Kratom is available for over-the-counter purchase in the United States typically in the form of powdered leaves and is used recreationally and as a purported self-treatment for a variety of conditions.1 The compound 7-hydroxymitragynine (7-OH), a potent μ-opioid receptor agonist, comprises roughly 2% of the total alkaloid content of natural kratom leaves.2 Proliferation of products containing concentrated amounts of 7-OH has prompted the US Food and Drug Administration to issue a report2 about the risks associated with 7-OH, such as respiratory depression, dependence, and withdrawal. We describe a patient taking 7-OH who experienced significant opioid withdrawal symptoms that resolved with high-dose buprenorphine-naloxone (BUP-NLX) treatment.
Case Report
A 49-year-old man presented for evaluation and treatment of depression and was hospitalized. He reported daily use of kratom pills, occasional insufflation of fentanyl (reported last used 7 days prior), and use of tetrahydrocannabinol drinks. He denied alcohol use, history of alcohol withdrawal, or use of other illicit substances. A urine drug screen was positive for cannabinoids and negative for amphetamines, barbiturates, benzodiazepines, buprenorphine, cocaine, ethanol, fentanyl, methadone, opiates, oxycodone, phencyclidine, and tramadol. He presented in no acute distress, and admission physical examination, laboratory studies, and vital signs were unremarkable. He was administered the Clinical Opiate Withdrawal Scale3 (COWS) to assess withdrawal severity. Three hours after admission, his initial COWS score was 1. He declined repeat COWS scoring 3 hours later and went to bed at 9:00 PM. At approximately 2:00 AM the following day, he awoke with a COWS score of 14. He received 2 mg BUP-NLX. Subsequent COWS scores and BUP-NLX administrations, recorded roughly every 2 hours, were as follows: 13 (2 mg BUP-NLX), 13 (2 mg BUP-NLX), and 14 (2 mg BUP-NLX). The repeat COWS score after the fourth dose of BUP-NLX was 21.
The patient was reapproached by the treatment team and asked to clarify if he had been using kratom or 7-OH. He reported taking 1,000 mg of 7-OH pills per day by mouth or insufflation, which he had been legally purchasing at a local tobacco shop. He was subsequently administered 4 mg BUP-NLX, and the repeat COWS score was 24. One hour later, he was administered 8 mg BUP-NLX with a repeat COWS score of 15 and reported subjective improvement in withdrawal symptoms. In the initial 24 hours of hospitalization, he received 40 mg of BUP-NLX. A total daily dose of 32 mg BUP-NLX was then scheduled in divided doses, and within approximately 36 hours of admission, COWS scores were recorded as consistently less than 6.
Following BUP-NLX induction, he reported a strong desire to remain abstinent from opioids and 7-OH products, begin residential substance use treatment, continue maintenance BUP-NLX therapy, and engage with outpatient mental health and addiction supports. He likened the effects of 7-OH as similar to his historic abuse of oxycodone, both in terms of intoxication and development of dependence. He stated that he did not initially report his use of 7-OH at admission due to fears that the treatment team would be unfamiliar with and incredulous of its effects.
Discussion
This case highlights the potent opioid properties and risk of dependence and withdrawal associated with 7-OH. We encourage clinicians to specifically inquire about “seven-o” when the use of kratom is reported, as our patient had significant opioid tolerance and required a higher-than-conventional-dose BUP-NLX induction to manage withdrawal symptoms, which can be seen in individuals using high-potency synthetic opioids.4
Article Information
Published Online: August 27, 2026. https://doi.org/10.4088/PCC.26cr04232
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(4):26cr04232
Submitted: March 18, 2026; accepted May 1, 2026.
To Cite: Held JT, Varicat FP. 7-hydroxymitragynine withdrawal treated with buprenorphine-naloxone. Prim Care Companion CNS Disord 2026;28(4):26cr04232
Author Affiliations: Department of Psychiatry, Minneapolis VA Health Care System, Minneapolis, Minnesota (Held, Varicat).
Corresponding Author: Jacob T. Held, PharmD, BCPP, Department of Psychiatry, 1 Veterans Dr, Minneapolis, MN 55417 ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Disclaimer: The contents do not represent the views of the US Department of Veterans Affairs or the United States Government.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect patient anonymity.
ORCID: Jacob T. Held: https://orcid.org/0009-0001-1313-5380
References (4)
- US Food and Drug Administration. FDA and Kratom. 2025. Accessed November 12, 2025. https://www.fda.gov/news-events/public-health-focus/fda-and-kratom
- Reissig CJ, Chiapperino D, Seitz A, et al. 7-Hydroxymitragynine (7-OH): an assessment of the scientific data and toxicological concerns around an emerging opioid threat. United States Food and Drug Administration; 2025. Accessed November 12, 2025. https://www.fda.gov/media/187899/download?attachment
- Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253–259. PubMed CrossRef
- Weimer MB, Herring AA, Kawasaki SS, et al. ASAM clinical considerations: buprenorphine treatment of opioid use disorder for individuals using high-potency synthetic opioids. J Addict Med. 2023;17(6):632–639. PubMed CrossRef
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