Improvising in an emergency: Doctors respond to medetomidine withdrawal with no roadmap
In Pennsylvania, a mystery fentanyl adulterant began causing withdrawal related heart attacks in 2024. Doctors have been rushing to catch up.
One reason Brandie wants to quit street fentanyl is she can't take the “brain zaps,” anymore; “It feels like somebody ringing a bell inside your head, and it goes through your whole body.” The zaps have become routine since late 2024, when medetomidine, a powerful tranquilizer, became the newest adulterant to compromise the Pittsburgh street fentanyl supply. The sensation can be so intense it brings Brandie to her knees.
Brain zaps have become an important signal for both clinicians and for people like Brandie. For Brandie, they’re a sign to either re-dose, get to the hospital, or risk stroke or heart attack. For Dr. Divya Venkat, an addiction and primary care physician in Pittsburgh, brain zaps are the fastest way to determine which patients are withdrawing from fentanyl alone, and which might soon be in critical condition. Rapid urine toxicology panels cannot detect medetomidine. Brain zaps are not a symptom of typical opioid withdrawal, but they are near-universal in medetomidine withdrawal, according to Venkat and other clinicians, as well as several first-hand accounts.
Medetomidine withdrawal patients have been filling Pennsylvania ICU wards for over a year, and the problem has yet to slow down. At the end of August, Pittsburgh’s Poison Control Center received 139 reports of medetomidine related emergencies in the space of just 5 days. Doctors are catching up on the fly—there’s no time for proper scientific procedure. Normally, researchers conduct experiments before landing on a preferred treatment, according to Dr. Michael Lynch, professor of toxicology, addiction and emergency medicine at the University of Pittsburgh Medical Center. They compare new interventions to placebo or an existing treatment, and figure out what’s best. But in a crisis like this one, where inaction can lead to seizures, heart attacks, and strokes, science must wait on doctors’ and patients’ experience, not the other way around. Lynch compared the situation to Covid-19. Before there was evidence, “we needed to do something, because people were very, very sick.”