Buprenorphine for the Management of 7-Hydroxymitragynine (7-OH) Use: A Retrospective Case Series.

Abstract

Kratom (Mitragyna speciosa) is increasingly used in the United States as a dietary supplement for pain, mood regulation, and opioid withdrawal. Its alkaloids, mitragynine and 7-hydroxymitragynine (7-OH), demonstrate μ-opioid receptor activity, with 7-OH exhibiting substantially greater opioid-like potency than mitragynine. There are concerns from the US Food and Drug Administration (FDA) regarding dependence and adverse effects. Purified 7-OH products may bypass metabolic pathways and deliver disproportionately strong opioid effects compared with natural kratom preparations, increasing the risk of dependence. Despite these concerns, 7-OH remains federally unscheduled, though listed as a "Drug of Concern" by the DEA. Although there is no standardized clinical guidance, buprenorphine has been used to manage kratom and 7-OH withdrawal with varying initiation strategies. To describe the clinical course and outcomes of buprenorphine initiation among patients with problematic 7-OH use, focusing on initiation timing, dosing strategies, and symptom monitoring. Retrospective chart review of patients treated at a low-barrier telehealth addiction medicine clinic between April and October 2025. Nine patients with purified 7-OH product use (as opposed to kratom use) met the inclusion criteria. The mean age was 33.5 years; 7 patients were identified as male. Low-dose initiation was used in 6 cases and standard initiation in 3 cases. Successful initiation and stabilization occurred in 88.9%, with no precipitated withdrawal or adverse events. Symptom improvement was reported in 8 of the total cases at a median 6-week follow-up. Buprenorphine initiation for problematic 7-OH use was feasible, well tolerated, and associated with symptom improvement, supporting development of pragmatic clinical approaches for this emerging substance use disorder.