Speakers - 2026

Title: Biphasic Withdrawal Delirium: Abrupt Cessation of a High-Dose Kratom-Kava Beverage

Abstract

We describe a 43 year-old man with generalized anxiety disorder and major depressive disorder, stable on escitalopram and lamotrigine for over twenty years, who presented after abrupt cessation of fifteen bottles per day of “Feel Free” Classic Tonic, a commercial kratom-kava beverage, taken daily for six months. He had been introduced to kava and kratom preparations during service in the U.S. Navy. Initial presentation was consistent with opioid-like withdrawal including autonomic hyperactivity and GI distress. On hospital day 5, the patient acutely decompensated with agitation, visual hallucinations, paranoia, and wandering, requiring ICU transfer and dexmedetomidine. The biphasic course is best explained by early withdrawal from kratom (mu-opioid agonism via mitragynine) followed by delayed GABAergic withdrawal from kavalactones. The patient improved with benzodiazepine management and was discharged with plan to attend outpatient abstinence program. This case highlights a poorly recognized dependence syndrome from an unregulated, legally available product.

What will the audience take away from your presentation?

1. Recognize the biphasic withdrawal trajectory of combined kratom-kava products. Kratom produces an early opioid-like withdrawal (GI distress, autonomic hyperactivity, tremor), while kava produces a delayed GABAergic withdrawal that can progress to delirium with psychotic features. This two phase pattern is predictable based on the divergent pharmacology and helps clinicians anticipate clinical deterioration in patients who initially appear to be improving.
2. Screen for unregulated commercial supplements in every substance use history. Products like “Feel Free” contain pharmacologically potent compounds at high doses but are marketed as herbal supplements and will not be detected on standard urine drug screens. Patients often do not consider these products to be drugs. A thorough history must explicitly ask about energy shots, tonics, and natural supplements.
3. Interpret toxicology in clinical context. In this case, a positive benzodiazepine UDS was temporally linked to ED administered lorazepam, not pre-admission use. Attributing this result to undisclosed benzodiazepine use would have led the clinical team down the wrong path. Toxicology results should always be cross-referenced with the medication administration record.
4. Apply a practical management framework. The kratom phase responds to supportive care and clonidine. The kava-driven GABAergic withdrawal requires symptom-triggered or scheduled benzodiazepines, with dexmedetomidine available for breakthrough agitation. Rapid improvement with benzodiazepines in this case confirmed the GABAergic withdrawal mechanism.
5. Anticipate dependence from legally available products and counsel accordingly. Kratom and kava remain unregulated at the federal level. Patients and clinicians alike may underestimate the risk of dependence and withdrawal from these substances. This case demonstrates that severe, life-threatening withdrawal is possible and warrants the same clinical seriousness as withdrawal from scheduled substances.