By Jimmy Leonard, PharmD, DABAT
Washington Poison Center (WAPC) was called about a 35-year-old female who had been regularly using 7-hydroxy, a liquid she bought from her local vape shop. It was advertised to her as a way to help treat pain naturally. After developing constipation and excessive drowsiness, she looked online to see exactly what she was buying and realized it was derived from kratom, much like the product in the photo.
Kratom is the common name for the glossy leaves of the Mitragyna Speciosa plant. This plant is native to Southeast Asia and has been used around the world for hundreds of years for various purposes. Its uses include pain treatment, opioid withdrawal management, increased energy, increased appetite, weight loss, depression, helping get through a day of hard labor, and many others. It has multiple active components, but the two main alkaloids of interest are mitragynine (MTG) and 7-hydroxymitragynine (7-OH).
While Kratom has been used internationally for years, it has had limited presence in the United States until the mid-2010s. Few cases were reported to poison centers from 2011 through 2014. From 2015 to 2018, exposures rose from 330 to 1400 per year. This stayed consistent through March 2025. Exposures increased drastically starting April 2025 and reached 1800 as of early August.
Kratom is not controlled at a federal level. In 2016, the DEA proposed classifying the alkaloids as Schedule I substances (high potential for abuse, no recognized medical uses) but withdrew this proposal. In mid-2025, the FDA expressed concerns about 7-hydroxymitragynine being sold as an extract.
Classically, people used kratom leaves either ground to a powder and brewed into tea or smoked. In the US, many of the products are either powdered or extracts of kratom. In the last couple of years, products shifted initially to mitragynine (see photo), and more recently, 7-hydroxymitragynine. In 2025, approximately one-third of kratom calls to WAPC have been about 7-OH extracts.
Mitragynine and 7-OH agonize the mu-opioid receptors. This results in analgesia, drug-liking, and subsequent withdrawal effects. Previous studies suggested that kratom did not cause respiratory depression, even with very high doses (DOI: 10.1101/2025.05.16.654392). The proposed mechanism was selective agonism. Kratom works on mu, but does not activate the pathway responsible for respiratory depression. A 2024 study in rats found that pure MTG results in respiratory stimulation (and seizures at high dose), but pure 7-OH reliably causes respiratory depression. Naloxone reverses the respiratory depression.
In most poison center cases, multiple symptoms are reported including sedation, agitation, withdrawal, nausea, vomiting, and rarely identified liver injury. Treatment is supportive including airway protection, IV fluid resuscitation, and naloxone. About one-third of patients use kratom in combination with other substances,) so they may require other interventions. Kratom withdrawal is treated with one of your Medications of Opioid Use Disorder (MOUD) with buprenorphine being the most common reported in the literature (DOI: 10.1097/ADM.0000000000000721).
Case resolution:
The patient was initiated on buprenorphine/naloxone in the emergency department with resolution of symptoms. She was prescribed 14 days of buprenorphine/naloxone and referred to her primary care physician for follow up.
Contact your regional poison center at 1-800-222-1222 for any questions or treatment advice.
Learn more:
Watch Dr. Leonard’s session from the 2025 Overdose Awareness Series covering kratom and other readily available substances like nitrous oxide and mushroom edibles:
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