1. Exposure characterization
- Product/brand and photograph
- Form: tablet / gummy / shot / powder / capsule / film / pouch / other
- Label claim per unit; units per dose; doses per day
- Estimated labeled mg/day; shortest redosing interval
- Duration of use; route
- Botanical kratom, extract, 7-OH, MP, MGM-15/16, or unknown mixture
- Source and date purchased; recent formulation change
- Prior kratom, Rx opioid, heroin, fentanyl, methadone, or buprenorphine
2. Dependence and use-disorder phenotype
- Interdose / nocturnal withdrawal; tolerance/escalation
- Unsuccessful reduction; use to avoid withdrawal; craving
- Time spent obtaining/using/recovering
- Occupational, financial, family, or medical consequences
- Continued use despite harm; prior overdose
- Likelihood of seeking fentanyl/counterfeit pills if supply ends
3. Last exposure and current syndrome
- Date/time of last dose; first symptom and onset
- Current COWS and serial trend
- GI symptoms and hydration; myalgias/restlessness/tremor
- Sweating/chills/piloerection; rhinorrhea/lacrimation/yawning
- HR / BP / temperature / SpO₂; insomnia hours slept
- Anxiety/dysphoria/irritability; craving and safety
- Confusion, psychosis, seizure, syncope, chest pain, respiratory symptoms
4. Coexposures and medication reconciliation
- Alcohol; benzodiazepines or Z-drugs; fentanyl/other opioids
- Nicotine/stimulants; gabapentinoids
- Antidepressants/antipsychotics; QT-prolonging drugs
- CYP3A/2D6/2C19 inhibitors or inducers; naltrexone
- OTC/herbal products
5. Medical and social risk
- Pregnancy/lactation; age/frailty; seizure disorder
- Cardiac disease; respiratory disease/OSA/hypoventilation
- Hepatic/renal disease; severe psychiatric illness/suicide risk
- Concurrent sedative dependence
- Housing, support, phone, transportation, pharmacy access
- Child-safety / storage concerns
6. Disposition screen
Consider emergency/hospital/medically managed care for: overdose or recurrent sedation; respiratory compromise; seizure; delirium/psychosis; severe agitation; chest pain/syncope/arrhythmia; uncontrolled vomiting/diarrhea/dehydration; pregnancy with significant dependence; severe polysubstance withdrawal; unstable medical illness; unsafe environment; or inability to avoid illicit-opioid substitution.
Consider observed or low-dose transition for: unclear product/last dose; q1–3h redosing; mixed fentanyl/MP/MGM exposure; previous precipitated withdrawal; inability to tolerate abstinence; or high consequence of a withdrawal spike.
Consider standard initiation for: credible short-acting exposure with convincing progressive withdrawal, adequate monitoring/support, and no indication for higher care.
7. Treatment plan
- Pathway: standard buprenorphine / low-dose / methadone referral / symptomatic / inpatient
- Rationale; objective withdrawal criteria
- Adjunctive medications; naloxone supplied and training
- Fentanyl/counterfeit-pill counseling
- Follow-up timing; escalation instructions
- Maintenance versus taper; pain, sleep, mood, other-SUD plan
Suggested note language: 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 OUD principles. The patient was counseled regarding naloxone, counterfeit-pill/fentanyl risk, and the danger of substituting non-prescribed opioids.