7-OH-Mitragynine–Induced Psychosis and Delirium

Mitragyna speciosa is a tropical tree native to Southeast Asia, the leaves of which are commonly known as kratom. 7-Hydroxymitragynine (7-OH) is a substance derived from kratom leaves and is marketed as a distinct product. Although its full properties are poorly understood, 7-OH’s known opioid-like effects and unregulated status in the United States have resulted in more widespread recreational use.¹ As 7-OH use gains prevalence, it becomes increasingly important to understand its constellation of adverse effects. We present the case of a patient who, following several months of heavy 7-OH use, developed psychosis and delirium that persisted for nearly a week following cessation. The patient was medically hospitalized and required several days of opioid withdrawal management and supportive care before returning to his baseline mental status.

Case Report

The patient was a 62-year-old man with a documented psychiatric history of opioid use disorder, alcohol use disorder in sustained remission, and cannabis use disorder. Several months prior, the patient began using 7-OH pills recreationally, taking upwards of 300–400+ mg/d. Two weeks before presentation, the patient experienced an episode of new-onset suicidal ideation, auditory and visual hallucinations, paranoia, confusion, and myoclonus. These symptoms persisted for over a week, prompting a family member to bring the patient to the hospital. On arrival, routine serum laboratory studies and brain imaging were all unremarkable. Urine drug screen was positive only for cannabinoids, and the patient reported using 0.5 ounces of cannabis daily. From the emergency department, the patient was transferred to an inpatient psychiatric facility for the management of psychosis and suicidal ideation. Over the following 3 days at the inpatient psychiatric facility, the patient experienced progressive confusion, nausea and vomiting, and intermittent unresponsiveness for which he was transferred back to our institution and admitted to the general medical floor for further care. Repeat workup during this admission remained unchanged from the workup 3 days prior. The addiction psychiatry team was consulted on hospital day 2 to evaluate if substance use was contributing to the patient’s presenting symptoms.

During addiction psychiatry evaluation, the patient endorsed suicidal ideation along with auditory and visual hallucinations. He repeatedly denied kratom use but reported last using 7-OH 5 days previously. Notably, the patient appeared physically restless, was oriented only to himself, and displayed inattentiveness, poor concentration, and fluctuating levels of arousal over the course of the interview, resulting in at times tangential and nonsensical responses to questions. Based on this presentation, a diagnosis of delirium was made, which was thought to be in the context of 7-OH intoxication and withdrawal.

The patient was started on buprenorphine/naloxone 4 mg/1 mg twice daily. The following day, the patient reported resolution of suicidal ideation and hallucinations, although he remained oriented only to himself. His attention and concentration were markedly improved. He reported cravings for 7-OH, and the buprenorphine/naloxone dose was increased to 8 mg/2 mg twice daily. The patient’s mental status continued to improve in subsequent days, and he was fully oriented by hospital day 5 with return to his baseline mental status. The patient expressed interest in treatment for his excessive 7-OH use, and resources were provided. He was discharged home on hospital day 7 on buprenorphine/naloxone 8 mg/2 mg twice daily with plans to enter a residential treatment program. He had a follow-up appointment at our outpatient clinic for the management of his buprenorphine/naloxone prescription to bridge him to the residential treatment program.

Discussion

Kratom is commercially available in the United States as an unregulated herbal supplement, commonly used for pain relief, mood enhancement, and self-treatment of opioid withdrawal.¹ The kratom plant contains over 40 alkaloids, though 2 compounds account for most of its psychoactive effects: mitragynine (MG) and 7-OH.² Both compounds act as partial agonists at the μ-opioid receptor and also exhibit activity at the δ and κ receptors.³ Compared to MG and the natural opioid morphine, however, 7-OH has been shown to be up to 30 and 17 times more potent, respectively, in animal models of analgesia.⁴ Traditional kratom preparations contain only trace amounts of 7-OH, typically less than 2% of the total alkaloid content.^5,6 However, synthetic compositions have been reported to contain 5 times higher levels of 7-OH,² amplifying the opioid-like potency and risk for adverse effects.

7-OH is commonly sold in gas stations and vape shops, as well as online, where 7-OH pills of 98% purity are available for purchase.^2,7 The US Food and Drug Administration has raised concerns about the ease with which 7-OH can be obtained given its potential toxicity, and in 2025, it formally requested that the US Drug Enforcement Administration (DEA) restrict 7-OH availability by placing it under Schedule 1 of the Controlled Substances Act, indicating high risk for misuse and no acceptable medical use.⁸ The DEA review process remains underway at the time of this publication.

Our case illustrates psychosis and delirium as potential adverse effects associated with chronic use of high-dose 7-OH. There are several case reports describing psychosis and delirium in the context of regular kratom use;^9,10 however, to our knowledge, this is the first documented report of such symptoms occurring with 7-OH use specifically. Importantly, this case draws attention to a necessary distinction: Kratom use must be distinguished from 7-OH use when collecting history from patients, as these are different compounds sold under different names and preparations. When explicitly questioned, our patient denied using kratom and only reported using 7-OH.

7-OH has known opioid-like properties, but the extent of its full effects remains poorly understood.^1,2 This creates clinical challenges because 7-OH use is difficult to identify, and its clinical effects are difficult to predict and manage. There is very little in the literature about 7-OH intoxication or withdrawal syndromes and their management. Accordingly, there are no standardized treatment guidelines or evidence-based recommendations. For our patient, initiation of buprenorphine/naloxone corresponded with improvement in both psychiatric and physical withdrawal symptoms, consistent with previous reports of opioid agonist treatment for managing kratom withdrawal.^11,12 Our experience thus suggests that 7-OH withdrawal can be effectively treated with buprenorphine/naloxone.

There are currently no diagnostic laboratory or imaging studies to identify 7-OH use. Routine serum and urine toxicology tests do not detect 7-OH, further complicating the diagnosis of 7-OH intoxication or withdrawal in the hospital setting.¹³ In the absence of available objective data suggesting 7-OH use, the clinical interview becomes the primary means by which 7-OH use can be identified. Clinicians should conduct a thorough substance use history and inquire about kratom and 7-OH use separately when evaluating patients with unexplained changes in mental status.

Conclusions

This is the first report, to our knowledge, of a patient developing psychosis and delirium following chronic high-dose ingestion of 7-OH tablets. This case emphasizes the need for clinicians to consider 7-OH toxicity as a potential cause of unexplained altered mental status or new-onset psychosis and highlights the importance of a thorough substance use history as part of the medical workup. Further research investigating the effects of 7-OH and treatment strategies is needed to better inform clinical management.

Article Information

Published Online: April 14, 2026. https://doi.org/10.4088/PCC.25cr04145
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(2):25cr04145
Submitted: November 20, 2025; accepted January 7, 2026.
To Cite: Elrokhsi NS, Lam CK, Balasanova AA. 7-OH-mitragynine–induced psychosis and delirium. Prim Care Companion CNS Disord 2026;28(2):25cr04145.
Author Affiliations: University of Nebraska Medical Center, Omaha, Nebraska (Elrokhsi, Lam); Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska (Balasanova).
Corresponding Author: Alëna A. Balasanova, MD, Department of Psychiatry, Poynter Hall 5th Floor, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Permission was received from the patient to publish the case report, and information has been de-identified to protect patient anonymity.
ORCID: Calvin K. Lam: https://orcid.org/0000-0003-2768-4230; Alëna A. Balasanova: https://orcid.org/0000-0001-9735-2712