The clink of ice in the glass had been an evening “wind down” routine ever since the pandemic. It had served as a way to drown remnants of stress that bubbled up throughout the course of the day. This “routine” developed over weeks, but eventually evolved into dependence, addiction even, he worried. I need to do something about this before I lose it all, he thought one morning upon waking with a throbbing headache.

Driving down the road one misty morning, he had encountered a natural herb store. Later at work, the herb store’s presence barged into his mind once more. He found himself on his employer’s network scrolling when he finally stopped at a 7-OH ad, marketed at helping with alcohol cessation. What is the worst thing that could happen? I need something now. He could feel the urgency building.

The store closed at 7 p.m., he was off at 6 p.m. There was time to stop to pick up the 7-OH product, though he wished there had never been. Initially, he felt great. However, this later proved to be self-limited. One day he forgot to bring his 7-OH with him on a day trip across the state which proved to him its robust withdrawal profile. He sat driving on the interstate with sweats, profound anxiety, stomach cramps, and nausea as well as pervasive thoughts about getting any 7-OH into his system to just feel normal again. He presented later to a low-barrier addiction medicine clinic to seek assistance in transitioning to buprenorphine.

What is 7-OH?

Kratom is natural, right? So what is the big deal? Kratom is derived from the plant Mitragyna speciosa which is native to Southeast Asia and has become a staple of many corner stores, smoke shops, and gas stations. Its primary alkaloids, mitragynine and 7-hydroxymitragynine (7-OH), demonstrate activity at many receptors, though importantly the mu-opioid receptor. As such, purified 7-OH preparations may bypass metabolic conversion pathways and deliver disproportionately strong opioid activity, heightening risk for adverse events. While 7-OH may be marked under the guise of a “natural remedy,” it is important to remember that 7-OH is not naturally present in high concentrations in kratom leaves.

The potency problem

Both kratom and 7-OH use has become increasingly more common for the management of depression, anxiety, chronic pain, and withdrawal syndromes, including alcohol and opioids. In the realm of chronic pain, 7-OH as compared to morphine is approximately 4 to 7 times more potent in terms of analgesic effects, in mouse models.

Despite its promises, clinical presentations suggest that regular users of 7-OH frequently develop tolerance, escalating use, financial consequences, and withdrawal syndromes when attempting to stop, thereby meeting several criteria for a use disorder. Despite this, 7-OH products remain unscheduled by the DEA at the federal level and not regulated by the FDA. As a result of lack of regulation, 7-OH has the propensity to be unpredictable in terms of potency and pharmacologic effects as well as run the risk of contamination and adulteration. However, the FDA has issued several warning letters to companies for illegally marketing 7-OH, serving as an ominous prelude to the potential destruction 7-OH can cause, proving a first step in the right direction in terms of public health.

Clinical implications

As such, patients similar to ours mentioned previously, alongside many others of whom are spending up to $1,500 per month on 7-OH to prevent withdrawal, are also requiring higher doses of buprenorphine than we have historically seen with kratom. 7-OH use often goes under-recognized within our health care system currently or is conflated generally with kratom use. It is important to recognize this as a growing public health problem that has the propensity to develop into a substance use disorder, much like fentanyl, heroin, and other opioids.

A call for coordinated response

A coordinated public-health response is urgently needed to address the emerging risks of high-potency kratom-derived products such as 7-OH.

First, clinicians must better educate themselves on how to evaluate as well as manage kratom and 7-OH withdrawal or dependence which are conditions increasingly encountered in clinical settings but rarely covered in training. If unable or uncomfortable with managing the withdrawal syndrome, it is of the utmost importance to connect these patients with your community’s addiction medicine resources (if available) to mitigate risk of continued use or transition to other illicit opioids such as fentanyl or heroin.

Second, consumers deserve transparent labeling and accurate potency information for all kratom-related products; without this, individuals may unknowingly ingest a compound with high potency opioid-level effects.

Third, systematic surveillance and data collection are essential to understanding the true prevalence and associated harms of high-potency botanicals, which remain significantly underestimated.

Fourth, health care systems should strive to expand access to low-dose and flexible buprenorphine induction strategies that can safely support patients transitioning off these substances, recognizing that while this is likely safer, there is little evidence to support long-term use.

Finally, policy efforts should prioritize regulating potency and product standards rather than blanket bans, which risk driving use underground and in turn perpetuating harm. A proactive, evidence-based approach grounded in clinical awareness, transparency, surveillance, treatment access, and thoughtful regulation can prevent a growing problem from becoming a more entrenched public-health crisis.

Emma Fenske is an internal medicine physician. Bradley M. Buchheit is a family physician.