Appendix B: 7-OH Clinical Assessment and Disposition Template
For clinician adaptation. Not a validated instrument.
Version: 1.2 | Reviewed: August 8, 2026
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: oral / sublingual / intranasal / inhaled / other
- Botanical kratom, extract, 7-OH, MP, MGM-15/16, or unknown mixture:
- Source and date purchased:
- Recent brand/formulation change:
- Prior kratom, prescription opioid, heroin, fentanyl, methadone, or buprenorphine use:
2. Dependence and use-disorder phenotype
- Interdose withdrawal:
- Nocturnal/early-morning withdrawal:
- Tolerance/escalation:
- Unsuccessful reduction attempts:
- 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 time:
- Current COWS and serial trend:
- GI symptoms and hydration:
- Myalgias/restlessness/tremor:
- Sweating/chills/piloerection:
- Rhinorrhea/lacrimation/yawning:
- Heart rate/BP/temperature/oxygen saturation:
- Insomnia and hours slept:
- Anxiety/dysphoria/irritability:
- Craving and ability to remain safe:
- Confusion, psychosis, seizure, syncope, chest pain, or 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 exposure:
- OTC/herbal products:
5. Medical and social risk
- Pregnancy/lactation:
- Age/frailty:
- Seizure disorder:
- Cardiac disease/channelopathy:
- 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. Suggested 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
- Chosen pathway: standard buprenorphine / low-dose buprenorphine / methadone referral / symptomatic / inpatient
- Rationale:
- Objective withdrawal threshold/clinical criteria:
- Adjunctive medications:
- Naloxone supplied and training completed:
- Fentanyl/counterfeit-pill counseling:
- Follow-up within:
- Escalation instructions:
- Maintenance versus taper discussion:
- Pain, sleep, mood, and 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.