When Lillian was booked into a rural Pennsylvania jail, she couldn’t stop vomiting. As she showered and changed into her jail uniform, “brain zaps” kept destabilizing her. “The corrections officer watching me kept having to grab me steady or I would have dropped and hit the floor,” Lillian recalled.
She was withdrawing from fentanyl laced with medetomidine, a powerful tranquilizer that started to spread as an adulterant in the illicit opioid supply two years ago. Medetomidine causes excruciating, complicated withdrawal symptoms, often within hours of someone’s last dose, and many institutions are ill-prepared to treat them. The treatment gap is especially acute in carceral settings.
Lillian was facing a withdrawal syndrome that can include life-threatening stroke and heart attacks. She said she only received ibuprofen and Pepto-Bismol. “It was hell,” said Lillian, who asked to use a pseudonym because of stigma in her community over drug use. “I’m genuinely amazed I didn’t die.”
Jails already have a spotty record safeguarding prisoners who go into withdrawal upon incarceration because they’ve suddenly lost access to opioids or other drugs they were using. Strained resources, understaffing, and lack of protocols and transparency all mean that deaths related to opioid withdrawal have surfaced in lawsuits across the country. These deaths are preventable; there are multiple effective, Food and Drug Administration-approved medications for opioid withdrawal.
Jails now face the added challenge of medetomidine withdrawal, which can require complex treatment with both oral and intravenous medications, some so heavily controlled they are only available in intensive care unit settings. The challenge is becoming more common: The Centers for Disease Control and Prevention reported this April that medetomidine, also called “dex” for dexmedetomidine, has been found in drug samples across all 20 sentinel sites, with highest prevalence in the Northeast and lowest in the West.
Pittsburgh on leading edge
How prepared jails are to treat medetomidine withdrawal is often a question of politics and resources. In Pittsburgh, about an hour away from the rural facility where Lillian was incarcerated, Chris, who chose to withhold his last name, went through the same withdrawal syndrome at the Allegheny County Jail. But he received Ativan and phenobarbital upon arrival, medications that have sometimes been found to alleviate symptoms. “I was grateful to get that, because I didn’t think that was something that they would do for you in the county jail,” Chris recalled. “They told me I could sit on this comfortable-looking bed that was in the medical area of processing, which I was pretty excited about, because when you’re incarcerated, you don’t get to sit in anything comfortable. So I hopped up on the bed, and that was the last thing that I remembered before I woke up in the hospital a few days later.”
That’s when he found out withdrawal from medetomidine had caused him to have a 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 medicine for Allegheny County Jail, was able to work directly with Michael Lynch, a physician at the University of Pittsburgh Medical Center who has been actively researching treatment for medetomidine withdrawal. When Ferro started to notice people showing up at the jail with unusually severe opioid withdrawal symptoms, she recalled asking Lynch, “Are you kind of seeing this too?” Lynch invited her to attend his webinars on treatment for medetomidine withdrawal.
Jails that have the infrastructure to treat opioid withdrawal and opioid use disorder are inherently better prepared to handle the medetomidine withdrawal crisis. As Ferro pointed out, since medetomidine withdrawal almost always accompanies opioid use disorder, it’s essential to treat both. The Allegheny County Jail has significantly expanded access to opioid use disorder and withdrawal treatment over the last few years, thanks in part to advocacy from Bethany Hallam, a member of the Allegheny County Council who has struggled with withdrawal during incarceration herself; and Stuart Fisk, who helped establish Prevention Point Pittsburgh, the city’s oldest harm reduction organization. Fisk worked directly within the Allegheny County Jail as a nurse practitioner to improve access to medication-assisted treatment for opioid use disorder (MOUD).
Fisk is now a member of the trust tasked with distributing opioid settlement dollars in Allegheny County, and advocated to have some of that money go toward offering addiction medicines. Federal law prohibits Medicaid from covering medications for people in jail, so they often come directly from the county budget, which can make any medication expansion a politically contentious issue.
Hallam said that she has had to push back against people who say withdrawal medications in jail are too costly or could carry the risk of diversion. Medications like buprenorphine and methadone can treat both opioid use disorder and withdrawal, because they are both full or partial opioids. When Hallam was incarcerated in 2017, she recalled, “If you were not pregnant, you did not get anything, and it was like a cold turkey detox.” Initially, Hallam could only persuade the jail to offer Sublocade, an injectable medication. But in the last two years, it’s expanded its offerings. A position paper from the National Commission on Correctional Health Care emphasizes the importance of offering a range of FDA-approved medications to people in jail suffering from opioid use disorder.
While Pittsburgh jails and hospitals are relatively well prepared to treat combined medetomidine and opioid withdrawal, it isn’t enough to save everyone. One week after he was interviewed for this story, Chris was arrested again while experiencing withdrawal, and taken immediately to the hospital, where he had a second heart attack. After spending five days in an induced coma, which was intended to help preserve his heart and brain, Chris showed small signs of recovery when he was removed from life support. But ultimately his heart gave out, and he died earlier this month.
Difficult to detect
As medetomidine spreads across the country, jails that are still inadequately prepared to treat opioid withdrawal alone could face an onslaught of severe cases. Ferro said she wishes all Pennsylvania jails would work together to prevent medetomidine-related health consequences. As it stands, she said she’s received just one inquiry from a rural jail about unusually severe withdrawal. “I said I think it’s not opioid withdrawal, it’s medetomidine withdrawal, and I’m happy to talk to you about this.” But they never followed up.
Ideally, many jails would take an approach similar to the Allegheny County Jail, said Kevin Fiscella, a physician at the University of Rochester who helped create withdrawal protocols for U.S. jails. Fiscella said that jails should seriously consider sending patients experiencing severe withdrawal to the hospital, which is exactly what the Allegheny County Jail is doing. He also pointed out that many jails already stock the blood pressure medication clonidine, an important tool for treating medetomidine withdrawal. Ferro noted that medetomidine withdrawal often requires much higher than typical doses of clonidine.
But jails can only respond appropriately to medetomidine withdrawal if they know what they’re dealing with. Lynch said it can be difficult to recognize. He recalled starting to see patients in severe distress in the fall of 2024. “They would come in and they’d be shaky, sweaty, nauseated, their heart rates and blood pressures would start to go up,” he said. “The kind of stuff that looked like it could be really bad opioid withdrawal, but more severe and much faster in onset.”
Rapid urine toxicology panels are not designed to detect medetomidine. Instead, emergency physicians often confirm medetomidine’s presence by observing whether symptoms continue even after patients receive medications that usually provide relief. Ideally, Fiscella said, jails should become “much more aggressive in starting treatment,” with medications like buprenorphine “to quickly clarify the situation,” and figure out whether medetomidine is involved.
But many jails do not offer buprenorphine or other medications for opioid use disorder and withdrawal. In 2022, the Department of Justice’s Civil Rights Division released guidance saying that jails who refuse these medications to patients with prescriptions are violating the Americans with Disabilities Act. Notably, this order does not provide specific protections for patients with opioid use disorder without an existing prescription to treat it — the same patients who would likely be experiencing severe withdrawal upon intake in jail. Still, the guidance suggests all jails should be legally obligated to have MOUDs available to at least some prisoners. But a national survey of jails conducted after the guidance was issued found that fewer than half of them offered any MOUD at all.
The availability of such medications in jail can improve mortality and health outcomes both during incarceration and after release. A randomized controlled trial compared jails that adopted National Commission on Correctional Health Care’s accreditation standards — which require MOUDs — to controls, and found that this accreditation can significantly reduce jail mortality. But jail accreditation is entirely voluntary, noted Marcella Alsan, a physician and economist at Harvard who co-authored the study. And because Medicaid and health insurance cannot legally fund jail health care, “It’s very difficult for them to finance this care, and yet they’re constitutionally obligated to provide it. Sheriffs themselves are being put in a very difficult position, and the counties themselves are being put in a very, very difficult position.”
The National Sheriffs’ Association came out against the Federal Medicaid Inmate Exclusion Policy, writing: “The MIEP policy makes no distinctions between those presumed innocent and those convicted. To deny a presumed innocent individual their eligible federal Medicaid, Medicare, CHIP or VA benefits, without due process of law, is a violation of their constitutional rights.”
“Some sheriffs are very active on this issue and very interested. Others feel like they have lots of other things to worry about,” Fiscella said. The dire symptoms of medetomidine withdrawal, he said, could have one benefit: “I would like to see this be a wake-up call for all jails to begin treating opioid use disorder seriously.”
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