Joe is a 38 yo man who comes to your clinic to discuss sleep issues. You learn that he discovered something at a gas station a few months back called kratom. His friends told him about the colorful bottles and little packets with capsules that improved their energy level and also calmed them down. Kratom originally gave Joe energy, but now he cannot sleep if he doesn’t take it.
What is kratom?
Kratom is the colloquial name for derivatives of the Mitragyna speciosa tree in the coffee plant family, found naturally in Southeast Asia. At lower doses, the leaf extract functions as a stimulant—increasing or sustaining energy. At higher doses, it acts more like an opioid—as an analgesic and/or sedative (Veltri 2019).
Kratom is composed of over 40 alkaloids. Mitragynine is the metabolically active component in the Mitragyna speciosa leaves. It is a weak partial agonist at the mu-opioid receptor that also binds to the adrenergic and serotonergic receptors. The more potent active metabolite of mitragynine, 7-hydroxymitragynine (“7-OH”), is highly selective for mu opioid receptor with a binding affinity higher than morphine. Other alkaloid derivatives act more specifically at adrenergic and serotonergic receptors (Leon 2021, Chiang 2025). There are also semi-synthetic mitragynine-derived alkaloids like mitragynine pseudoindoxyl that are active at mu, kappa, and delta opioid receptors according to animal studies (Obeng 2021).
Kratom is completely unregulated and can be found as pills, gummies, liquid, and powders. It is marketed to address pain (most commonly), stress, and energy levels. According to recent surveys, almost 10% of US adults have used kratom (Grundmann 2025). People report taking kratom in tablet form to manage opioid withdrawal or opioid use disorder, as a tea to increase energy, as leaf or extract powders to improve sleep, and as kratom liquid to relieve pain. Some say that if taking kratom leaf extract is like chewing coca leaves, then taking 7-OH capsules is like snorting powder cocaine.
Not surprisingly, as the doses and concentration of the kratom consumables have increased, so has the incidence of adverse effects and addiction. The lack of standardization, dose consistency, and regulation of kratom products means there are unpredictable effects with significant morbidity and mortality reported. In July, 2026, the DEA announced its intent to schedule 7-OH and related substances as Schedule 1. Kratom leaf products that naturally have trace amounts of 7-OH will remain unregulated by the DEA (DEA, 7/2026).
While the DSM-V does not include a specific diagnosis for kratom use disorder (KUD), expert consensus recommends diagnosing KUD based on criteria for opioid use disorder, given the action of kratom on the mu opioid receptor. Based on case reports and an online cross-sectional sample study, an estimated 25% of people who use some form of kratom ultimately develop a use disorder, comparable to 5-15% for cocaine and 1-34% for opioids. The heterogeneity of populations, definitions, and follow-up periods in various studies make it hard to land on one number (Chandra 2020, Hill 2024, Smith 2024, Swart 2024, NSDUH 2026, Nielsen 2022, Wagner 2002, Curbsiders 7/2026).
Back to Joe:
Joe shares that he originally got a lot of energy from the kratom liquid in tiny bottles. He started to notice that he needed to drink more of them to get the same boost over time so he switched from the liquid shots to capsules. Now, by the end of the morning, after taking 3 or 4 capsules, he actually feels more tired. His friends told him that it’s weird that he doesn’t hang out with them as much now and spends so much time in smoke shops looking for kratom. He realized recently that he can’t go an hour without looking for or taking kratom because he hates how he feels without it now. When he does run out of kratom, he gets very anxious, sweaty, goosebump-y, and his joints ache.
You ask Joe more details about what he does and doesn’t like about kratom, how it’s affecting his life, the names of the products he’s getting, what they contain, and if he can estimate how much and how often he’s using kratom or 7-OH (Curbsiders Addiction Medicine podcast, 7/2026). You share with Joe the criteria for opioid use disorder (OUD). Based on his answers, you share that you’re concerned Joe’s developed a physical dependency and addiction to kratom. Review this previous PsychSnap on how to diagnose a substance use disorder.
How do you treat kratom use disorder (KUD)?
Just as there’s no formal KUD diagnostic criteria, there are no RCTs of treatment options for KUD. There are, however, numerous case reports and case series that can inform how we treat kratom withdrawal (most akin to opioid withdrawal) and KUD (treated like OUD). Buprenorphine is most commonly used for both kratom withdrawal and KUD. Comfort medications like clonidine and loperamide can also be used to manage kratom withdrawal symptoms (Hendler 2026, Schmuhl 2020, Smith 2024).
Previous PsychSnaps reviewed “traditional” buprenorphine starts for OUD and “low-dose, overlapping” starts for people using fentanyl. The lipophilicity and potency of synthetic products containing the high affinity 7-OH compound creates a theoretical concern for precipitated withdrawal when starting buprenorphine. Most experts recommend that patients wait as long as possible and ideally at least 12-24 hours since last kratom use to reduce the risk of precipitated withdrawal when starting sublingual buprenorphine (Kong 2017, Curbsiders 7/2026). Case reports suggest that people with KUD often need 8-32mg of buprenorphine a day and may benefit from switching to a monthly long-acting injectable buprenorphine to help manage symptoms more smoothly and improve quality of life (Swatt 2024).
Back to Joe:
You recommend that Joe stop using kratom and wait as long as possible (ideally >24 hours) until he is experiencing objective withdrawal symptoms, specifically goosebumps, yawning, joint aches, stomach upset, and restlessness. He should then start taking at least 2mg of sublingual buprenorphine when he feels these withdrawal symptoms and take an additional 2-4mg every few hours in the first day as needed to manage ongoing withdrawal symptoms (akin to a traditional buprenorphine initiation). You provide him with a handout with written instructions and review the day-by-day plan.
On day 2, he would take the total amount of buprenorphine he took on day 1 as his first morning dose. He can evaluate how he feels every 3 hours to see if he needs 2-4mg more of sublingual buprenorphine to address any lingering withdrawal symptoms. On day 3, he takes the total from day 2 first thing in the morning.
Joe is not happy about having to wait and feel sick but understands the rationale for this plan. He tells you he’s ready to start because he wants to go back to living without the wearing off symptoms of kratom that, in his mind, are way worse than the low energy he was having prior to starting to use kratom. You make a plan to follow up by phone in 2 days and schedule a video visit in 5 days to see if the daily buprenorphine dose needs to be adjusted.
Key Points:
- The prevalence of kratom use in the US is reported to be 9% and increasing. Approximately 25% of people who use kratom may ultimately develop a kratom use disorder.
- Kratom—from the Mitragyna speciosa tree—is a diverse entity with many unregulated forms, components, and uses. Ask patients what they are using, how they are taking it, how often, and what effects it is having in their life.
- If a patient meets applied diagnostic criteria for kratom use disorder, discuss the potential for using buprenorphine for withdrawal management and treatment.
Related PsychSnaps
References
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