Health Affairs Policy Brief: Kratom Derivatives Are Now a Retail Opioid Crisis—DEA Must Act on FDA's 7-OH Scheduling Request

Why it matters

Two addiction medicine clinicians at one of the nation's first low-barrier SUD treatment programs in Oakland argue that concentrated 7-OH products represent a new retail opioid crisis requiring urgent federal action—specifically, DEA must act on the FDA's year-old scheduling recommendation.

The big picture

The opioid epidemic has moved through a sequence of supply shifts—prescription opioids, heroin, then fentanyl—each outpacing clinical and regulatory response. The authors argue concentrated 7-OH, sold in gas stations and vape shops as a "natural" supplement, is the latest phase: a full opioid agonist approximately 13 times more potent than morphine, yet unscheduled and widely available. The FDA formally recommended DEA schedule 7-OH in July 2025, but the DEA has not acted.

Key findings

• 7-OH is approximately 13 times more potent than morphine and 46 times stronger than mitragynine, yet is sold legally as a supplement in most states
• The authors' Oakland SUD clinic has seen a sharp rise in patients with severe opioid-type withdrawal who had never used heroin or fentanyl—only 7-OH kratom products
• The FDA recommended DEA scheduling of 7-OH in July 2025; as of May 2026, the DEA has still not acted
• Mitragynine pseudoindoxyl (MPI), an even more potent kratom derivative, is already appearing in consumer products—some patients required buprenorphine doses of 24–36 mg/day for acute withdrawal
• Compound-by-compound scheduling cannot keep pace with the market; the authors advocate a class-wide scheduling approach like Congress used for fentanyl analogs

What they say

"The question is not only whether our systems can respond to 7-OH in time, but whether we can use this momentum to build a surveillance and regulatory model capable of detecting and intervening on the next retail synthetic opioid before it scales," wrote Dr. Nicholas Stine and Dr. Monish Ullal, clinicians at Oakland's Highland Hospital addiction program.

Bottom line

Two frontline addiction doctors warn that concentrated 7-OH is a new chapter in the opioid epidemic—sold legally as herbal kratom—and demand the DEA immediately act on the FDA's 2025 scheduling recommendation before dependence scales further.