When Lillian was incarcerated in a rural prison in Pennsylvania, she couldn’t stop vomiting. The “brain zap” continued to destabilize her as she showered and changed into her prison uniform. “The prison guard who was watching me had to keep a firm grip on me, otherwise I would have fallen and hit the floor,” Lilian recalled.
She had stopped taking fentanyl mixed with medetomidine, a powerful tranquilizer that began becoming a common adulterant in illegal opioid supplies two years ago. Medetomidine often causes excruciating and complex withdrawal symptoms within hours of the last dose, and many medical institutions are unprepared to treat them. The treatment gap is particularly acute in cancer care settings.
Lillian faced withdrawal syndrome, including a life-threatening stroke and heart attack. She said she was given only ibuprofen and Pepto-Bismol. “It was hell,” Lillian said. She asked to use a pseudonym because of the stigma in the community against drug use. “I’m really surprised he didn’t die.”
Prisons already have a shaky track record of protecting inmates who become reclusive after incarceration because they suddenly no longer have access to opioids or other drugs they were using. Stretched resources, staffing shortages, and a lack of protocols and transparency all mean deaths related to opioid withdrawal are surfacing in lawsuits across the country. These deaths are preventable. There are several Food and Drug Administration-approved medications that are effective against opioid withdrawal.
Prisons now face the additional challenge of medetomidine withdrawal. This may require complex treatment using both oral and intravenous drugs, some of which are tightly controlled and may only be available in intensive care units. The challenge is becoming more common. The Centers for Disease Control and Prevention reported in April that medetomidine (also known as dexmedetomidine) was detected in drug samples at all 20 sentinel sites, with prevalence highest in the Northeast and lowest in the West.
cutting edge pittsburgh
How prepared a prison is to treat medetomidine withdrawal is often a matter of politics and resources. In Pittsburgh, about an hour away from the rural facility where Lillian is being held, Chris, who chose to withhold his last name, experienced the same withdrawal syndrome at the Allegheny County Jail. However, he received Ativan and Phenobarbital upon arrival. These are drugs that are sometimes found to reduce symptoms. “I was grateful for that, because I didn’t expect to be able to do that in the county jail,” Chris said. “They told me I could sit on this comfy-looking bed in the medical processing area, so I was really looking forward to it, because when you’re incarcerated, you don’t get to sit on anything comfortable. So I jumped up on the bed and that was the last thing I remembered before I woke up in the hospital a few days later.”
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That’s when I learned that medetomidine withdrawal caused the heart attack.
Pittsburgh, one of the cities hardest hit by medetomidine, is also uniquely prepared to deal with the problem. Elizabeth Ferro, director of addiction treatment at the Allegheny County Jail, was able to work directly with Michael Lynch, a physician at the University of Pittsburgh Medical Center who is actively researching treatments for medetomidine withdrawal. When Ferro began noticing that people with unusually severe opioid withdrawal symptoms were showing up in prisons, she recalled asking Lynch, “Are you feeling the same way?” Lynch invited her to participate in a webinar on treating medetomidine withdrawal.
Prisons with the infrastructure to treat opioid withdrawal and opioid use disorder are inherently better equipped to handle a medetomidine withdrawal crisis. As Ferro pointed out, medetomidine withdrawal is almost always accompanied by opioid use disorder, so treating both is essential. The Allegheny County Jail has significantly expanded access to treatment for opioid use disorder and withdrawal symptoms in recent years, thanks in part to the support of Allegheny County Councilwoman Bethany Hallam, who herself suffered from withdrawal symptoms while incarcerated. Stuart Fisk helped found Prevention Point Pittsburgh, the city’s oldest harm reduction organization. Fisk worked directly as a nurse within the Allegheny County Jail to improve access to medication treatment for Opioid Use Disorder (MOUD).
Mr. Fisk is currently a member of the trust tasked with distributing opioid settlement money to Allegheny County, and is advocating for a portion of that money to go toward providing addiction treatment drugs. Federal law prohibits Medicaid from covering medicines for people in prison, which often comes directly from county budgets, making drug expansions potentially politically controversial.
Ms Hallam said she had had to push back against those who argued that withdrawal drug treatment in prison was too expensive or posed a risk of diversion. Drugs such as buprenorphine and methadone can treat both opioid use disorder and withdrawal symptoms because they are both full or partial opioids. Hallam recalled that when she was jailed in 2017, “If you weren’t pregnant, you didn’t get anything, so it was like a cold turkey detox.” At first, Hallam was only able to persuade the prison to provide him with the injectable drug Subrocade. But over the past two years, it has expanded its services. A position paper from the National Commission on Correctional Health Care emphasizes the importance of providing a variety of FDA-approved medications to people in prisons who suffer from opioid use disorder.
Pittsburgh jails and hospitals are relatively equipped to treat medetomidine and opioid withdrawal symptoms, but not enough to save everyone. A week after being interviewed for this article, Chris was arrested again while in withdrawal and immediately rushed to the hospital, where he suffered a second heart attack. After spending five days in an induced coma to save his heart and brain, Chris showed slight signs of recovery when he was taken off life support. But his heart eventually failed and he passed away earlier this month.
difficult to detect
As medetomidine spreads across the country, prisons not yet equipped to treat solely opioid withdrawal could face an onslaught of seriously ill patients. Ferro said she wants all Pennsylvania prisons to work together to prevent health risks related to medetomidine. Currently, the agency has received only one inquiry from a rural prison regarding an unusually serious case of hikikomori. “I said, “I think this is medetomidine withdrawal, not opioid withdrawal, and I’m happy to talk to you about this.” But they never followed up.
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Kevin Fischera, a University of Rochester physician who helped create exit procedures for U.S. prisons, said ideally many prisons would take a similar approach to the Allegheny County Jail. Fischera said jails should seriously consider sending patients in severe withdrawal to hospitals, and the Allegheny County Jail is doing just that. He also pointed out that many prisons already stockpile the antihypertensive drug clonidine, which is an important means of treating medetomidine withdrawal. Ferro noted that stopping medetomidine often requires a much higher dose of clonidine than the usual dose.
However, prisons can only respond appropriately to medetomidine withdrawal if they know what they are dealing with. Lynch said that can be difficult to recognize. He recalled that in the fall of 2024, he began seeing patients with severe symptoms. “They arrived at the hospital shaking, sweating, nauseous, and their heart rate and blood pressure began to increase.” “It appeared to be very severe opioid withdrawal, but it was more severe and had a much earlier onset.”
Rapid urine toxicology panels are not designed to detect medetomidine. Instead, emergency physicians often confirm the presence of medetomidine by observing whether symptoms persist after the patient has been given drugs that usually relieve symptoms. Ideally, prisons should “be more aggressive in initiating treatment” with drugs such as buprenorphine and “quickly clarify the situation” to figure out whether medetomidine is involved, Fischera said.
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However, many prisons do not offer buprenorphine or other medications for opioid use disorder or withdrawal symptoms. In 2022, the Department of Justice’s Civil Rights Division issued guidance stating that prisons that deny these drugs to patients with prescriptions violate the Americans with Disabilities Act. Notably, the order provides no special protections for patients with opioid use disorder who do not have an existing prescription for treatment, patients who are more likely to experience severe withdrawal symptoms if incarcerated in prison. Still, the guidance suggests that all prisons should have a legal obligation to make MOUD available to at least some prisoners. However, a national survey of prisons conducted after the guidance was published found that fewer than half of prisons offered MOUD at all.
The availability of such medicines in prisons could improve mortality and health outcomes both during incarceration and after release. A randomized controlled trial compared prisons that adopted National Board of Correctional Health Care accreditation standards (requiring MOUD) with a control group and found that this accreditation can significantly reduce prison mortality rates. But study co-author Marcela Alsan, a Harvard physician and economist, pointed out that prison accreditation is completely voluntary. And because Medicaid and health insurance can’t legally fund prison health care, “it’s very difficult for them to fund this health care, but they’re constitutionally obligated to provide it. The sheriff himself is put in a very, very difficult position, and the county itself is put in a very, very difficult position.”
The National Sheriff’s Association opposes the federal Medicaid inmate exclusion policy, writing, “The MIEP policy does not distinguish between the presumed innocent and the convicted. Denying presumed innocent individuals access to eligible federal Medicaid, Medicare, CHIP, and VA benefits without due process of law is a violation of their constitutional rights.”
“Some sheriffs are very active and very concerned about this issue. Others feel like they have a lot of other things to worry about,” Fischera said. The dire symptoms of medetomidine withdrawal may have an upside, he said. “We hope this is a wake-up call for all prisons to begin serious treatment for opioid use disorder.”
STAT’s chronic health coverage is supported by a grant from. bloomberg philanthropy. our financial supporter It has no role in any of our journalism decisions.
