Kratom (Mitragyna speciosa) is a plant with opioid properties and potential for tolerance and dependence due to the psychoactive alkaloids mitragynine and 7-hydroxymitragynine, the latter up to 13 times as potent as morphine [1]. Withdrawal symptoms can include myalgias, insomnia, anxiety, and gastrointestinal distress [2]. Its prevalence of use has risen in the U.S., creating new perioperative challenges for anesthesiologists and surgeons [3].

There is limited evidence guiding the management of kratom withdrawal, though case reports have described using buprenorphine-naloxone, methadone, and clonidine to mitigate symptoms [2–3]. Recognition of kratom use is essential for anticipating opioid tolerance, hyperalgesia, and potential withdrawal. This report describes successful treatment of kratom withdrawal with methadone and highlights the importance of perioperative screening and coordinated management strategies.

A 41-year-old female with autoimmune hepatitis underwent living donor liver transplantation. Postoperatively, she experienced severe right abdominal pain unrelieved by multimodal analgesia including erector spinae plane, external oblique and intercostal fascial plane blocks, ketamine infusion, and hydromorphone PCA. Her pain severity remained up to 10/10 despite receiving 24 milligrams of hydromorphone in 24 hours. Further inquiry revealed daily kratom use for two months leading up to surgery. Given the suspicion of kratom withdrawal, intravenous methadone 10 mg daily was initiated, which achieved significant pain relief and decreased opioid requirement within 24 hours. The dosage was increased to 30 mg daily by mouth with sustained pain relief and resolution of withdrawal symptoms. At outpatient follow-up, her methadone was successfully tapered to 15 mg daily, with continued success. The patient expressed high satisfaction with her care.

This case illustrates the rising perioperative challenge of chronic kratom use. This patient’s opioid tolerance and withdrawal symptoms likely reflectedkratom-induced opioid tolerance. Multimodal analgesia was insufficient for her underlying hyperalgesia. Methadone’s long half-life and NMDA receptor antagonism offered dual benefits to her hyperalgesia and withdrawal, resulting in rapid pain control and decreased opioid requirements. She was successfully weaned off methadone completely after discharge, with no recurrence of withdrawal symptoms at follow up.