Patient reports repeated use of a concentrated commercial 7-hydroxymitragynine / kratom-derived product with physiologic dependence and withdrawal. Product composition and direct high-dose human 7-OH pharmacokinetics are uncertain. Treatment planning is based on reported exposure, objective withdrawal findings, supplemental symptom assessment, coexposures, medical risk, and established opioid use disorder treatment principles. The patient was counselled regarding naloxone, counterfeit-pill and fentanyl risk, and the danger of substituting non-prescribed opioids.
7-OH clinical assessment & disposition template
A structured intake and disposition worksheet for a patient presenting with concentrated 7-OH or kratom-derived opioid exposure. Designed to be printed, filled in at the bedside, and adapted to your own setting.
Appendix B
Version 1.2
Reviewed 8 August 2026
Not a validated instrument
Read this first
This is a clinician-adaptable worksheet, not a validated instrument. It has not been psychometrically tested, it does not generate a score, and no threshold on it determines a disposition by itself. It exists because the exposure history that matters for this drug class — product, labelled milligrams, redosing interval, coexposures — is exactly the history that a standard opioid intake does not ask for. Adapt it to your setting and to local protocol. The reasoning behind each section is in the treatment module.
Printing hides the navigation and lays the form out for a clipboard.
Exposure characterisation
The single most useful section. Patients rarely volunteer this and rarely describe it as opioid use.
| Field | Entry |
|---|---|
| Product / brand, and photograph if available | |
| Form — tablet, gummy, shot, powder, capsule, film, pouch, other | |
| Label claim per unit | |
| Units per dose | |
| Doses per day | |
| Estimated labelled mg per day | |
| Shortest redosing interval | |
| Duration of use | |
| Route — oral, sublingual, intranasal, inhaled, other | |
| Botanical kratom, extract, 7-OH, MP, MGM-15/16, or unknown mixture | |
| Source and date purchased | |
| Recent brand or formulation change | |
| Prior kratom, prescription opioid, heroin, fentanyl, methadone, or buprenorphine use |
Why the interval, not just the daily total
Frequent redosing — particularly every one to three hours, or waking at night to dose — often reveals the severity of dependence more reliably than the reported daily milligram figure, which rests on a label that may not be accurate.
Dependence and use-disorder phenotype
| Feature | Entry |
|---|---|
| Interdose withdrawal | |
| Nocturnal or early-morning withdrawal | |
| Tolerance and dose escalation | |
| Unsuccessful reduction attempts | |
| Use to avoid withdrawal rather than for effect | |
| Craving | |
| Time spent obtaining, using, or recovering | |
| Occupational, financial, family, or medical consequences | |
| Continued use despite harm | |
| Prior overdose | |
| Likelihood of seeking fentanyl or counterfeit pills if supply ends |
Last exposure and current syndrome
| Finding | Entry |
|---|---|
| Date and time of last dose | |
| First symptom and onset time | |
| Current COWS and serial trend | |
| Gastrointestinal symptoms and hydration | |
| Myalgias, restlessness, tremor | |
| Sweating, chills, piloerection | |
| Rhinorrhoea, lacrimation, yawning | |
| Heart rate, blood pressure, temperature, oxygen saturation | |
| Insomnia and hours slept | |
| Anxiety, dysphoria, irritability | |
| Craving and ability to remain safe | |
| Confusion, psychosis, seizure, syncope, chest pain, respiratory symptoms |
Do not let a low COWS reassure you
A published high-dose patient remained substantially symptomatic at roughly 48 hours after the last dose with a COWS of only 5.E25 Record the affective, sleep, and craving domains alongside the score, and trend it serially. The COWS problem, in full.
Coexposures and medication reconciliation
| Agent or class | Entry |
|---|---|
| Alcohol | |
| Benzodiazepines or Z-drugs | |
| Fentanyl or other opioids | |
| Nicotine, stimulants | |
| Gabapentinoids | |
| Antidepressants, antipsychotics | |
| QT-prolonging drugs | |
| CYP3A, 2D6, or 2C19 inhibitors or inducers | |
| Naltrexone exposure — including extended-release | |
| Over-the-counter and herbal products |
Interaction mechanisms and the distinction between observed human interactions and modelled predictions are set out in module 05.
Medical and social risk
| Domain | Entry |
|---|---|
| Pregnancy or lactation | |
| Age, frailty | |
| Seizure disorder | |
| Cardiac disease or channelopathy | |
| Respiratory disease, OSA, hypoventilation | |
| Hepatic or renal disease | |
| Severe psychiatric illness, suicide risk | |
| Concurrent sedative dependence | |
| Housing, support, phone, transport, pharmacy access | |
| Child-safety and storage concerns |
Suggested disposition screen
A prompt for judgement, not an algorithm. The principle is the least intensive setting that is safe.
Consider emergency, hospital, or medically managed care for
Overdose or recurrent sedation; respiratory compromise; seizure; delirium or psychosis; severe agitation; chest pain, syncope, or arrhythmia; uncontrolled vomiting, diarrhoea, or dehydration; pregnancy with significant dependence; severe polysubstance withdrawal; unstable medical illness; an unsafe environment; or inability to avoid illicit-opioid substitution.
Consider observed care or a low-dose transition for
Unclear product or unclear time of last dose; redosing every one to three hours; mixed fentanyl, MP, or MGM exposure; previous precipitated withdrawal; inability to tolerate an abstinence interval; or a high consequence should a withdrawal spike occur.
Consider standard initiation for
Credible short-acting exposure with convincing progressive clinical withdrawal, adequate monitoring and support, and no indication for a higher level of care.
There is no fixed hour
Nothing on this worksheet establishes a safe interval between the last dose and buprenorphine initiation. No such interval has been validated for concentrated 7-OH, because direct high-dose human pharmacokinetics have not been characterised.E25E26 Initiate on convincing, progressive clinical withdrawal and the whole exposure picture.
Treatment plan
| Element | Entry |
|---|---|
| Chosen pathway — standard buprenorphine / low-dose buprenorphine / methadone referral / symptomatic / inpatient | |
| Rationale | |
| Objective withdrawal threshold or clinical criteria used | |
| Adjunctive medications | |
| Naloxone supplied and training completed | |
| Fentanyl and counterfeit-pill counselling | |
| Follow-up within | |
| Escalation instructions and named contact | |
| Maintenance versus taper discussion | |
| Pain, sleep, mood, and other substance use plan |
Suggested note language
Adapt before use; it is a starting point, not a template to sign unread.
Behind the worksheet
The reasoning for every field is in the treatment module
Disclaimer
This worksheet is educational, is not a validated instrument, is not a standard of care, and does not constitute medical advice or create a physician–patient relationship. It does not replace examination, local protocols, toxicology consultation, or individualised clinical judgement. Anyone experiencing withdrawal from or toxicity due to kratom or 7-OH products should be evaluated by an addiction medicine professional — start with the buprenorphine prescriber finder.