Severe kava withdrawal managed with phenobarbital

Piper methysticum, known as "kava", is a plant endemic to and historically consumed in the Pacific islands. The roots contain psychoactive kavalactones with sedating and anxiolytic effects. While often marketed for anxiety or as a safe alcohol alternative, dermopathy and more rarely hepatotoxicity are well described with heavy use. Reports of withdrawal are rare. The leaves of Mitragyna speciosa, also referred to as "kratom", contain psychoactive alkaloids with interactions at μ and δ-opioid receptors. Kratom is commonly used for its stimulant and opioid-like effects, for which dependence and withdrawal are much more well documented. A 45-year-old man presented to the emergency department (ED) with auditory and visual hallucinations, anxiety, insomnia, and diffuse muscle jerking. He had been heavily using a supplemental beverage containing both kava and kratom, but stopped several days prior. His primary physician initiated buprenorphine therapy for suspected kratom withdrawal. Bedside evaluation in the ED was concerning for ongoing GABAergic withdrawal in the setting of kava use. Phenobarbital was given with significant improvement in symptoms, with eventual transition to diazepam. He was discharged home several days later in good condition. Given the increasing popularity of herbal supplements including kratom, and more uncommonly kava, clinicians should be aware of their potential for abuse, dependence and severe withdrawal syndromes. Kratom may be managed in a fashion analogous to that of an opioid. While kava's pharmacologic properties remain poorly understood, withdrawal may be severe enough to warrant hospitalization. Phenobarbital or benzodiazepines may be considered as a potential therapeutic approach.