Abstract Introduction Opioid withdrawal syndrome (OWS) is increasingly encountered in hospitalized patients as both prescription and over-the-counter opioid use rises. A recent US survey stated that nearly 66.7% users meet DSM-5 criteria for kratom use disorder. Kratom (Mitragyna speciosa)—a herbal supplement readily available online—has gained popularity for self-management of pain and opioid dependence. Its active metabolite, 7-hydroxymitragynine (7-OH), is a potent μ-opioid receptor agonist. Chronic kratom use may lead to physiologic dependence, and abrupt cessation can precipitate withdrawal syndromes that mimic other acute conditions in the ICU. Case presentation A 32-year-old woman with a history of Crohn’s disease presented with two days of severe abdominal pain associated with nausea and multiple episodes of vomiting. She also reported palpitations, diaphoresis, anxiety, and shortness of breath during these episodes. Vitals were stable on presentation. Physical examination revealed an ill-appearing, diaphoretic woman and mild diffuse abdominal tenderness. Laboratory evaluation showed mild leukocytosis, a normal GI pathogen panel, and urine toxicology was only positive for cannabinoids. Urinalysis revealed pyuria. Abdominal ultrasound was normal. ICU was consulted as the patient was complaining of anxiety, sweating, and palpitations. The patient disclosed daily use of an over-the-counter product called “7-OH,” which she had stopped two days before admission. Given her presentation and medication history, she was diagnosed with opioid withdrawal syndrome secondary to chronic 7-hydroxymitragynine use. She was treated with midazolam and Librium as needed, which resulted in symptom resolution. On day 4 of admission, she left AMA and was lost to follow-up. Discussion Over-the-counter (OTC) opioid-like compounds have emerged as an underrecognized cause of opioid dependence and withdrawal. Chronic exposure can produce physiologic dependence and withdrawal syndromes indistinguishable from those of traditional opioids. This case highlights the importance of a thorough medication and supplement history when evaluating patients with unexplained agitation, diaphoresis, or gastrointestinal distress, especially if they have pre-existing GI conditions. Standard urine toxicology screens typically fail to detect kratom or 7-OH, as they are not cross-reactive with conventional opioid immunoassays—potentially delaying recognition of withdrawal or toxicity. The Clinical Opiate Withdrawal Scale (COWS) provides a validated, structured tool to quantify withdrawal severity and guide therapy. Management focuses on symptomatic control and opioid replacement therapy. Mild to moderate withdrawal can be treated with α2-agonists (e.g., clonidine) and supportive measures, while buprenorphine-naloxone is preferred for maintenance therapy in dependent users. This abstract is funded by: None
Shaji et al. (Fri,) studied this question.