doi.org/10.1002/bab.2392
30. Mustafa RR, Sukor R, Mohd Nor SM, Saari N, Mohsin AZ. Development of Methyl Ester Antibody-Based Competitive Indirect ELISA for Quantitative Detection of Mitragynine in Human Urine. ACS Omega. American Chemical Society; 2023;8:47412–26. https://doi.org/10.1021/acsomega.3c02734
31. Le D, Goggin MM, Janis GC. Analysis of Mitragynine and Metabolites in Human Urine for Detecting the Use of the Psychoactive Plant Kratom. J Anal Toxicol. 2012;36:616–25. https://doi.org/10.1093/jat/bks073
32. Gowing L, Ali R, White JM, Mbewe D. Buprenorphine for managing opioid withdrawal. Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2017 [cited 2026 Feb 23]; https://doi.org/10.1002/14651858.CD002025.pub5
33. Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. Clinical pharmacology of buprenorphine: Ceiling effects at high doses. Clinical Pharmacology & Therapeutics. 1994;55:569–80. https://doi.org/10.1038/clpt.1994.71
34. Chapter 3D: Buprenorphine. Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Updated 2021 [Internet] [Internet]. Substance Abuse and Mental Health Services Administration (US); 2018 [cited 2026 Mar 5]. https://www.ncbi.nlm.nih.gov/books/NBK574909/. Accessed 5 Mar 2026
35. Prescribing guidelines. Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence [Internet]. World Health Organization; 2009 [cited 2026 Mar 5]. https://www.ncbi.nlm.nih.gov/books/NBK143167/. Accessed 5 Mar 2026
36. Greenwald MK, Herring AA, Perrone J, Nelson LS, Azar P. A Neuropharmacological Model to Explain Buprenorphine Induction Challenges. Annals of Emergency Medicine. 2022;80:509–24. https://doi.org/10.1016/j.annemergmed.2022.05.032
37. Srivastava AB, Mariani JJ, Levin FR. New directions in the treatment of opioid withdrawal. The Lancet. 2020;395:1938–48. https://doi.org/10.1016/S0140-6736(20)30852-7
38. Kuszmaul AK, Palmer EC, Frederick EK. Lofexidine versus clonidine for mitigation of opioid withdrawal symptoms: A systematic review. Journal of the American Pharmacists Association. 2020;60:145–52. https://doi.org/10.1016/j.japh.2019.10.004
39. Sarris J, LaPorte E, Schweitzer I. Kava: A Comprehensive Review of Efficacy, Safety, and Psychopharmacology. Aust N Z J Psychiatry. SAGE Publications Ltd; 2011;45:27–35. https://doi.org/10.3109/00048674.2010.522554
40. Martin JC, Gainer D. Psychiatric Uses of Gabapentin. Innov Clin Neurosci. 2022;19:55–60.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Wojciech Baran, Patrycja Bartkiewicz, Ewelina Lachowska, Tomasz Jędrasek, Adrian Korman, Wafa Al-Batool
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The periodical offers access to content in the Open Access system under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
Stats
Number of views and downloads: 59
Number of citations: 0
