A 36-year-old woman, gravida 5, at 20 weeks’ gestation with a dichorionic-diamniotic twin pregnancy, ADHD, and anxiety was referred by her obstetric provider to stop 7-OH. She reported a two-year history, currently 15 mg six times daily (90 mg/day) from an online distributor, with escalating doses to maintain effect and avoid withdrawal, consistent with tolerance and dependence. An intake drug screen did not detect 7-OH, as routine immunoassays do not identify mitragynine or metabolites. She underwent a 7-day low-dose buprenorphine/naloxone protocol, titrating from 0.5 mg/day to 12 mg/day, then continued titration to 32 mg/day, above the FDA-labeled maximum, discontinuing 7-OH 18 days after completing induction. She was maintained on 16 mg/day at cesarean delivery at 38 weeks. Neither twin developed neonatal opioid withdrawal syndrome (NOWS) (birth weights 2670 g and 2830 g; Apgars 8 and 9; both appropriate for gestational age; length of stay 4 days). Postoperatively she took two kratom capsules for pain and was maintained on 24 mg/day.

Discussion: Low-dose buprenorphine induction enabled 7-OH cessation in pregnancy without a pre-initiation withdrawal period, with a favorable neonatal course and no NOWS in either twin. The requirement of 32 mg/day reflects both the increased buprenorphine metabolism of pregnancy and the dependence liability of concentrated 7-OH products, which differ substantially from traditional whole-leaf kratom. The buprenorphine-naloxone combination product was used, consistent with cohort data showing comparable or more favorable outcomes relative to buprenorphine alone. Because standard immunoassays do not detect 7-OH, a negative screen does not exclude use.