Emerge in EM

E14: 7-Hydroxymitragynine (7-OH) toxicity with Dr. Pizon

• Mohamed Hagahmed

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In this episode of EMERGE, I sit down with my friend and colleague, Dr. Tony Pizon, Chief of Medical Toxicology at UPMC, to dive into a topic that’s been showing up more and more in our emergency departments: 7-Hydroxymitragynine (7-OH).

I wanted to understand what 7-OH is, how it’s connected to Kratom, and why it’s suddenly making headlines. Tony and I break down the science, discuss the clinical effects, and talk about why products like vapes and gummies containing 7-OH are so concerning—especially when they’re packaged to look like candy and marketed as “natural.”

We share real cases, practical management tips (including when and how to use naloxone), and highlight the risks for kids and the importance of public health reporting. My goal with this conversation is to give you the latest insights, actionable advice, and a better understanding of how to recognize and manage this emerging toxicology threat.

Whether you’re a fellow healthcare professional or just want to stay informed about what’s happening in emergency medicine, I hope you find this episode as eye-opening and useful as I did.

M0:

welcome again to EMERGE where we explore emergency medicine education, resuscitation and global health empowerment. I'm your host, Dr. Mohamed Hagahmed. Today we are tackling something that is making headlines and unfortunately showing up in our emergency departments. 7-OH or 7-Hydroxymitragynine. To help us unpack this, I'm joined by a colleague, a friend, and a human being that I admire. This is Dr. Tony Pizon I'll let you introduce yourself to our audience. Tell us about who you are and what's new in your life these days.

Tony:

Thank you Mohamed, and kudos to you too. You a good friend, colleague. Mohamed has been a longstanding friend, so thank you for inviting me and being part of your show. My name is Tony Pizon. I'm the chief of Medical toxicology at UPMC, and I live everything poisoning and overdose. You think I would've tried some of these drugs at some point in my life, Mo, but I'm the biggest weeb known to mankind. But we are here to talk about drugs

M0:

Don't try anything stupid, Tony.'cause we need you. And that's why we need you here to educate us and inform us about what's happening out there on the streets. I feel like Tony, we can't get enough. First was Fentanyl, heroin xylazine and medetomidine And now this new 7-OH. So can you tell us exactly what 7-OH

Tony:

is? Yeah. 7-Hydroxymitragynine, it's really a metabolite or a semisynthetic compound from Mitragynine, which comes from a plant in Southeast Asia. It's been well known and well used in that area of the world, and now it's sort of making its way here for various nefarious reasons, of course, you know, for people to enjoy, get high, use it illicitly and so forth. So, yeah, it's um. started off as Mitragynine the plant substance and the metabolite, 7-Hydroxymitragynine has become much more popular and now has become the mainstay because it's more potent and, and a more avid mu agonist.

M0:

You know what Tony? I do walk by these vape shops, and I always see these big, bright, shiny signs of Kratomm and all these flavored vapes and it's just so tempting. And when you get in, you just get hit with this kind of interesting smells and incense and you almost like calm down immediately as soon as you get to one of these shops. I'll tell you what, like Kratom, I was not aware of what that is until I read about Can you tell us more about Kratom? What is it actually used for?

Tony:

Yeah, Kratom has been used for lots different things, usually to treat, you know, pain, diarrhea, anxiety, depression. It's been touted to, to treat all sorts of different things. Granted, there's no medical evidence that it really helps or treats any of these illnesses. But based on its mechanism, it does make sense to help these things. So it's been used for many years, many decades,

M0:

And the reason why I'm bringing up Kratom'cause Kratom is. Naturally, like you said, natural plants and I love the word natural'cause the moment you say natural is implied as safe and healthy and detoxifying. So 7-Hydroxymitragynine is an active alkaloid that is found in Kratom. And what is the difference between the two? Obviously one is more synthetic and one is more natural. Like how did we get from Kratom to 7-OH.

Tony:

Everyone's always looking for that. Bigger, better, more potent high and buzz and so forth. And you hit the nail on the head too. Mo it, it's, I always chuckle to myself and we say, this is natural, so it must be healthier. Tobacco is a natural plant, but we know it has dozens of carcinogens. I. So too, like Kratom, we don't know it's carcinogenicity, but we do know that it has these effects that people are seeking. And 7-Hydroxymitragynine is, like you said, it's semisynthetic, that it's really metabolite of Mitragynine. But now that we know that it's. Much more potent than the parent compound. People are chemically synthesizing 7-Hydroxymitragynine so that we can take that directly and not worry about having metabolize it. And then you can have more potent effects of Mitragynine. So that's really where we've gone make things more potent. That way you can get, a bigger clinical effect or a bigger high, if you will

M0:

Got it. And what are the physiologic effects of 7-OH?

Tony:

Yeah, most people will say that low dose, they get a stimulant like effect from it. Maybe some euphoria, maybe, a little bit of amped up if you will. But then in higher doses, what we definitely see. Are more sedative effects pinpoint pupils severely. In severe case, you can have some respiratory depression more opioid like effects at higher concentrations.

M0:

I see. So this is to Kratom what cocaine is to coa leaves, and morphine to poppy, right? This is this a correct analogy?

Tony:

Yeah, I think it's very similar and honestly, I look at Kratom much like maybe Suboxone because it has A higher affinity for the mu receptor, but it seems as if it behaves more like a partial agonist than a full agonist.'cause we're not seeing, fortunately, with it, even though it, it's an opioid, if you will, or has opioid like effects. We're not seeing the, the severe respiratory depression in most cases.

M0:

I was looking into this from a data perspective and I was asking myself who's actually using this. I know we see a lot of patients who vape. But I was specifically interested like who's the specific population using this? And the data really are limited. But the poison centers, I think they started tracking 7-OH specifically this year between February and May. So not enough data. And the numbers that I saw they had over 50 cases. Including kids, and please correct me if I'm wrong, by July, that number had climbed to 1 65 cases and overall the Kratom related exposures were already higher than the total for all of last year.

Tony:

Yeah.

M0:

Is that right? You're seeing something different.

Tony:

No, you're exactly right. It's interesting we're, it's not a huge issue. When you compare it to, the fentanyl epidemic and even cocaine use and alcohol use and so forth as the numbers you've mentioned, but it's the trend that's concerning to us both you and me. Prior, in 2023, we were seeing maybe 30 cases reported to the poison center. Now, in this year alone we're seeing well above that. So you can see the trend is what's concerning, like where is this going and who's using it? It, and I don't know that we have a great grasp on that because the Poison Center data is limited, but they have everybody of all age ranges from toddlers to 80 year olds in that mix. And I don't know if it's. People seeking a high, somebody looking for an antidepressant, toddlers getting into parents' medications or stashes of drugs. So it's hard to know.

M0:

Can people with chronic pain who might be looking for a different alternative for pain control, use that as well.

Tony:

Yeah, it's been used for pain for many years. That's why I think, honestly, it may not be bad to research a little bit to see if, does it have better pain effects without the terrible effects that we see with a lot of the other opioids that we're using. So there may actually be something to this. The FDA has taken the stance of putting a big no-no on it because it's not FDA approved for any indication at the moment.'cause there's just not any research on it at the moment. So there's just nothing known about its safety profile.

M0:

Has it always been mixed in vape products? Or this is like a new kind of discovery that this specific 7-OH can result in potent euphoria or dependency.

Tony:

That's a

good question. Yeah. Kratom traditionally was smoked

Tony:

or you would ingest or make a tea. Even people with some people would chew it, like chewing tobacco. That's traditionally how it was used. And here too, that's how most people would use it. You'd get the plant material, you can make a tea, chew it. Put it in pill form and swallow it whole. But yeah. Now like you had mentioned. The trend is to take something and make it as potent and as strong as possible. So now moving towards taking the Kratom taking the mitragyniotic Kratom and synthesizing that 7-hydroxymitragynine so your body doesn't have to metabolize, but instead you can have an immediate more potent effect. So it it seems like this is becoming a newer trend, to your point.

M0:

I randomly walked into a vape shop, and I was really just curious, looking at the packaging and everything else. What jumped at me, just like the bright colors the candy-like gummies. It almost like walking into a dessert shop. Like after having dinner, I might just maybe get a little sip of 7-OH for my dessert just to feel good. Let's get, get the night going. But to me that's so dangerous. These bright colors and kids going in with their parents trying to get their vape. Can I get a gummy of this pink stuff? It's like there's a risk for accidental pediatric exposures. So I wanted to ask you, have you seen kids overdose on this?

Tony:

Yeah it's, that's a huge point because we see this with marijuana too. You're right. Those vape shops are very appealing. Neon lights are bright and colorful. Yeah. Who are they marketing to? Because it's unlike other marketing. And we do see toddlers get into this, or children who don't know what this may be, it looks appealing, so they may get into it. I'm not aware of Kratom in any candies or whatnot, so I don't think it's to that level, but I could certainly see that coming down the pipe. We definitely see this with marijuana products. They're marketed very colorfully. They look like candy. They taste like candy. They are candies, but they just have lots of marijuana in there, but you're right I think the packaging is very concerning and certainly does not dissuade a child from opening it.

M0:

So let's get into some clinical scenarios just to help our listeners think about this in practice. So the first case it's a college student, 21-year-old, brought in by EMS being bagged after being found in a dorm. And the roommate told EMS that he's been hitting a vape that he bought from the local shop. EMS is bagging the college student. Pinpoint pupils, hypoxic initially with bagging goes up to maybe 89% GCS of seven. So this to me, Tony looks like a opioid toxidrome. And I see them and give Narcan. Is that what you would do as well? Is there anything else that I should be thinking about?

Tony:

That hit the nail on the head. Everything is pattern recognition for us too. And this is just another toxidrome that fits the opioid toxidrome: respiratory depression, pinpoint pupil, sedation. So regardless of the opioid or opioid- like compound that may be causing it. Naloxone would be the answer. And Naloxone has shown to have benefit with severe cases of Kratom. Rarely do we see it to this degree, but certainly if you are exposed to enough, anything is possible.

M0:

And obviously we consider other differential diagnoses, right? CNS, infection, trauma, rhabdo, all the other stuff. Electrolytes, of course, but.

Tony:

yeah.

M0:

Specifically Narcan. So let me just get dive deeper into Narcan for this situation. What would be your initial starting dose? The usual two milligrams. Intranasal, intramuscular? Would you go higher? Would you go lower?

Tony:

If we are talking first responders and all they have access to is the intranasal four milligrams, by all means give it. You're talking more, you're getting more sophisticated with a paramedic who has a little bit of time to start an iv. And you can titrate 0.4 milligrams or 0.2 milligrams at a time. I preferably like the smaller doses because I like the breathing, but, sleeping patient, right? You push too much naloxone and then you precipitate withdrawal potentially, and then you have vomiting and agitation, and then you have to deal with that backend. So I'm not sure a college student necessarily in this case scenario, would have that level of tolerance. You'd worry about that. But if you're, depending upon your level of training first, responder bystander, give what you have. If you have time. And you're a paramedic or a physician or nurse, and you can give smaller doses. That's what I would do, but get what you have access to first because obviously you want the patient awake and breathing

M0:

Absolutely. So keep them breathing. Not fully awake to prevent and avoid withdrawal symptoms. Now, I know you love urine drug screen. Tony, you dream about UDS, you dream about CUDS which is a comprehensive urine drug screen and all of the chemical structures associated with it. Would this show up on the UDS, the plain UDS that you and I order in the ed? Not the comprehensive ones.

Tony:

No, the structure is very different from other opioids and opiates, so it's not gonna trigger your opiate depending upon what your hospital screen may look like. You may have an opiate screen that's not gonna trigger that positive. If you have an individual fentanyl screen or methadone screen or what have you, it's not gonna trigger those positives, unfortunately. Now, the comprehensive that we love here as well, that we order frequently, we do this by LCMS, that we can find that on the comprehensive that takes an hour or two to come back. It's a little. Labor intensive. It's not as quick as the urine drug screen and most hospitals don't have access to that. It may take days to come back. We do have that luxury. So yeah, the regular drug screen know more comprehensive drug testing.

M0:

And regardless, the management is the same, supporting the airway, supporting the hemodynamics, and like. Preventing withdrawal, which is a nice segue to the next case. So this is a 48-year-old who was taking oxycodone for chronic back pain. Very anxious, very diaphoretic hypertensive in triage was vomiting, so the nurse moved him to the high acuity area and he reported taking 7-OH gummies to supplement his oxycodone therapy for his chronic back pain about two days ago. So this sounds like withdrawal symptoms, tachycardia, hypertension tremulous agitated, anything that I should be more cautious when it comes to managing these patients with withdrawal symptoms like this.

Tony:

Yeah. Now the, now you're getting into more typical dependency issues. And you're right, since Mitragynine may be a partial agonist, you may actually precipitate withdrawal with it. That's definitely a possibility for someone who has the tolerance to more traditional opioids like oxycodone. Now, yeah, this becomes an opportunity. It's hard for the, the emergency medicine physician, but now I'm wearing my addiction hat, right? This is an opportunity for us to maybe engage them with addiction treatments, buprenorphine, methadone, something else to get them off of these chronic opioids. I know they have your, this person has chronic pain, so that's another issue to deal with as well. But yeah, this is a, an opportunity now, less emergency related stuff. In terms of pushing Narcan, but maybe an opportunity to get them to the right direction in terms of seeking help and maybe Buprenorphine or Suboxone or something along those lines.

M0:

And walk me through your algorithm When managing these patient acutely, would you directly go with buprenorphine.

Tony:

Honestly, it really depends on the patient. The, if the patient is not ready to engage in treatment, then it's, it stops right there. And this patient may not have a true addiction problem. Maybe it may be dependence depending upon what the back scenario is for their chronic pain. Maybe they do have pain and maybe they've had bad advice and have been on opioids for a long time for this chronic issue that didn't really require opioids. So that sometimes becomes tricky what to do with that. And you may have to deal with the pain first before you get them help with their addiction so that it's hard. If a person recognizes they have an addiction or they've been using higher doses, honestly, buprenorphine and buprenorphine products are really easy to start in the emergency department. Methadone's a little bit trickier because they need to go to a methadone clinic daily, but buprenorphine products, whether it be long-acting depot effects or the strips or what, those are usually fairly easy to get patients started on from the emergency department if the patient's ready.

M0:

Do these patients with these 7-OH gummies or overdoses and then not present to you with like withdrawal symptoms, do they have a tendency to get admitted to the ICU? Like the same thing we've seen with Medetomidine withdrawal.

Tony:

No, Medetomidine is a whole another animal, but yeah, typically, no. Fortunately, most opiate withdrawals, are managed at home as an outpatient, which is fine. It's been a new phenomenon that we've unfortunately been admitting many withdrawal patients to the ICU, thanks to the Medetomidine surge. So yeah, usually it could be managed at home as long as they can. They're not vomiting terribly. They can take stuff by mouth.

M0:

Depending on the severity of the withdrawal, just thinking out loud, so maybe clonidine, buprenorphine ondansetron, just symptom management. Severe withdrawal. We're thinking about IV routes, so maybe IV pain medications. Benzos?

Tony:

I try to avoid benzos for the overall patient. But yeah, you can do IV opioids if you have to. Yeah, the sky's the limit. If they're really vomiting, we've given a. IM doses of opioids. If you can't get an IV easily sometimes, obviously IV access is a struggle with patients struggling with IV opioid use disorder.

M0:

That makes a lot of sense. So let's get to the last and scariest scenario for me. So a 6-year-old boy brought into the ed, found lethargic open candy- like package that is labeled as 7-OH apple chews found near the child at that time by EMS. On arrival to the ED heart rate of 140s, BP 150s/90s. Pinpoint pupils intermittently apneic, O2 SATs 89% just on high flow. But then now he's being assisted with ventilation with BVM. Anything else I should consider specifically for these type of overdoses, other than what we normally do in the ED when it comes to airway support and hemodynamic support.

Tony:

That's the nice thing about this, Mohamed, is that, we have the tools for this already, even though it's a new substance to us or newer emerging, if you will. We have naloxone. We have our typical agents, so we have, quote, an antidote. Unlike marijuana, we really don't have a great antidote. So sometimes kids come similarly presenting hypoxic, respiratory, depressed after marijuana gummies. They just get intubated, right? There's no good antidote. But fortunately with Kratom, we can try Naloxone to see if that helps and maybe avert some of the other downstream

M0:

And Tony, can you tell me a little bit about the pharmacodynamics? What is a half-life for 7-OH? How long do they last in the body? And how long should be washing these patients adults and pediatrics?

Tony:

That's a good question. Yeah, the halfway is about three to four hours, so it's on the shorter end, fortunately. You know in Tox, everything's six hours, right? So we watch everybody for six hours. But honestly and truthfully if someone comes in after exposure and you're worried, especially in a toddler who got into a parent's package of gummies and you're not sure, we would say you would see something within a couple hours. But typically just to be sure, watch'em for six to make sure nothing. Avails of itself. But these are also good opportunities too to teach the parents like, we need to keep this stuff outta harm's way. Lock boxes are super handy. Or sending patients and families home with naloxone, the intranasal type so that they have it in case something happens to their, not just them, but their children. I think some people resisted to taking Naloxone home because, oh I don't need it, but I'm like, Hey, what, maybe your friend needs it. Maybe your child needs it. So that's sometimes just the opportunity to talk to them in terms of giving that to them. But you're right, it's just, those are the same very typical scenarios

M0:

And and you addressed Tony, some of the public health intervention that we can do and which is something that we do honestly in Ed for all of our patients with opioid or overdose related, emergencies. One thing I think that I just question from a legal and ethical standpoint for those pediatric overdoses, Tony what is the threshold to activate a child line for these kind of patients? Is this something that we have to jump on immediately or something have to consider?

Tony:

Yeah, absolutely. Yeah. This is an automatic child line for sure. Yeah. A child is getting into an illegal substance. And is sick hospitalized. Yeah. That's automatic child line, unfortunately for the parents. But that's just something that has to be done. No, you hit the nail on the head.

M0:

This is something that we have to. Be aware of and ensure the safety of the other children if they do exist in the house as well. Because this is a highly toxic substance 7-OH. Is there anything specifically about the acute care that we need to be mindful of? When it comes to managing 7-OH, is there any kind of a reporting line that we have to pursue If we suspect that what are some of the considerations that, that our audience need to know? Tony?

Tony:

This little plug. Thank you, Mo, for the poison center. No, the poison center is your advocate. Is a great reporting. The good news, bad news about the poison center is we're there 24 7. We're always there to help, but we're passive. So we need people like you, Mo and your colleagues and your listeners to call into the poison center.+1 800-222-1222. Within the United States that is. To call and report these kinds of things.'cause we don't know it's a problem until we're made aware that it's a problem. So this data is super important. Helps us track what the current trends are of the day. Who would've known Mitragynine or 7-Hydroxymitragynine would be such a hip new thing. I'm not sure it will last it has any staying power, but, uh, but I mean, you never know these days.

M0:

I hope it is removed from the market as soon as possible. I know the FDA's been talking about it. I know. But just other agencies as well.

Tony:

Yeah. American College of Medical Toxicology is the organization I'm involved with. But America's poison centers too, again, are another great resource for people if they, yeah. Even. Even not that passively report the information, but if you need advice, Hey, we have this product. What is in this? A child got out, get in, got into it, or what do we need to worry about? We can help you with those kinds of things. So not only do we receive your information, but we can help provide you helpful clinical information too. So it goes both ways,

M0:

Awesome. Thank you Tony. So I'm gonna try to wrap up with some take home points for our audience. First, 7-OH is often sold in vapes, gas stations, even online in these bright colors disguised as candy or quote unquote natural drinks. It's not picked up on routine urine drug screens. Obviously this is something that can be picked up on a comprehensive drug screens, but this is not available in most emergency departments. Clinical presentations mimic opioid overdose. So you will see respiratory depression pinpoint pupils, CNS depression. Naloxone will work and the goal is to provide enough naloxone to support ventilation, not making them awake. There is a high risk of dependence and withdrawal, so we treat them similarly with what we have and what we know. And of course, we have to be very vigilant for pediatric exposures and accidental ingestions, and we have to have a low threshold to activate child line to make sure the child is protected. Anything else I missed or anything else you wanna add? Tony?

Tony:

No, that's perfect.

M0:

This is not gonna be the last time. I hope to get you back in soon, despite your busy schedule. I appreciate you enlightening us about this and giving us a recommendation. And thank you so much, Tony, for what you do, because I really appreciate you as a friend as well.

Tony:

Thank you Mo. My honor, being invited and I'd come back in a heartbeat any day.