Kratom and 7OH (Dembar & Rubin, 8/12/26)

A recording of this presentation is available HERE.

Thanks so much to our Addiction Medicine Fellows, Drs. Allie Dembar and Rebecca Rubin for a super super important presentation on Kratom and 7OH, two opioid like substances with high dependence risk and rising rates, despite a 2026 California ban on sale of such products.

Please watch their presentation if you don't know what 7OH is and/or if you work in primary care, emergency rooms, with children, etc. . .

Here are my notes:

Kratom is a plant from Southeast Asia, formal name, mitragyna speciosa. The active ingredient, mitragynine, has a mild stimulant effect when the leaves are chewed (think coca leaves from S. America) as well as a mild opioid effect at higher concentrations. 

7OH is a synthetic version of mitragynine, which is much more potent (and only present in <2% of the plant substance). It appeared in the US market ~2024. Some studies suggest higher potency than morphine

Both have been available for sale across the US, mostly in gas stations and smoke shops and until recently were not regulated. In 2026, Governor Newsom announced a ban in California of their sale (though they can still be found in local smoke shops per reliable reports). 

The increase in Kratom/7OH availability has led to an increase in kratom toxicities. By 1200%!

Men>> Women

Age group most affected is 20-39 year olds, followed closely by 40-59 year olds

There have been 233 Kratom-associated deaths between 2015 and 2025, 79% included multiple substances, and opioids are often co-reported

There are advocacy groups pushing for liberation of Kratom/7OH across the country, most of whom are being led by  chronic pain patients who feel abandoned by the medical system and looking for an answer to treatment for their chronic pain (in light of opioid prescription reduction over the last decade+). Kratom and 7OH are largely unregulated. This map below is produced by a pro-Kratom advocacy group. Notice the variance across traditionally aligned red and blue states and even the discrepancy up and down the Pacific coast.

The political landscape is evolving quickly

On July 1, 2026, the DEA "moved temporarily schedule 7OH and related substances to protect public safety". This federal action was aimed at synthetic 7OH (not directly at the plant based Kratom). A Schedule 1 label means that the drug has a high potential for abuse with no accepted medical use. 

Note that 7OH intoxication and withdrawal closely mirror that of opioid intoxication and withdrawal. 7OH is a potent mu opioid receptor full agonist. Small amounts can lead to euphoria>> larger amounts to respiratory depression. 

Withdrawal is functionally similar to opioid withdrawal. Half life is 1-5 hours (patients usually start withdrawing within 2 hours of stopping-- use habits require frequent use during the day, up to 6 times per day). You can increase the half life with chronic use up to abou 24 hours.

Treatment of Kratom withdrawal is buprenorphine, buprenorphine, buprenorophine. . .

Unlike with fentanyl, you will not precipitate withdrawal and you do not need to micro-dose, but can go straight to micro-dose-- 16mg SL plus don't forget your adjunct (ondansetron, loperamide, gabapentinoids, hydroxyzine, and if inpatient, can consider benzos for anxiety/agitation). 

Of note, you can order a sendout lab checking for mitragynine in urine (but this will typically not show up as an opioid in our standard utox).