Outpatient Sedation for Kratom

Outpatient Sedation for Kratom
What Non Anesthesiologists Should Know

Kratom, an herbal product derived from Mitragyna speciosa, is increasingly used in the United States for pain relief, mood enhancement, and self-treatment of opioid withdrawal. As its popularity grows, outpatient clinicians—dentists, gastroenterologists, and proceduralists offering moderate sedation—are more frequently encountering patients who take kratom.

Why Kratom Matters in Sedation
Kratom’s active compounds, mitragynine and 7-hydroxymitragynine, interact with opioid, adrenergic, and serotonergic receptors, leading to clinically significant effects.

• Opioid-like activity:
  • Regular users can develop tolerance and dependence, which may blunt the effect of standard opioid-based sedatives and analgesics, potentially requiring higher doses.
• Withdrawal risk:
  • Abrupt withholding can cause agitation, hypertension, and restlessness, which is a concern when patients are restricted from oral intake before a procedure.
• Unpredictable interactions:
  • Kratom can intensify central nervous system depression when combined with benzodiazepines, propofol, or opioids, increasing the risk of oversedation or respiratory compromise.
• Physiologic effects:
  • Tachycardia, hypertension, nausea, and even arrhythmias have been reported, complicating hemodynamic management.

Practical Considerations for Outpatient Providers:

• History Matters
  • Always ask specifically about kratom use—patients may not volunteer this information unless prompted. Clarify frequency, duration, and last ingestion, as heavy users face higher risks of tolerance and withdrawal.    
• Expectation Setting
  • Let patients know that their sedation may act differently; some may require higher doses, while others may become more deeply sedated than expected.    
• Sedation Planning
  • Consider avoiding opioid-based sedation when feasible, as kratom users might be tolerant and prone to unpredictable synergy.
  • Use incremental dosing and observe carefully rather than following fixed protocols
  • Employ capnography and continuous pulse oximetry whenever possible, even if not standard in your setting.  
• Monitoring and Staffing 
  • Have reversal agents (naloxone, flumazenil) available, but do not rely solely on them for safety. 
  • Ensure trained staff are present to manage airway obstruction or apnea.    
  • Treat chronic kratom users with the same vigilance as patients with chronic opioid use.   

When to Pause:
If a high-risk patient appears agitated, hypertensive, or withdrawn on arrival, consider postponing elective sedation until anesthesiology can be involved

When to Involve Anesthesia, Refer to, or co-manage with anesthesia colleagues if:    

• The patient uses kratom daily or at high doses. 
• There is a history of poly-substance use or psychiatric issues.
• The planned procedure is prolonged, painful, or needs deep sedation.
• There are other comorbidities such as sleep apnea or significant cardiovascular/hepatic disease. 

Bottom Line
Kratom is not a harmless supplement regarding sedation. Its opioid-like actions, withdrawal risks, and unpredictable drug interactions frequently complicate even routine outpatient cases. For non-anesthesiologists, prioritize awareness, direct history-taking, cautious dosing, enhanced monitoring, and prompt anesthesia consultation for at-risk patients. Integrating these precautions heightens patient safety and helps avoid unexpected complications in your outpatient practice.

Sources:

1. Anesthetic Challenges Posed by Heavy Kratom Users - PMC (https://pmc.ncbi.nlm.nih.gov/articles/PMC8982483/)[1]
2. Kratom: A Narrative Review of the Possible Clinical Uses and ... (https://pubmed.ncbi.nlm.nih.gov/39640144/)[2]
3. Kratom's rising role in the potential exacerbation of mental health ... (https://www.sciencedirect.com/science/article/pii/S2773021222000621)[7]
4. Kratom—Pharmacology, Clinical Implications, and Outlook (https://pmc.ncbi.nlm.nih.gov/articles/PMC7203303/)[3]
5. Narrative Review of Kratom, an Emerging Psychoactive Substance ... (https://pubmed.ncbi.nlm.nih.gov/35986675/)[6]
6. Clinical Characteristics of Kratom Exposures Reported to the ... (https://www.ashdin.com/articles/clinical-characteristics-of-kratom-exposures-reported-to-the-georgia-and-alabama-poison-control-centers-from-20162020-a-retrospect-91100.html)[8]
7. Understanding Kratom Use: A Guide for Healthcare Providers (https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2022.801855/full)[4]
8. Kratom and opioid use disorder in the perioperative period (https://wmpllc.org/ojs/index.php/jom/article/view/3348)[