7-Hydroxymitragynine and Nicotine Pouch Withdrawal Syndrome: A Case Report.

Novel psychoactive substances (NPSs) such as kratom and oral nicotine pouches present new challenges in clinical management, particularly regarding dependence and withdrawal. We report a case of severe withdrawal from concentrated 7-hydroxymitragynine (7-OH), a potent kratom alkaloid, and high-dose oral nicotine pouches, following long-term use in a patient with a history of polysubstance use. The patient developed acute, overlapping opioid-like (insomnia, myalgia, anxiety, diaphoresis, and gastrointestinal upset) and nicotinic (intense craving, irritability, restlessness, and difficulty concentrating) withdrawal symptoms. These symptoms rapidly escalated to severe agitation, psychosis, and respiratory compromise requiring intubation and intensive care. The clinical course was further complicated by failed outpatient management, precipitated withdrawal after initiation of buprenorphine, and eventual discharge against medical advice (AMA). This case report highlights the diagnostic and therapeutic complexities of managing withdrawal from novel psychoactive substances, the need for multidisciplinary and flexible approaches, and the importance of systematic assessment and harm reduction as these products become increasingly prevalent.