Imagine that it is 2 a.m., and a patient presents with sweating, vomiting, and an inability to sleep, afraid of what will happen without the next tablet or shot. Until recently, the product that kept them feeling this way may have been purchased from a gas station, smoke shop, or online and was marketed for “calm,” “focus,” pain relief, or as an alternative to alcohol dependence. Countless patients present this way. Many of them were not seeking an opioid. They were marketed one.

What this patient, and others like them, did not understand was that the product contained a substance known as 7-hydroxymitragynine, or 7-OH, an opioid receptor agonist capable of producing tolerance, dependence, withdrawal, and respiratory depression. In my Houston-based addiction medicine practice, I see increasing numbers of patients seeking help for 7-OH dependence. Some can no longer afford their escalating use. Others have tried to stop and experienced severe opioid-like withdrawal. Increasingly, they also fear legal consequences as federal regulators move to restrict the substance.

In July 2026, the Drug Enforcement Administration (DEA) published notices of intent to temporarily place 7-OH and three related substances in Schedule I of the Controlled Substances Act. At the time of writing, the controls would take effect only after publication of separate temporary scheduling orders.¹ The action targets concentrated or synthetic products above specified thresholds, but not natural kratom leaf containing only trace amounts of 7-OH.²

A Potent Opioid Hiding in Plain Sight

Kratom and 7-OH are not interchangeable. Mitragynine is the predominant alkaloid in natural kratom leaf; 7-OH is ordinarily present only in small amounts. Commercial products, however, may contain enhanced, isolated, or semisynthetic 7-OH in tablets, gummies, powders, drink mixes, and liquid shots, because the herbal supplement market is largely unregulated. Preclinical studies show that 7-OH acts as a partial μ-opioid receptor agonist and produces opioid-like behavioral and antinociceptive effects.³ The U.S. Food and Drug Administration (FDA) has also identified evidence of reinforcement, tolerance, physical dependence, withdrawal, and respiratory depression.⁴

These are not merely botanical wellness products that make you feel good. 7-OH products have opioid affinity and carry clinically meaningful potential for harm. By 2025, the FDA warned manufacturers that 7-OH could not lawfully be sold as a dietary supplement, added to conventional food, or marketed as an unapproved drug.⁵ Federal authorities later seized approximately 73,000 units of 7-OH products.⁶ Those actions addressed unlawful commerce but did not create a treatment pathway for people already dependent.

What Scheduling Cannot Do

Restricting 7-OH may be justified, but it is not, by itself, a public health strategy. Scheduling may reduce future exposure, but it does not treat patients who wake up in withdrawal. It does not expand resources to help patients create an addiction appointment, cover medication, or arrange transportation to follow-up care.

Without a bridge to treatment, abrupt loss of retail access may drive patients toward emergency departments, street drugs, or the criminal justice system. That is the policy failure emergency physicians should anticipate. We will see the consequences once these products leave the shelves and people turn to emergency departments.

What Emergency Physicians Should Know

Patients may present with opioid toxicity, withdrawal, or complications of polysubstance use. Toxicity management begins with airway and ventilation support, naloxone for significant respiratory depression, evaluation for co-ingestants, and consultation with poison control or medical toxicology when indicated. A negative routine urine drug screen does not exclude 7-OH exposure. Standard 5-panel and 10-panel urine drug screens (UDS) do not detect mitragynine or 7-OH.⁷

These alkaloids are identified only by specialized assays that target them directly, and those panels are rare; reserved for specific legal, medical, or treatment settings. As a result, a patient may present with a classic opioid toxidrome and a negative screen. Do not let the limitations of laboratory testing override the clinical presentation.

The toxidrome is real, and it still responds to naloxone. In 7-OH exposure, the history is the best diagnostic test. Ask about the product name, formulation, labeled milligrams, daily amount, frequency, time of last use, and co-use of fentanyl, prescription opioids, alcohol, benzodiazepines, stimulants, or other kratom products.

There is no validated 7-OH-specific withdrawal scale or standardized treatment protocol. Physicians should therefore extrapolate from opioid use disorder care. Case reports and small case series describe successful use of buprenorphine for kratom- and 7-OH-associated withdrawal and use disorder, but the evidence remains limited.^8-10

Standard buprenorphine should be initiated when the patient is in moderate withdrawal. Low-dose microinduction may be considered in selected patients, but current evidence on the safest approach to 7-OH is lacking.² Severe symptoms, unstable medical or psychiatric illness, polysubstance withdrawal, or inability to access timely outpatient care may justify observation or admission.

The Policy Patients Deserve

Federal action should include three commitments:

• Create a time-limited treatment bridge: no-cost rapid assessments, medication coverage without prior authorization, naloxone distribution, and funding for emergency department-initiated buprenorphine with seamless handoffs to continuing care.
• Fund the science with the same urgency as enforcement. Physicians need prospective data on toxicity, withdrawal timing, buprenorphine initiation, low-dose protocols, methadone treatment, pregnancy, relapse, and long-term outcomes.
• Direct enforcement toward manufacturers and sellers that market opioid-like products as benign wellness aids. Treatment should take precedence over incarceration.

In addition to federal support, emergency physicians have a role. We can ask about gas-station and smoke-shop products when there is a discrepancy between toxidrome and toxicology screening. We can report suspected cases to poison control centers, treat withdrawal without stigma, initiate evidence-based opioid use disorder care when appropriate, and insist that policies account for the patients they leave behind.

A patient who purchased a strategically labeled “wellness” product should not discover its opioid pharmacology only when trying to stop. The patient from 2 a.m. will still be in an emergency department bed when the scheduling order takes effect. The product may become illegal, but the dependence will not just stop. The DEA can remove a substance from a store shelf. It cannot remove established substance dependence, fear within a family, or responsibility from a health care system.

Scheduling should be the beginning of the response, not the end.

Dr. Anyanwu practices emergency medicine and addiction medicine in Houston.

Disclaimer: Opinions in this piece do not represent the views of ACEP nor ACEP official policy.

References

1. Drug Enforcement Administration. Schedules of controlled substance: temporary placement of 7-hydroxymitragynine above a specified threshold in Schedule I. Fed Regist. 2026;91(127):40917-40924. https://www.federalregister.gov/d/2026-13580. Accessed August 6, 2026.
2. Mulloy K, Nawab A, Patel D. Successful buprenorphine microinduction in patient with severe kratom (7-OH) use disorder. Poster presented at: 57th ASAM Annual Conference; April 24, 2026; San Diego, CA. https://annualconference.asam.org/fsPopup.asp?PosterID=776788&efp=UUdYWkdSQVIyNjg4MA&mode=posterInfo. Accessed August 6, 2026.
3. Obeng S, Wilkerson JL, León F, et al. Pharmacological comparison of mitragynine and 7-hydroxymitragynine: in vitro affinity and efficacy for μ-opioid receptor and opioid-like behavioral effects in rats. J Pharmacol Exp Ther. 2021;376(3):410-427. https://pmc.ncbi.nlm.nih.gov/articles/PMC7923387/. Accessed August 6, 2026.
4. US Food and Drug Administration, Center for Drug Evaluation and Research. 7-Hydroxymitragynine (7-OH): An Assessment of the Scientific Data and Toxicological Concerns Around an Emerging Opioid Threat. US Food and Drug Administration; 2025. https://www.fda.gov/files/drugs/published/7-hydroxymitragynin_7-oh_an_assessment_of_the_scientific_data_and_toxicological_concerns_around_an_emerging_opioid_threat.pdf. Accessed August 6, 2026.
5. US Food and Drug Administration. FDA issues warning letters to firms marketing products containing 7-hydroxymitragynine. July 15, 2025. https://www.fda.gov/news-events/press-announcements/fda-issues-warning-letters-firms-marketing-products-containing-7-hydroxymitragynine. Accessed August 6, 2026.
6. US Food and Drug Administration. FDA seizes 7-OH opioids to protect American consumers. December 2, 2025. https://www.fda.gov/news-events/press-announcements/fda-seizes-7-oh-opioids-protect-american-consumers. Accessed August 6, 2026.
7. Stolbach A, Connors N, Nelson L, et al. ACMT position statement: interpretation of urine opiate and opioid tests. J Med Toxicol. 2022;18(2):176-179. https://pmc.ncbi.nlm.nih.gov/articles/PMC8938527/. Accessed August 6, 2026.
8. Wightman RS, Hu D. A case of 7-OH mitragynine use requiring inpatient medically managed withdrawal. J Addict Med. Published online August 4, 2025. doi:10.1097/ADM.0000000000001558. https://pubmed.ncbi.nlm.nih.gov/40758956/. Accessed August 6, 2026.
9. Hendler R, Karavolis Z, Kim J, et al. A case of 7-hydroxymitragynine use disorder treated with buprenorphine. J Addict Med. Published online March 24, 2026. doi:10.1097/ADM.0000000000001685. https://pubmed.ncbi.nlm.nih.gov/41875249/. Accessed August 6, 2026.
10. Weiss ST, Douglas HE. Treatment of kratom withdrawal and dependence with buprenorphine/naloxone: a case series and systematic literature review. J Addict Med. 2021;15(2):167-172. https://pubmed.ncbi.nlm.nih.gov/32858563/. Accessed August 6, 2026.