Emergency Medicine Clinical Guide: How to Recognize, Evaluate, and Manage Kratom in the ED

Why it matters

With kratom-related emergency department visits rising sharply, this comprehensive clinical guide from Army and Penn Medicine clinicians gives ER providers concrete protocols for managing kratom toxicity, overdose, and withdrawal — filling a major gap in emergency practice.

The big picture

Kratom poisoning calls to U.S. poison centers increased more than 10-fold between 2010 and 2015, and continued surging through 2025. Despite this trend, there are no published consensus guidelines for ED management of kratom presentations. Emergency physicians increasingly encounter patients presenting with kratom overdose, withdrawal, or complications — yet standard urine drug screens do not detect kratom alkaloids, complicating diagnosis.

Key findings

• Kratom's primary alkaloids mitragynine and 7-HMG act as partial mu-opioid receptor agonists; 7-HMG is 40 times more potent for analgesia than mitragynine in isolation
• Standard urine drug screens do NOT detect kratom — diagnosis requires liquid chromatography or ion mass spectrometry, which will not return results in a clinically useful timeframe
• Kratom overdose can present with opioid-like toxidrome, acute agitation, or hallucinations; withdrawal mimics opioid withdrawal with onset within 12–24 hours of cessation
• Complications documented in case reports include rhabdomyolysis, Brugada pattern ECG changes, QTc prolongation up to 654ms, cholestatic liver injury, and new-onset heart failure
• Naloxone should be administered for respiratory depression; buprenorphine at 4–8mg is a reasonable starting point for withdrawal meeting substance use disorder criteria

What they say

"Kratom overdose can present with seizure-like activity or being 'found down', although clinicians should note that there is often co-ingestion of other substances that may be contributory. Kratom withdrawal can largely mimic opioid withdrawal symptoms," the authors wrote, emphasizing the challenge of accurate diagnosis in the ED setting.

Bottom line

Kratom does not show up on standard drug screens, can cause life-threatening cardiac arrhythmias and rhabdomyolysis, and emergency physicians need specific diagnostic and management protocols to treat it safely.