Unlabeled kratom alkaloids detected in products marketed as kava

INTRODUCTION: In October 2025, the Alabama Poison Information Center and local addiction medicine providers identified a cluster of cases involving liquid products marketed as containing kava associated with opioid-like withdrawal symptoms. Kava is not typically associated with physical dependence, raising concern for opioid-active substances. METHODS: Five unique retail products were submitted for laboratory analysis. Three underwent quantitative ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) testing for kavalactones, kratom alkaloids, and related semisynthetic derivatives, with additional screening for 260 substances. Two products underwent qualitative gas chromatography-mass spectrometry (GC-MS) testing for mitragynine and kavalactones. RESULTS: Qualitative GC-MS detected both mitragynine and kavalactones in one product, while another contained mitragynine with no detectable kavalactones. Quantitative UPLC-MS/MS identified both kavalactones and kratom alkaloids in three products, with mitragynine pseudoindoxyl predominating at concentrations of 0.16-0.21 mg per bottle. DISCUSSION: Detection of kratom alkaloids and related semisynthetic derivatives in products labeled as kava may explain the observed opioid-like withdrawal. Mitragynine pseudoindoxyl, which has greater opioid activity than mitragynine and 7-hydroxymitragynine, was identified as the predominant kratom-related compound. CONCLUSION: Unrecognized exposure to opioid-active kratom compounds may occur through products marketed as kava, highlighting the need for improved surveillance and increased awareness.