Kava-potentiated Withdrawal in Persons Using Multiple Substances: A Case Series of Kava and Kratom Co-ingestion

Kava (Piper methysticum) is indigenous to Pacific Island nations and has a long history of use in traditional medicine and ceremonies. Kava has effects similar to benzodiazepines, but its detailed mechanisms are uncertain. Although legal across the United States, kava is not without side effects. Currently, there are many kava and kratom blends accessible at stores and online. Recent case reports have emerged describing patient experiences with kava withdrawal when co-ingesting kava and kratom together; however, research remains scarce. This case series aims to add to the limited literature on kava withdrawal in co-ingestion of kava-kratom.

Publications before July 2025 were searched using the Ovid Medline, PubMed, and Google Scholar databases using the terms "kava", "kratom", "withdrawal", and "case report". The 2 case reports were found describing kava withdrawal symptoms and treatment when co-ingesting with kratom. This case series presents 2 additional cases from our institutions.

All 4 patients were male with underlying histories of psychiatric illness and alcohol use disorder. All consumed more than the recommended amounts of the kava and kratom. Kava withdrawal symptoms were similar to sedative withdrawal. The onset of these symptoms varied considerably in relation to the last dose. Paradoxically, symptoms of kava withdrawal were observed in some cases despite sedatives still being present in the patients' systems; however, the involvement of polysubstance complexes the exact etiology of symptoms. All patients improved with phenobarbital and/or benzodiazepines.

Exact kava mechanism is complex and not fully understood. Further research is warranted.