Tox In Focus

Focused Clinical Reference

Vol. 06 · Kratom · July 2026

Drug Quick Reference

Drug Class / Mechanism

Mitragyna speciosa plant alkaloids

Opioid receptor agonists (mitragynine, 7-OH)

Street Names

Herbal Speedball, Biak-biak, Ketum

Kahuam, Ithang, Thom

Routes of Administration

Oral: capsule, tablet, powder, tea, extract

Less common: chewed leaf, smoked

Commonly Detected With

Opioids · Benzodiazepines, other sedatives

Metabolism

Hepatic: ester hydrolysis, O-demethylation, glucuronidation

Nine mitragynine metabolites identified

Window of Detection

Urine: not formally established

Est. 1 to 5 days from half-life (LC-MS/MS)

Control Status

Kratom leaf: not federally scheduled

Concentrated / synthetic 7-OH: DEA Schedule I intent (Jul 2026)

State laws vary

KRATOM

Mitragynine, 7-OH, and why routine opioid screens miss it

Kratom (Mitragyna speciosa) is a Southeast Asian tree whose leaves contain the alkaloids mitragynine and 7-hydroxymitragynine (7-OH), both opioid receptor agonists.³ Effects are dose dependent: lower doses are stimulant-like, higher doses are opioid-like, and typically last 2 to 5 hours.³ Standard opioid immunoassays do not detect kratom; identification requires LC-MS/MS.⁴

Why This Matters Now

On July 1, 2026, the DEA filed two Notices of Intent to temporarily place concentrated and synthetic 7-OH and three related substances (mitragynine pseudoindoxyl, MGM-15, MGM-16) into Schedule I of the Controlled Substances Act; HHS found no accepted medical use and high potential for misuse.¹ FDA had recommended Schedule I control of 7-OH in 2025.² The action targets concentrated and semi-synthetic 7-OH products sold as tablets, gummies, and dissolvable strips, not natural leaf kratom below the specified threshold.¹

⚠ Kratom is invisible to routine opioid screening. A person using kratom, or a high-potency 7-OH product, can return a negative opioid immunoassay; order LC-MS/MS when kratom use is suspected.

Clinical Presentation

INTOXICATION

Lower doses: increased alertness, stimulant-like effects

Higher doses: opioid-like sedation, analgesia, euphoria

Nausea, pruritus

Sedation, delirium at higher doses

Effects last approximately 2 to 5 hours

WITHDRAWAL

Follows repeated, sustained use

Opioid-like withdrawal features

Anxiety, irritability, restlessness

Myalgia, GI upset

Craving

Important: 7-OH-mitragynine is a far more potent opioid agonist than mitragynine. Concentrated and semi-synthetic 7-OH products can carry opioid-like overdose risk that natural leaf kratom does not; naloxone may be considered for opioid-like respiratory depression.

UDT Considerations

Kratom alkaloids are not detected by standard opioid immunoassays and are not part of routine screening panels. Definitive identification uses targeted LC-MS/MS measuring mitragynine and 7-OH-mitragynine, reported quantitatively in ng/mL.⁴ Ask the laboratory specifically for kratom (mitragynine) testing; it will not appear on a standard opioid confirmation unless requested.

Clinical Guidance

Ask directly about kratom and 7-OH product use; routine opioid screens will not reveal it.
When kratom use is suspected, order targeted LC-MS/MS for mitragynine and 7-OH-mitragynine.
Distinguish natural leaf kratom from concentrated or semi-synthetic 7-OH products; the latter carry greater opioid-like risk and are the focus of 2026 federal scheduling action.
A positive result indicates probable recent use within the window of detection; it does not establish dose or product source.
Screen for co-use of opioids and sedatives; kratom is frequently used alongside other substances.

Point-of-Care Testing Availability

Available strips

No commercially available point-of-care strip detects kratom alkaloids.

Clinical use

Kratom is not on standard opioid immunoassay panels; routine opioid screens do not detect it.

Limitations

Confirmation requires targeted LC-MS/MS for mitragynine and 7-OH-mitragynine.

KRATOM | Clinical & Program Guidance

Tox In Focus Vol. 06 · July 2026 · Page 2 of 2

Interpreting the Test Result

▲ If Testing Is Positive

Confirms recent kratom exposure. Detection of mitragynine and/or 7-OH-mitragynine indicates probable use within the window of detection.

Quantity does not equal dose. Levels are reported in ng/mL but do not establish the amount taken or the product source.

Screen-negative is expected. A positive LC-MS/MS result can accompany a negative opioid immunoassay; the two are not contradictory.

▼ If Testing Is Negative or Not Done

Does not fully exclude use. Absence may reflect timing of last use, low dose, or concentrations below the cutoff.

Not covered by opioid screens. A negative opioid immunoassay says nothing about kratom; only targeted testing does.

Window is limited. Half-life data suggest urine detection for roughly 1 to 5 days; longer gaps may read negative.

Metabolism & Urinary Markers

Kratom's principal alkaloids and the analytes measured on definitive testing.

Metabolite	Clinical Significance
Mitragynine	Primary alkaloid and main urinary test target; opioid receptor agonist.
7-OH-mitragynine	Minor alkaloid, substantially more potent opioid agonist; concentrated forms drive current safety concern.
Mitragynine metabolites (9 identified)⁵	Ester hydrolysis, O-demethylation, and glucuronidation products; parent drug found in urine in the low ng/mL range.⁴

Key References

Drug Enforcement Administration. DEA to Temporarily Schedule 7-OH and Related Substances to Protect Public Safety. Press release. July 1, 2026.
US Food and Drug Administration. FDA recommends Schedule I control of 7-hydroxymitragynine (7-OH). 2025.
Trakulsrichai S, et al. Pharmacokinetics of mitragynine in man. Drug Des Devel Ther. 2015;9:2421-2429.
Lu S, et al. Quantitative analysis of mitragynine in human urine by HPLC-tandem mass spectrometry. J Chromatogr B. 2009;877:2499-2505.
Philipp AA, et al. Studies on the metabolism of mitragynine in rat and human urine using LC-linear ion trap mass spectrometry. J Mass Spectrom. 2009;44:1249-1261.

DISCLAIMER: This document is intended for clinical reference and educational purposes only. It does not constitute medical, legal, or professional advice and should not replace independent clinical or programmatic judgment. Content reflects published data available at time of preparation. ToxiPharm LLC makes no warranties regarding completeness or applicability in all settings. | © 2026 ToxiPharm LLC | toxipharm.org