When "Kava" Isn't Kava: Opioid-like Withdrawal Responsive to Buprenorphine: A Case Study.

Abstract

We report a case of severe opioid-like withdrawal symptoms following cessation of a commercially available beverage marketed as a "kava" product. A 36-year-old White male with opioid use disorder in sustained remission developed rapid tolerance, frequent redosing, nocturnal withdrawal, prominent gastrointestinal and autonomic symptoms, and generalized pruritus after heavy use of a gas-station-sold "kava" shot. Symptoms were refractory to benzodiazepines but improved rapidly with buprenorphine/naloxone; this suggests µ-opioid receptor-mediated dependence. The clinical presentation was inconsistent with kava withdrawal, which is typically mild and anxiety predominant. Review of product labeling indicated the presence of akuamma (Picralima nitida), a botanical containing μ-opioid receptor-active alkaloids; secondary qualitative testing of independently purchased samples of the same product by the UAB toxicology lab confirmed the presence of kratom (Mitragyna speciosa) derivatives and kavalactones. In the context of kratom prohibition in Alabama and overlapping manufacturer product lines, this case highlights the risks of mislabeled or adulterated polyherbal products and underscores the need for clinicians to consider opioid-mediated mechanisms and symptom-guided treatment when evaluating withdrawal from purported nonopioid supplements.