7‑OH in the Field: A Street‑Level Guide for BLS and ALS

# Understanding 7-OH: The Hidden Dangers of Kratom's Potent Metabolite

Snapshot for Busy Crews

7-OH (7-hydroxymitragynine) is the potent opioid metabolite found in kratom. It depresses respirations, responds to naloxone, and can lead to relapses after short-term improvements. Treat it like an opioid overdose, with extra vigilance for co-ingestants and rebound sedation. Ventilate early, titrate naloxone to respirations, monitor capnography, transport promptly, and document everything meticulously.

The Call

02:17. Convenience store parking lot. A midsize sedan idles, its windows fogged. In the cupholder: a neon “herbal wellness” shot, a crumpled “ultra extract” packet, and two empty energy drinks.

Your patient, a 24-year-old, slumps in the driver’s seat. Shallow breaths, pinpoint pupils, and a pulse oximeter reading in the high 80s. The passenger is anxious, mumbling about “kratom” and “just one more gummy.”

You know the drill for an opioid picture. The twist? The source isn't a pill bottle. It's a vape-counter product spiked with a kratom derivative that hits like an opioid. That derivative is 7-OH.

What Exactly is 7-OH?

Full name: 7-hydroxymitragynine.

Where it shows up: Tiny amounts in kratom leaf; higher levels appear after the body metabolizes mitragynine. Many modern “enhanced” shots, gummies, and tablets crank up the potency.

Receptor action: Potent mu-opioid receptor agonist (partial agonist by pharmacology), clinically behaves like an opioid. Naloxone works.

Why EMS cares: These products are easy to buy. Dosing is opaque. Co-ingestants are common. The toxidrome overlaps with classic opioids but can be sneakier about rebound sedation.

Street Reality: How it’s Packaged & Described

Expect euphemisms: “7-HMG,” “7-Hydro,” “ultra/extra strength,” “enhanced kratom,” “extract shot,” “relax/gold reserve.” Packaging often mimics energy drinks or candy. Leaf tea users represent a different risk profile. The trouble we see pre-hospital is concentrated or adulterated products—vapes, shots, pills, powders, or gummies of all types.

Pharmacology in Plain Language

Potency: Stronger effect per milligram than morphine (3-10x) in animal models. Don’t translate that directly to dosing; translate it to respect.

Kinetics you can use in the field: 7-OH rises faster and fades sooner than mitragynine, but the parent compound hangs around. That’s your “rebound” risk after initial improvement.

Reversal: Naloxone reverses 7-OH. Titrate to respirations, not to full wakefulness unless you must. Be ready for redosing. Infusions may be needed in the ED.

Interactions: CYP3A inhibitors (azole antifungals, some antibiotics, certain cardiovascular meds, grapefruit), alcohol, benzos, and other sedatives can amplify respiratory depression. Polysubstance use is common and will complicate patient presentation.

Clinical Picture: What You’ll Actually See

Primary: Depressed mental status, hypoventilation, miosis (not guaranteed), hypoxia, hypercapnia.

Secondary: Nausea/vomiting, aspiration risk; occasional agitation after partial reversal; rare seizures reported; hypotension is less common than with polysubstance use.

Complicators: Co-ingestants are the rule, not the exception (alcohol, benzos, stimulants, antihistamines). Products may contain undisclosed opioids.

BLS Playbook (Do the Basics Perfectly)

1) Scene Safety: Watch for needles, powders, agonal drivers, and agitated bystanders. If the vehicle is running, secure it.

2) Primary Survey: Airway, breathing, circulation. Position for airway patency. Suction as needed.

3) Ventilations: If RR is low or tidal volume is poor, go straight to BVM with O2. Aim for visible chest rise. If you have ETCO₂, use it: expect elevated values with hypoventilation. Target 35–45 mmHg with assisted ventilations.

4) Naloxone (per local protocol):

IN: 4 mg spray; repeat every 2–3 minutes if inadequate respirations.

IM: If available, typical 0.4–2 mg; repeat titrated to respirations.

Goal: Restore adequate breathing, not trigger a combat nap.

5) Monitor & Package: SpO₂, mental status, RR, ETCO₂ if available. Anticipate relapse. Prepare for vomiting.

6) Transport: Even if they look “better,” the parent compound can outlast your naloxone. Don’t leave them on scene without a solid plan and local policy allowing it.

Documentation Pearls: Product names, where obtained, approximate time and amount used, co-ingestants, response to naloxone (dose and timing), ETCO₂ trends, mental status trajectory.

ALS Playbook (Refine & Anticipate)

Airway & Breathing:

Prioritize BVM and oxygenation first. Avoid reflexive intubation if naloxone is likely to restore ventilations.

Continuous waveform capnography. Persistent ETCO₂ >50 with poor effort is a resuscitation problem, not a “wait and see.”

Circulation:

IV/IO access. Consider fluids for hypotension if present. Check glucose and treat if low.

Naloxone Strategy:

Unknown Dependence: Start 0.4 mg IV/IM/IN, reassess in 2–3 min. Escalate as needed.

Known or Suspected Opioid Dependence: Start 0.04–0.1 mg IV, titrate in small increments to achieve RR ≥12 and protective airway reflexes.

No IV Access: 2 mg IN/IM and repeat as needed.

Rebound or Persistent Depression: Coordinate early with the receiving facility for naloxone infusion. A common ED starting point is two-thirds of the effective total bolus per hour, then titrate. Your job is to flag the risk and communicate doses given and the relapse pattern.

Seizures or Severe Agitation:

Treat seizures per protocol with benzodiazepines. Protect the airway. Avoid stacking sedatives in hypoventilating patients unless you’re prepared to ventilate aggressively.

Monitoring & Trajectory:

Serial ETCO₂, RR, mental status, pupils, lung sounds, and SpO₂. Expect waxing/waning sedation as 7-OH falls and other agents persist.

Consults & Destination:

Consider higher-acuity destination if multiple doses of naloxone were required, if infusion is anticipated, or if co-ingestants and aspiration risk are high.

Special Populations

Pediatrics:

Smaller airways, faster decompensation, weight-based naloxone dosing per protocol. Bring the parents into the history early; packaging may resemble candy.

Pregnancy:

Airway edema and aspiration risk; prioritize left uterine displacement if indicated, oxygenation, and maternal stability. Early transport is essential.

Geriatrics & Hepatic Impairment:

Higher sensitivity, prolonged effects, more drug interactions. Lower initial naloxone doses and slower titration can reduce complications while you secure ventilation.

Field Clues for 7-OH

Packaging: Energy-shot vials, blistered “extract” tablets, gummy pouches, droppers.

Language: “Legal high,” “herbal opioid,” “7-hydro,” “reserve,” “ultra,” “extra strength.”

History: “I only took kratom” plus alcohol or benzos. Ask about antifungals, certain antibiotics, or grapefruit, which can intensify effects.

Leave-Behind and Harm-Reduction

If your system supports it, leave-behind naloxone with brief teaching for family/friends.

Explain the risk of mixing kratom extracts with alcohol, benzos, sedatives, or “downers.”

Advise medical follow-up; emphasize that “herbal” does not mean safe.

Training Corner: Drill Your Peeps

Ten-minute scenario:

1. Bystander 911 for a parked-car “sleeping” driver. RR 6, shallow; SpO₂ 89%; ETCO₂ 56; pupils 1–2 mm.

2. In the console: “7-Hydro Ultra” shot and gummy bag; passenger admits both used “a while ago” with two beers.

3. Run the BLS and ALS checklists above.

4. Debrief on early BVM, naloxone titration choices, ETCO₂ targeting, packaging clues, and handoff language.

   
   

Performance metrics:

Time to first effective BVM ventilation.

Time to first naloxone dose when indicated.

ETCO₂ trend documented pre/post interventions.

Handoff quality: did the receiving team hear “7-hydroxymitragynine” or "7-OH" and “risk of rebound” clearly?

Quick Reference Cards

BLS

• Airway position, suction, BVM with O₂.

• IN naloxone 4 mg; repeat q2–3 min to ventilations.

• ETCO₂ if available; target 35–45 with assistance.

• Anticipate vomiting and relapse; transport.

  
  

ALS

• BVM and O₂ first; continuous ETCO₂.

• IV/IO; glucose check.

• Naloxone: 0.04–0.1 mg IV for dependent or 0.4 mg IV/IM/IN if unknown; escalate as needed. Consider infusion at the hospital if repeated doses are needed.

• Treat seizures per protocol; avoid stacking sedatives in hypoventilation without aggressive ventilatory support.

  
  

Final Word

Kratom leaf tea isn’t what’s putting your patients in respiratory failure. The concentrated, “enhanced” products are. If it looks like an opioid and breathes like an opioid, treat it like one. Ventilate early, titrate naloxone to breathing, expect relapse, and communicate the story. That’s how you turn a fogged windshield and a bad decision into a clean handoff and a living patient.

Disclaimer: Follow your local protocols and medical direction. This article is an educational resource for EMS providers and does not replace protocol or physician orders.