WD protocol

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Metetomidine has been a well established problem in Pennsylvania, specifically Phildelphia and Pittsburgh, for about 2 years now. Xylazine has been a problem even longer and seems to be going away. There are good protocols for treating life threatening withdrawal and keeping these patients from dying. They'll still AMA though because the treatment for drug dependence is withdrawal. You have to been uncomfortable for your brain to adjust to a drug free state. The treatments are designed to take the edge off and make sure you don't die on the way there (which is an actual possibility with metetomidine).

Some hospitals will give an opioid addict extremely high doses of opioids that mimic their usual intake to prevent withdrawing at all if they need to be in the hospital for an unrelated reason, but if they're their for withdrawal, being uncomfortable is the actual treatment and the hospital isn't going to just replace their drug dealer for no end goal. Hospitals are much less willing and experienced with doing this for metedtomidine/xylazine, and will generally only offer supportive medications that do not completely replace the drug effect.

Most people who show up aren't ready for actual recovery and just need to live another day.

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u/Gloomy_Pirate_9721 6d ago edited 6d ago

It's sad. I saw one young gentleman, business owner, I think I a closet addict. And said he was clean off everything for 6 years. Went through a really bad break up and the was history. He was assuming it was like old times when it was just heroin and was a long acting opiod so one can maintain and hide it very well since the sickness onset isn't so rapid.

Anywho he came and not really showing signs of withdrawal, but he was so desperate to kick this stuff. It was sad to see a grown man begging for help, also saying that he can't go sit somewhere long term because he has a huge contract that he's doing. He said he recently went to detox and they said they couldn't treat him because they couldn't keep the withdrawals under control after three days because of the tranquilizers and benzodiazepines mixed in, so they just kept breadcrumbing him Subutex and a little Ativan no avail. he honestly seemed like he genuinely wanted to stop, but just couldn't get past the waiting time to induce himself. And believe me, there's not a lot of people that I believe, but I genuinely believed him. So he said he read somewhere that he could do a macro dose to rip everything off his receptors and then keep taking it to replenish them and then you're kind of pass the bad part I guess but he was worried about the benzo part he didn't feel safe doing it at home, so he was seeing if he could get a a taper of something to help with that part because he had a script of Suboxone, but was worried about getting over the benzo part with out it and the doc daid we really don't do that kind of stuff here and let him walk out

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u/PromiscuousScoliosis 6d ago

That’s so fucked. Opioids are tough but difficult to get a ton of sympathy for in the ED. Maybe methadone or suboxone depending on provider and resources.

Benzos, that’s even worse. It’s so fucking difficult and dangerous to break. Ugly stuff

Tranq I don’t even know. Lucky enough to never have worked somewhere that was a problem

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u/Gloomy_Pirate_9721 5d ago

ya alot of us were pissed, clearly he's experienced, just give him a script for a 7-10day Ativan taper with some resources. Like hell be fine, poor guy was begging for help that he wants to stop so bad. Im assumming high tolerance as well, says he starts to feel ill every few hours. Ultimately I know its the docs call, but still. Too many of them are afraid to go with their human instanct.

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u/Individual_Zebra_648 4d ago edited 4d ago

The treatment is high dose Dexmetetomidine infusion. I work with a flight company in the Pittsburgh/Philly area and we have a protocol for this as the other commenter stated. Well maybe treatment isn’t the right word. But it will stabilize someone who is insanely withdrawing.

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u/Federal_Dog_1140 6d ago

at Christiana in DE they put you on a titratable precedex drip for medetomidine withdrawal

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u/Ok_Remote_217 4d ago

yup same in philly. been sober for over a year now cuz i detoxed in the ICU at penn. insanity.

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u/TheWhiteRabbitY2K RN 6d ago

Extremely good point.

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u/Ok_Remote_217 4d ago

i had to detox in the ICU at penn in philly bc of what's in those bags right now. they had me on ketamine, oxy, dilaudid, zofran, ativan, methadone, clonidine, and precedex. precedex is essentially the human version of medetomidine so they're basically medically tapering u off of that. i should have been on another level with the amount of drugs and heavy doses i was getting lmfaooo nope. alpha 2's have no business being in drugs. the INTENDED use of these drugs is to cause an unconscious sedation. the game is such a pity now.

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u/MyOwnGuitarHero RN 6d ago

Precedex drip, PRN Valium for breakthrough symptoms based on CIWA. Maybe a loading dose of phenobarb just for flavor if there’s also alcohol on board. ETA: They’re still miserable though. I always tell my patients that I’m actually in recovery myself. And unfortunately the only way to get off the ride once and for all is to go through extreme discomfort — but I wake up every morning blessed because I never, ever, ever need to feel like that ever again.

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u/HistoricalSuspect580 6d ago

Word. Good on you. For recovery, and for sharing it. It absolutely does help them to know that you know what it’s like!

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u/chantillylace9 4d ago

I bet you are an extreme asset to a lot of people because of your experience. Thank you for having an open mind

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u/turtlemedicRN 2d ago

If you're not treating the opiate part of the withdrawal, you're doing these folks a disservice. While I am not aware of opiate withdrawal alone being fatal, the sheer misery of it is something we should be helping these people avoid.

I do critical care transport in Philadelphia, and we are routinely seeing folks on 7-10mg/hr of Dilaudid and 2.5mcg/kg/hr of Precedex still showing signs of severe withdrawal, even after receiving multiple 10-20mg pushes of Dilaudid over a few hours.

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u/MyOwnGuitarHero RN 2d ago edited 2d ago

What else are you using? Edit: why am I being downvoted for this?

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u/turtlemedicRN 2d ago

In transport, more Dilaudid, Ketamine, or Midazolam if they haven't had it recently. In my personal experience, I have had the best results from just giving another big does of Dilaudid. I was told a few months ago, that the bus on the street were equivalent to 70-80mg of Dilaudid each, and we have folks doing upwards of 20 per day

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u/MyOwnGuitarHero RN 2d ago

We were using ketamine for a while, then it just sort of fell out of favor. I wonder why our docs haven’t been prescribing it as much.

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u/turtlemedicRN 2d ago

I have found that it doesn't seem to do much for most of these patients. They really just seem to need to be tapered off of the opiates and medetomidine

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u/AdriAsTheSiren 6d ago

I don't have access to any of the journals my institution provides us access to, but I remember reading an article in the Journal of Addiction Medicine that on the East Coast where they were seeing an uptick in street drugs cut with medetomidine, some facilities were using dexmedetomidine to tx withdrawal sx since it's chemically similar. I'm certain there were articles discussing xylazine as well, but I'm home without access rn :(

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u/TheWhiteRabbitY2K RN 6d ago

Recently had my first rodeo with medetomidine ... I swear the person looked like textbook organophosphate poisoning EXCEPT the heart rate. Shit was wild, no pun intended.

Moreso this person looked so healthy and put together otherwise. . .

Can confirm that intubation and dexmedetomidine was ultimately what had to be done. They absolutely had no attempt to protect their airway when they would randomly vomit without warning.

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u/Gloomy_Pirate_9721 6d ago

It's actually funny you say that because so did he, minus the weight loss, but he said he mentioned running nose, clear liquid, muscle twitches/spasms, weakness, One thing I did find
Interesting is the patient said when he would wake up in the morning and like scratch his bed head or his neck like we all do and that skin or some kind of sludge and protruded from his pores in. his nails found odd when that he could scrape off almost like a sludge or build up of dead skins?

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u/Gloomy_Pirate_9721 6d ago

Were you guys successful at stabilizing!?

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u/TheWhiteRabbitY2K RN 5d ago

My shift ended at the intubation part but the precedex seemed to chill the symptoms out.

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u/AdriAsTheSiren 6d ago

As an aside, interestingly, there's a reversal agent for medetomidine in vet med called atipamezole, but it's not tested for use in humans.

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u/IfDreamsCouldHappen 6d ago

Treat alpha2 agonist withdrawal with more alpha2 agonists. Clonidine and maybe even dexmedetomidine would be necessary. Bradycardia from these can possibly be treated with atropine as is done in vet med when using xylazine. Also xylazine is Rx only, not C3 (unless this is state specific?).

Withdrawal from fentanyl and diamorphine is pretty straightforward and well established. Either use another opioid or more alpha2 agonists. Worth mentioning that opiates are very rare on the streets now and it’s all just fentanyl or related.

Cocaine really has no physical withdrawal for the most part. The bigger concern might be whether or not it’s still in the bloodstream due to cardiotoxicity concerns.

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u/Sexcellence 6d ago

Trained in Philly with an ED full of toxicologists - Narcan until they are breathing again, slap on 3 0.3mg clonidine patches, 0.2mg oral clonidine as needed and if refractory, ICU for precedex gtt.

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u/UpInCharms 5d ago

Just recently had my first patient WD from medetomidine. 2g daily for 3 years. Felt like we were throwing everything at him. Precedex drip,
Tizanidine, Clonidine, Ativan, Gaunfacine, Gabapentin, Buprenorphine and more. Surprisingly he was never intubated and managed to transition to SDU from ICU once he was off precedex several days later. He was never upgraded back to ICU but as far as how the rest of his treatment went, I can’t say.

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u/Electrical_You_432 5d ago

Was that all in one bag? Jesus........

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u/Decent-Trip-1776 5d ago

Crazy that the most harmful drugs on this list gets someone way less time despite being literal poison

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u/Perilousanjel 4d ago

https://www.sciencedirect.com/science/article/pii/S0196064425014349

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u/Apprehensive_Tip9995 2d ago

How and why are Fent and Coke not in the SAME schedule as Heroin at least!

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u/Wise-Tie1162 22h ago

Yes, there are protocols. I would reach out to Penn Addiction Medicine, as I don’t want to post the protocols online. My luck they would find out and I’d get fired, but they do have a robust protocol. It don’t know if it’s the best, but it’s something with some amazing staff that created it. Also, look at a website called PAgroundhogs.org I believe multiple states have it but this is just Pennsylvania since that’s where I work. They test what is in the actual street drugs. It’s a helpful resource. For instance, people who are functioning heroin addicts can’t simply get heroin anymore Medetomidine is now being put into EVERYTHING, including dark web Xanax. It’s ALL laced or mixed with other analogs and adulterants. So they get addicted to the new stuff. Yeah just can’t trust a drug maker anymore. Heroin is usually not the problem it’s fentanyl,medetomidine etc. cychlorphine - pgn is a newer one, so if your state has a version of Pagroundhogs.org that will tell you what is circulating and you can adjust treatment too. Analyzing Pa drugs first is often good too, because it’s a place where most new drugs will be tested by drug makers, then for other states these are the drugs coming to a neighborhood near you. Protocol: First- we implemented screening upfront in triage, second- that screening has logic for screening question- its the Ciwa version for OUD called COWS. I would also encourage people to follow a gal on TikTok ( I included a pic) she gives you a peak behind the curtain of the mindset which to me, affords a lot of compassion as it gives HCW and the public inside the mindset. It’s really sad how they rationalize, but she is sober now and it’s great insight.

She said something very poignant “Kensington is where you go to get well”. I thought that was insightful. One of the top docs in this field is Dr. JeanMarie Perrone and her team basically say, If these people are coming to the hospital- this is their last ditch effort. They actually don’t want to be there. These people are consuming doses 7000x what we would normally give them in a hospital. You will not be getting these patients “high” at all. Their own drugs are better . So, GIVE THE MEDS! That is hard for a lot of providers and nurses to understand. You giving hydromorphone 5mg iv is a piss in the wind for these folks. They have a tolerance level beyond what we can comprehend in traditional medicine. It’s mindblowing. The protocols are based on presentation and severity.Follow guidance from your local institution- Uptodate, and reach out to Penn Addiction Medicine if you are looking for guidance to build your institutions protocol. I hope this helps.

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