New Peer-Reviewed Review:
What Physicians Need to Know About Kratom

A new review in Missouri Medicine by Drs. Mark Gold and Nicole Avena urges physicians to distinguish natural kratom leaf from the concentrated and synthetic 7-OH products sold under the kratom name.

A new peer-reviewed article, Kratom in Clinical Practice: What Physicians Need to Know, by Mark S. Gold, M.D. (University of Florida College of Medicine) and Nicole M. Avena, Ph.D. (Icahn School of Medicine at Mount Sinai), appears in the July–August 2026 issue of Missouri Medicine, the journal of the Missouri State Medical Association. It is now indexed in PubMed.

The review gives physicians practical guidance on screening, counseling and documenting care for patients who use products labeled "kratom" - many of which are not natural kratom leaf at all and require differentiation in terms of treatment and care.  Its central point is that the type of product matters more than the label.

Key takeaways

  • Not all "kratom" is the equal - an in fact many products that call themselves kratom are not. Natural kratom leaf contains a mix of alkaloids, the most abundant beingmitragynine, and contains only trace amounts of natural 7-hydroxymitragynine (7-OH). Many products now sold labeled falsely as ‘kratom’ contain concentrated, semi-synthetic or synthetic alkaloids. In some of them, synthetic 7-OH is present at more than 100 times the level found in the leaf.

  • The risks are different. The review notes that regular use of the leaf can lead to mild to moderate  tolerance and dependence in some people. However, controlled clinical studies of measured doses of whole leaf reported no serious adverse events. Concentrated synthetic  7-OH products, by contrast, have opioid-like potency and have been linked to respiratory depression and greater abuse liability.

  • Adverse-event data need careful reading. Surveillance systems often don't separate whole leaf from high-potency synthetic products like synthetic 7OH, and many reported cases involve other substances. From 2017 to 2023, poison centers recorded 23 deaths associated with "kratom," and more than a third of those involved other substances. Over the same period, more than 2,000 deaths were linked to opioid-related calls.

  • Ask, document, respond. The authors recommend that physicians ask whether a patient uses whole-leaf powder, an extract or a concentrated synthetic 7-OH product, and record which one in the chart. Patients using concentrated synthetic products need closer monitoring, especially those with a history of opioid use disorder.

  • Regulation should draw the same line. The authors observe that some state actions treat every kratom-labeled product the same. They cite Missouri's 2026 enforcement against synthetic 7-OH retailers as an example of targeting concentrated products specifically.

[Download the one-pager (PDF)]

Read the full article (free): https://pmc.ncbi.nlm.nih.gov/articles/PMC13585002/
PubMed listing: https://pubmed.ncbi.nlm.nih.gov/42757335/
Press release: HERE

Citation: Gold MS, Avena NM. Kratom in Clinical Practice: What Physicians Need to Know. Missouri Medicine. 2026 Jul–Aug;123(4):292–297. PMID: 42757335.

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