In this episode of ASAM Practice Pearls, Dr. Stephen Taylor hosts researchers Dr. Kirsten Smith and Katie Hill to explore the rapidly evolving landscape of kratom and 7-hydroxymitragynine (7-OH). They examine kratom’s complex pharmacology, review current research on kratom and 7-OH, discuss kratom’s addiction potential, withdrawal patterns, and the challenges of kratom in the clinical setting. The episode provides listeners with a basic understanding of kratom and 7-OH products, helping clinicians better understand where to begin when treating patients who use kratom and kratom-derived products. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at education@asam.org. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Kirsten Smith, PhD, LMSW Dr. Kirsten Smith is a leading expert on kratom, with over 90 peer-reviewed publications on kratom and related topics like kava and tianeptine. From 2023-2025, she was an Assistant Professor at Johns Hopkins University School of Medicine’s Department of Psychiatry. She joined Hopkins after earning her Master’s from the University of Kentucky, PhD from the University of Louisville, and completing a 4-year postdoctoral fellowship at the National Institute on Drug Abuse Intramural Research Program (NIDA IRP). At NIDA IRP, she completed her K99-funded project that involved a national ecological momentary assessment of daily kratom use and a controlled drug administration sub-study that investigated the acute effects of commercial kratom products. Her R00-funded study at Johns Hopkins examined kratom pharmacokinetics/pharmacodynamics of kratom and assessed spontaneous kratom withdrawal among chronic consumers. She also received an R01 to study the safety, tolerability, and abuse potential of kratom in healthy adults, which is ongoing. She has conducted surveys and qualitative research on kratom and 7-hydroxymitragynine (7-OH). Dr. Smith is currently transitioning from academia to clinical practice but consults on kratom regularly and welcomes opportunities for collaboration. Disclosure: There are no relevant financial relationships. Expert Katherine Hill, MPH Katherine (Katie) Hill is a PhD candidate in Epidemiology of Microbial Diseases at Yale School of Public Health. Her research interests include substance use and harm reduction. Her doctoral research employs mixed methods to evaluate the impact of emerging substances, such as xylazine and kratom, on people who use drugs. Disclosure: There are no relevant financial relationships. 📖 Show Segments 00:05 - Introduction 01:49 - Defining Kratom 04:42 - Consumers of Kratom 05:48 - Is Kratom an Opioid 07:29 - Differences Between Kratom and 7-OH 11:39 - Addiction Potential 16:50 - Toxicity, Acute Intoxication, and Toxidrome 18:55 - 7-OH Withdrawal and Overdose 24:16 - Patient History and Assessment 26:25 - Practice Pearls for Clinicians 30:48 - Patient Motivations and Harm Reduction 33:03 - Conclusion and Additional Learning Opportunity 📋 Key Takeaways “Kratom” is often used as a broad term for kratom-derived products: Kratom can refer to powdered leaves, capsules, teas, concentrated extracts, or semi-synthetic 7-OH products, many of which may also contain caffeine, kava, CBD, or other additives. When a patient says they use "kratom," it provides little clinical clarity. Clinicians need to ask which product, form, and brand the patient is using to better understand their usage patterns. Understand the product your patient is using: Product composition, potency, and co-ingredients of kratom are variable. Clinicians need to gather information on formulation, dosing, frequency, route, motivations, and co-use to gain a clear history. Self-report gives far more insight than current toxicology assays. Kratom’s pharmacology is complex: Kratom can produce pain relief via the serotonin and opioid system. Effects from kratom also include increases in energy and mood elevation. Some kratom alkaloids and metabolites have atypical mu-opioid receptor activity as well as non-opioid activity, making kratom’s pharmacology complex. Kratom does not appear to cause respiratory depression, but can result in physical dependence symptoms when consumed regularly. 7-OH is different from natural kratom: 7-hydroxymitragynine is found only in trace amounts in kratom leaves, but exists in much higher levels in commercial semi-synthetic products. These formulations behave differently and have low bioavailability, making their clinical effects distinct. Mild to moderate dependence and withdrawal are possible: Daily, repeated kratom use commonly leads to tolerance and withdrawal symptoms such as restlessness, irritability, fatigue, and cravings. Severe withdrawal appears uncommon in current data, though more evidence is needed, especially for 7-OH products. People can develop a kratom use disorder: About 25% of people using kratom meet criteria for kratom use disorder based on modified DSM-5 Criteria, though most presentations appear to be mild to moderate. Standard drug testing has limitations: Urine assays detect mitragynine, but a positive result can't distinguish between kratom leaf products and 7-OH products containing residual mitragynine. 7-OH is unstable in blood and rapidly metabolized, making detection challenging. Rely on self-report and consider asking patients to bring in their products for better clarity. Understand motivations for use: Many people who use kratom and 7-OH are not seeking intoxication. They're trying to manage pain or mood, function at work, self-treat withdrawal, etc. Treatment planning should account for these functional goals and incorporate motivational interviewing and shared decision-making. Help is needed to move the field forward: Researchers are behind front-line clinicians in understanding these substances. There is still a lot that is unknown about kratom and kratom-derived products. Clinicians are encouraged to publish case reports, develop internal protocols, describe withdrawal symptoms, and refine assessments to better guide emerging best practices. 🔗 Resources ASAM’s 57th Annual Conference - Register HERE General Session: Understanding the Evolving Drug Landscape: From Epidemiology to Clinical Practice Focus Session: Beyond Kratom: Novel Products Containing 7-OH, Pseudo, MGM, and Kava Chapter 5: Kratom-related Physical Dependence and Addiction - Smith KE, Singh D, Grundmann O. In: Kratom History, Science and Therapeutic Potential. Academic Press; 2026:59-78. https://doi.org/10.1016/B978-0-443-27412-1.00005-5 Clinically characterizing adults who use kava or kratom: Substance use disorder assessment challenges for increasingly popular botanical products - Hill K, Boyer EW, Smith KE. Drug Alcohol Depend Rep. 2025;17:100394. Published 2025 Nov 9. doi:10.1016/j.dadr.2025.100394 Controversies in Assessment, Diagnosis, and Treatment of Kratom Use Disorder - Smith KE, Epstein DH, Weiss ST. Curr Psychiatry Rep. 2024 Sep;26(9):487-496. doi: 10.1007/s11920-024-01524-1. Epub 2024 Aug 13. PMID: 39134892; PMCID: PMC11344726 The Rise of Novel, Semi-synthetic 7-hydroxymitragynine Products - Smith KE, Boyer EW, Grundmann O, McCurdy CR, Sharma A. Addiction. 2024;120(2):387-388. doi:10.1111/add.16728 National Institute on Drug Abuse (NIDA): Kratom - Learn more about kratom, ongoing research, and additional resources. 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you!
