Kratom is legal, widely available, and increasingly landing patients in emergency departments—yet it often goes completely undetected on standard drug screens. In this episode of the Super Nurse Podcast, we break down the real-world nursing implications of Kratom use, from its dose-dependent stimulant and opioid effects to the rise of high-potency extracts driving overdoses in 2026. We cover bedside assessment blind spots, airway and aspiration risks, seizure red flags like “the wobbles,” dangerous drug interactions, and what nurses need to know about managing Kratom withdrawal. This is a critical listen for ER, ICU, PACU, psych, and inpatient nurses who want to stay ahead of an evolving substance-use crisis and protect patient safety through informed, judgment-free care.
Check out SuperNurse.ai for AI-powered learning, comic-book style printables, and common sense courses.Â
Kratom is a dose-dependent substance that acts as a stimulant at low doses and an opioid at higher doses
High-potency extracts, including concentrated 7-hydroxymitragynine products, are driving increased hospitalizations
Standard urine drug screens do not detect Kratom, creating a major assessment blind spot
Nurses must ask targeted history questions about herbal teas, powders, energy supplements, and brand names
“Toss and wash” ingestion carries serious airway and aspiration risks due to thick, hydrophobic powder residue
Kratom toxicity can present in three primary ways: opioid-like respiratory depression, stimulant-induced agitation, or seizures
Seizure risk is increased due to Kratom’s adrenergic effects and its inhibition of key liver enzymes that metabolize many medications
“The wobbles” is a critical slang term indicating neurotoxicity and increased seizure risk
Long-term use may cause hepatotoxicity, jaundice, pruritus, hyperpigmentation, and dental changes
Kratom withdrawal is severe and often leads to patients leaving against medical advice if not treated aggressively
Best practice withdrawal management includes buprenorphine, clonidine, and gabapentin
Chronic Kratom use creates cross-tolerance, complicating anesthesia and post-operative pain control
Nurses must approach assessment without judgment to reduce stigma and improve disclosure
Legal status does not equal safety, and Kratom represents a growing clinical and public health concern
Host: Welcome everyone to the Super Nurse podcast. I am so glad you're here with us today. This show is created by Brooke Wallace, a 20-year ICU nurse, an Oregon transplant coordinator, clinical instructor, and a published author. And our whole mission here is to empower the next generation of super nurses. Today, we're diving into what you could call a silent epidemic. It's something that is almost certainly happening in your hospital, probably on your unit right now, and there's a very good chance you aren't seeing it on the box screen.
Guest: Exactly. We're talking about Kratom and I think for a long time it felt like this niche internet thing, but the research we're looking at today shows a completely different story. The shift has been massive and it feels like it happened overnight. The clinical data we're seeing now from 2026 suggests the numbers are just staggering. Something like 20 million adults in the US are using it. And we're not just talking about some herbal tea anymore; the big change is this massive surge toward high potency extracts.
Host: And that's what's landing people in the ER.
Guest: Right. So, our mission today is really to equip you, the nurse at the bedside, with what you need to know. We're going to hit the pharmacology, the assessment tools for that clinical blind spot and the specific withdrawal protocols.
Host: Okay, so let's jump right into the pharmacology because this is where it gets interesting.
Guest: Well, it's weird. They call it a chameleon drug and that really fits. It's the best way to describe it. It's completely dose dependent which is, you know, something we see every day. The actual nature of the drug's effect flips based on how much is taken.
Host: So a low dose, what are you talking like one to five grams?
Guest: Yeah, exactly. 1 to five grams of the raw leaf powder. In that range, it acts pretty much just as a stimulant.
Host: So on my assessment, I'm looking for tachycardia. Maybe the patient's super alert, anxious.
Guest: Yep. It looks like a mild amphetamine response or just way way way too much caffeine. But, and here's the pivot. At high doses, say 6 to 15 grams, it flips. It becomes an opioid, you get euphoria, sedation, analgesia, the whole nine yards.
Host: Which explains why we see patients presenting with that classic picture, you know, unconscious, slow breathing, pinpoint pupils. But the mechanism behind it isn't just hitting opioid receptors, is it?
Guest: It's messy. It's incredibly messy. The alkaloids, mitragynine and 7-hydroxymitragynine, act as partial mu-opioid agonists. That's the opioid part. But they also hit adrenergic and serotonergic pathways. That's the stimulant part. So you've basically got a speedball, an upper and a downer all wrapped up in one plant.
Host: Wow. And that brings me to this trend that the 2026 data is highlighting, the rise of 7-OH. This seems like the real game changer.
Guest: It is. It absolutely is. For years, the argument was that raw Kratom was safer than say fentanyl because it had a respiratory ceiling effect.
Host: That's it was a partial agonist.
Guest: Exactly. So it wouldn't fully depress breathing as easily as a full agonist like heroin. It was like a dimmer switch that couldn't go past 50% brightness.
Host: A perfect analogy.
Guest: But these 7-OH tablets are different. They're semi-synthetic highly concentrated extracts of just the 7-hydroxymitragynine.
Host: So they isolated the most potent part.
Guest: And research is showing that in this concentrated form it acts much more like a full agonist.
Host: So it breaks the dimmer switch. It completely removes that safety ceiling.
Guest: That's it. And that's why we're seeing hospitalization rates climb. People think you're taking a legal supplement, but pharmacologically, it's behaving like a very potent synthetic opioid.
Host: That is terrifying. Which leads us right into the clinical blind spot, the assessment piece, the toxicology trap. This is the bane of every ER doc and nurse right now. A patient comes in, they're nodding out, pupils are tiny, respiratory rate is like eight.
Guest: Classic opioid overdose.
Host: So, you run the standard five panel, maybe even a 10 panel urine drug screen. And you get nothing. It comes back clean. And I can see a newer nurse or even a seasoned one thinking, okay, well, it's not opioids. But Kratom just doesn't show up.
Guest: It does not. Not unless you order a very specific test for mitragynine, which can take days to come back. So, your assessment has to be all about history and observation. You can't just ask, "Do you use drugs?". I've had patients look me dead in the eye and say, "No," because to them, it's a natural supplement. You have to speak their language.
Host: Yeah. Ask about herbal teas. Ask about energy powders or even specific brands, right? Like Liquid Gold or OPMS.
Guest: Exactly. And speaking of how they take it, there's a huge nursing risk. We need to talk about the toss and wash.
Host: Uh, I've read about this. It sounds awful.
Guest: It is. So, the powder itself is hydrophobic. It repels water.
Host: It clumps.
Guest: Yes. So, this method involves just dumping a scoop of dry chalky powder into the back of your throat and then trying to chase it with water.
Host: It's like that old cinnamon bin challenge, but with a psychoactive drug.
Guest: Precisely. Now, imagine your patient does that, gets sedated, maybe passes out, and then vomits. That vomit isn't liquid. It's a thick, clumpy, hydrophobic paste. It just coats everything.
Host: In a standard suction catheter, it would clog instantly. We're seeing some really nasty aspiration pneumonia cases because of this. So, if your patient admits to toss and wash, you have to be on high alert for airway protection. It's such a critical pearl. Okay, so let's shift to the ER presentations. The research talks about three faces of toxicity. It's not always the sleepy patient.
Guest: No. And that's what makes triage so difficult. The first phase is the one we know, the opioid mimic. Slow breathing, low blood pressure, maybe blue lips.
Host: And for that patient, we're still giving Narcan.
Guest: Absolutely. Naloxone is still first line, but the data suggests you might need higher or repeated doses compared to a heroin overdose because the alkaloids bind really tightly to those receptors.
Host: Okay. But then there's the second phase which is the complete opposite, right? The stimulant agitation presentation. This is your patient with a heart rate of 130. They're diaphoretic, combative, maybe even paranoid. So that looks more like a meth or coke overdose.
Guest: It does. And giving Narcan to that patient isn't going to do much. The treatment there is benzodiazepines, Ativan, to calm them down.
Host: Okay, so that's two. What's the third phase?
Guest: The third one is the one that really catches people off guard, the seizure.
Host: This one really jumped out at me in the notes. I mean, a natural leaf causing status epilepticus.
Guest: And it's not just in overdose situations. It's a perfect storm of neurology and believe it or not liver metabolism.
Host: How so?
Guest: Well, first Kratom itself can lower the seizure threshold because of those adrenaline surges. But the bigger sneakier problem is the drug interaction. Kratom is a potent inhibitor of key liver enzymes, specifically CYP3A4 and CYP2D6.
Host: Okay, so let's break that down. Those enzymes are the workhorses that metabolize a ton of our medications, a huge percentage of them. So picture this, you have a patient with epilepsy, stable on their phenytoin, they start taking Kratom for their back pain, and the Kratom blocks the enzymes that break down the phenytoin.
Guest: Exactly. So their seizure med levels go completely haywire. All of a sudden, a patient who's been seizure-free for years is in full-blown status in your ER.
Host: That is terrifying. Is there any kind of warning sign?
Guest: There often is, but you have to know the slang for it. Users call it the wobbles.
Host: The wobbles. Sounds almost cute.
Guest: It sounds harmless, but physiologically it's nystagmus, that involuntary eye twitching. They'll say their vision gets jumpy or they feel really dizzy. If a patient tells you they got the wobbles, that is a massive red flag for neurotoxicity.
Host: So, if I hear that phrase, I'm thinking seizure pads, suction at the bedside immediately.
Guest: That's your warning shot. Absolutely.
Host: Okay. So, moving from the acute ER presentation, let's say we have a patient admitted for something else entirely and they're a chronic user. What are the long-term signs we should look for?
Guest: You want to look for what some are calling the yellow presentation. That's the hepatotoxicity. It's idiosyncratic, so we can't predict it, but it usually shows up 2 to 8 weeks after they start using.
Host: So, we're talking jaundice, tea-colored urine and extreme itching. Pruritus. If you have a healthy 25-year-old in sudden liver failure with no other risk factors, you have to ask about Kratom. And what about Kratom teeth? Is that a real thing?
Guest: It is. It looks a bit like meth mouth, but it's from severe chronic dry mouth, xerostomia, plus the general neglect you sometimes see with heavy use.
Host: Any skin changes?
Guest: Yes, hyperpigmentation. We see these dark brownish patches on the cheeks.
Host: Okay, so we've identified our patient. They're in the hospital, they can't take their Kratom. Now we're facing withdrawal and from what I've read they call it the flu from hell.
Guest: It's brutal. You have to remember they're withdrawing from an opioid and a stimulant at the same time. It's a double whammy.
Host: What's the one symptom that makes someone leave AMA?
Guest: Almost always the restless leg syndrome, but it's more than that. They describe it as body zaps or like their skeleton is trying to crawl out of their skin. It's unbearable.
Host: So, if we don't treat that aggressively, we lose them. What's the protocol? Are we still using the COWS scale?
Guest: Yes, the clinical opiate withdrawal scale is still the tool to use, but the medication management has really been refined. The gold standard in 2026 is Suboxone (Buprenorphine).
Host: Okay. Now, with fentanyl, starting Suboxone is really tricky. Is it the same with Kratom?
Guest: It's actually a bit easier because Kratom is a partial agonist. The risk of putting them into precipitated withdrawal is lower. You can often start the Suboxone much sooner like 8 to 12 hours after their last dose.
Host: That's huge for getting them comfortable fast. But Suboxone won't fix that adrenergic storm, the anxiety and sweating.
Guest: No, for that you absolutely need Clonidine. And for the RLS, I cannot stress this enough: Gabapentin is critical.
Host: Gabapentin really seems to be the MVP for that crawling out of your skin feeling.
Guest: It is. If you're not pushing for Gabapentin for these patients, you're leaving them in agony and they are much more likely to walk out. And we can't forget the mental health aspect. The psychological crash is severe. Profound depression, even suicidal ideation, especially in the first 48 hours. Their brain chemistry is just bottoming out. They need close observation.
Host: This all brings up the real world problem of stigma. The patient has to be honest with us for any of this to work. And they're terrified of being labeled a drug seeker. If they sense judgment, they'll shut down.
Guest: I always say safety first, judgment never. If you frame it as "I need to know what you're taking so I don't accidentally harm you," you're more likely to get the truth.
Host: Exactly. And speaking of harm, let's talk about the anesthesia curveball. Oh, this is fascinating. What's happening in the OR?
Guest: Massive cross tolerance. A chronic Kratom user goes for surgery. They wake up in the PACU and the standard dose of fentanyl, it does nothing. It just bounces right off.
Host: That's a PACU nurse's nightmare. The patient is in agony and your go-to meds aren't working.
Guest: And that's when you have to pivot. Anesthesiologists are finding they have to use things like ketamine drips or other non-opioid strategies because mu receptors are just saturated.
Host: I want to touch on one last sensitive topic before we wrap this up. Nurses as users.
Guest: It's a very real thing. The job is physically and emotionally draining. Kratom is marketed as this natural way to get energy and manage back pain. And because it's technically legal in many places people think their license is safe. But that's changing as random drug testing in healthcare expands to include Kratom. People are putting their entire careers on the line.
Host: It really hammers home that legal does not equal safe.
Guest: Not at all. We have states passing the Kratom Consumer Protection Act to regulate it. But that doesn't change what it does in the brain. It still hits opioid receptors.
Host: Okay, we have covered so much ground. Let's boil it down. What are the top takeaways for a nurse walking onto their shift right now?
Guest: Four things. One, Kratom is a hybrid: stimulant at low doses, opioid at high doses. Two, don't trust the drug screen. You have to ask the right questions about teas and powders. Three, watch for seizures. If you hear "the wobbles," think neurotoxicity and be ready. And four, treat withdrawal with everything you've got: Suboxone, Clonidine, and especially Gabapentin. Be aggressive with their comfort.
Host: This is all such critical information. Thank you so much for breaking it down for us.
Guest: Of course.
Host: Before we sign off, I just want to leave our listeners with one final thought you brought up which I think is so important. We have this substance, right? It's sold in gas stations, acts like an opioid, causes seizures, and it evades our standard tests. So, the question we have to ask ourselves is, are we treating a supplement problem? Or are we really looking at the next wave of the opioid crisis just disguised as a cup of tea?
Guest: A really powerful question to consider.
Host: That's all the time we have for today. To keep learning and to become the most prepared nurse you can be, visit super nurse.ai. We have AI powered courses and tons of superpowered nursing resources waiting for you. Be sure to subscribe so you don't miss our next episode. Stay safe out there.