Treat the exposure and the clinical state.

Ask now

Ask specifically about 7-OH, 7-hydroxy, hydroxie, kratom extract tablets, films, shots, gummies, capsules, powders, MGM-15, MGM-16, and pseudoindoxyl. Many patients deny “opioid use” because they bought the product at retail.

Document product/brand (photograph when possible), labeled mg/unit and units/day, route, redosing interval, duration, nocturnal/interdose withdrawal, last dose, coexposures, and likelihood of seeking illicit opioids if supply ends. Do not convert to morphine milligram equivalents—no validated 7-OH-to-MME conversion exists.

Severity beyond COWS

COWS remains useful for objective opioid-withdrawal findings but can under-read insomnia, dysphoria, GI distress, craving, and mixed-product symptoms. Assess hydration, autonomic burden, functional collapse, and evolving withdrawal for the chosen transition strategy.

Escalate the setting when

• Overdose, respiratory depression, or recurrent sedation
• Severe dehydration, uncontrolled vomiting/diarrhea, electrolyte risk
• Seizure, delirium, psychosis, severe agitation, or uncertain polysubstance withdrawal
• Arrhythmia concern, chest pain, syncope, marked QTc risk
• Pregnancy; frailty; significant organ disease
• Heavy alcohol/benzo use or concurrent fentanyl/other opioid dependence
• Unreliable product history; prior precipitated withdrawal; high substitution risk

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