Management of kratom dependence with buprenorphine/naloxone in a veteran population.

Kratom is a substance that when ingested produces an opioid-like effect. As kratom continues to gain popularity, increasing numbers of cases of addiction, dependence, and adverse events have been reported, as well as an increase in mortality associated with its use. George E. Wahlen Department of Veterans Affairs Medical Center has been using buprenorphine/naloxone for the treatment of kratom withdrawal and dependence in both primary care and specialty addiction treatment settings in the Veteran population. We present three cases that describe the use of buprenorphine/naloxone for kratom dependence. For each case, we describe the withdrawal symptoms from kratom, induction and long-term maintenance on buprenorphine/naloxone in kratom dependence, the impact of polysubstance use disorders in management of kratom dependence, and the use of urine drug screens for kratom alkaloids during treatment. This case series demonstrates that patients with kratom dependence can effectively be treated with buprenorphine/naloxone. It appears that it is safe to induce buprenorphine/naloxone as early as eight hours after last kratom use and maintenance dosing for kratom use was similar to maintenance doses used in opioid use disorder. Prolonged and continued withdrawal symptoms were reported despite treatment with buprenorphine/naloxone and multiple daily doses of up to 24mg per day may be beneficial for prolonged withdrawal symptoms and for cooccurring pain. Polysubstance use with kratom dependence may require higher levels of care and higher doses of buprenorphine/naloxone. Urine drug screens may be best practice for monitoring kratom alkaloids concentrations and facilities that utilize buprenorphine/naloxone to treat kratom dependence should have testing available. Further research is needed on the impact and the treatment of kratom dependence.