Managing 7-Hydroxymitragynine Use Disorder with Buprenorphine-Naloxone.

Kratom, a plant native to Southeast Asia, is legal in Hawai'i and is used for many purposes including pain relief and opioid withdrawal. Kratom contains many alkaloids with mitragynine being the most abundant. 7-hydroxymitragynine, one of the minor alkaloids in kratom, is approximately 46 times more potent than mitragynine. In recent years, 7-hydroxymitragynine has been available online and in Hawai'i vape shops where any individual can purchase it. In July 2026, due to its negative side effects, including substance use disorder development, the United States Drug Enforcement Administration announced its intent to temporarily placing 7-hydroxyitragynine under schedule I; kratom, which contains 7-hydroxymitragynine, remains uncontrolled. This case describes a patient with a history of getting off illicit opioids using kratom who developed tolerance and transitioned to 7-hydroxymitragynine. The patient believed 7-hydroxymitragynine, a "natural" plant product, was safe. She eventually also developed tolerance to 7-hydroxymitragynine, spending approximately $150 per day. This financial burden affected her mental health and contributed to the development of suicidal ideation. In the hospital, her withdrawal symptoms from 7-hydroxymitragynine were similar to opioid withdrawal. She was managed with buprenorphine-naloxone, requiring 40mg-10mg per day to control her cravings. This case highlights the adverse effects of 7-hydroxymitragynine and demonstrates the successful treatment of 7-hydroxymitragynine withdrawal and substance use disorder (specifically 7-hydroxymitragyinine) with high-dose buprenorphine-naloxone. Although the temporary scheduling of 7-hydroxymitragynine may limit its availability, other psychoactive botanical products may emerge as alternatives. Therefore, clinicians are recommended to routinely inquire about patients' use of botanical supplements in addition to illicit substances.