Community Paramedics Addressing the Evolving Opioid Crisis: A Case Series Addressing the Kratom Derivatives 7-Hydroxymitragynine and MGM-15.

Concentrated 7-hydroxymitragynine (7-OH) and dihydro-7-hydroxymitragynine (MGM-15) are derived from the primary psychoactive alkaloid in kratom, and until recently were sold over the counter with kratom products. These highly potent kratom derivatives can produce opioid-like dependence, but evidence around prehospital treatment of 7-OH and MGM-15 withdrawal symptoms remains limited. This case series assesses two cases of community paramedics (CPs) providing treatment and linkage to care for individuals in acute opioid withdrawal from 7-OH and MGM-15. In our first case a 74-year-old individual called 9-1-1 experiencing acute opioid-like withdrawal symptoms after abruptly discontinuing over the counter 7-OH following six months of progressively escalating use. Connection was made with a prehospital buprenorphine program (PBAP) and the CP administered 24mg of buprenorphine and expedited connection to outpatient treatment with medication for opioid use disorder (MOUD). Our second case involved a 38-year-old individual who called a CP requesting expedited linkage to MOUD following a period of escalating use of 7-OH and MGM-15. This patient was linked to MOUD treatment within 48 hours of contacting the CP and required 32mg/8mg of buprenorphine/naloxone to treat severe opioid withdrawal symptoms after discontinued use of MGM-15 tablets. Both patients were retained in MOUD treatment at 30 days. These cases describe use of CP-based PBAPs addressing severe 7-OH withdrawal and expediting treatment to outpatient MOUD, highlighting that concentrated over the counter 7-OH products can produce physical opioid dependence leading to opioid use disorder, and requiring full-dose buprenorphine induction which may be considered within existing prehospital opioid withdrawal treatment protocols. Additional research is necessary to characterize withdrawal from concentrated 7-OH products and to determine implications for PBAP protocols and 7-OH dosing in the United States.