Understanding Medetomidine: Emerging Challenges for Addiction Medicine

In the Season 2 premiere of ASAM Practice Pearls, Drs. Stephen Taylor and Jeanmarie Perrone follow up on Season 1’s episode, Emerging Illicit Substances: What Clinicians Need to Know. Together, they discuss how medetomidine has continued to spread to different regions and what has changed over the past year. They explore strategies for managing medetomidine withdrawal, keeping patients safe, and preparing for this growing public health threat. 

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Stephen M. Taylor, MD, MPH, DFAPA, DFASAM

Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states.

Expert

Jeanmarie Perrone, MD, FASAM, FACMT  

Dr. Jeanmarie Perrone is a Professor in the Department of Emergency Medicine and the founding Director of the Center for Addiction Medicine and Policy at the University of Pennsylvania. Dr. Perrone leads programs for the treatment of Opioid and Alcohol Use Disorders from the emergency department and via a virtual telehealth bridge clinic (CareConnect). Her work has been funded by city health departments and by NIDA, PCORI, CDC, and SAMHSA. She has advocated at the state and national level and contributed to working groups to enhance low-barrier treatment access for substance use disorders and improving toxicosurveillance. She has been recognized with awards for leadership, education, and mentorship. 

📖 Show Segments

• 00:05 - Season 2 Introduction
• 01:03 - New Drug Crisis: Medetomidine 
• 02:34 - Pharmacology and Withdrawal Symptoms
• 05:58 - Clinical Management and Patient Care
• 08:22 - Public Health and Harm Reduction
• 11:56 - Regional Impact and Future Concerns
• 15:21 - Key Takeaways and Action Items
• 19:26 - Conclusion and Additional Learning Opportunities

📋 Key Takeaways

• Recognize the symptoms: Medetomidine withdrawal presents with refractory vomiting and tremors and is complicated by severe hypertension and tachycardia, within 2 hours of last use. 
• Treat aggressively with clonidine, an alpha-2 adrenergic agonist, and olanzapine: Use high doses of clonidine (0.2-0.4 mg, as often as every 2 hours) combined with alpha-2 adrenergic agonists for concurrent opioid withdrawal, and olanzapine to help control nausea and vomiting to prevent escalation to the ICU. 
• Use dexmedetomidine for severe cases: Approximately one-third (or more) of patients require dexmedetomidine infusion in the ED or ICU to manage symptoms. Coordinate early with critical care if symptoms worsen despite initial treatment. 
• Distinguish from alcohol or benzodiazepine withdrawal: If a patient presents with what looks like alcohol or benzodiazepine withdrawal but doesn't respond to benzodiazepines or barbiturates, consider adding dexmedetomidine. If the patient responds to the dexmedetomidine, medetomidine withdrawal should be considered. 
• Update naloxone education: Teach patients and bystanders that the goal for naloxone is improved respiratory effort, not wakefulness. Medetomidine may keep the person sedated even after successful opioid reversal. 
• Provide medetomidine test strips: In areas with lower medetomidine prevalence, test strips can help patients identify and avoid adulterated supplies.