Message #: PDPH-HAN-00463U-06-22-2026
Philadelphia Department of Public Health
Division of Substance Use Prevention and Harm Reduction ● 123 South Broad St, 11th Floor, Philadelphia, PA 19107
https://www.substanceusephilly.com ● https://www.phila.gov/programs/substance-use-prevention-and-harm-reduction ● https://hip.phila.gov
DANIEL TEIXEIRA DA SILVA, MD, MSHP
Director,
Division of Substance Use Prevention and Harm Reduction
Philadelphia Department of Public Health
Division of Substance Use Prevention and Harm Reduction
PALAK RAVAL-NELSON, PHD, MPH
Health Commissioner
Health Update
Emerging practices for managing medetomidine withdrawal in the outpatient setting
June 22, 2026
Morbidity and mortality from drug use in Philadelphia
remain a public health priority. Although overdose
deaths decreased in 2024, the addition of
medetomidine to the drug supply has led to severe
health consequences.
1
Since medetomidine was
first detected in Philadelphia in April 2024,
emergency room visits for withdrawal have
increased by 291%. There is increasing recognition
that alpha-2-agonist dependence and withdrawal
from medetomidine require dedicated treatment.
Over the past two years, healthcare systems have
updated hospital protocols to treat medetomidine
withdrawal.
2–4
However, there has been less focus
on the management of medetomidine withdrawal in
the outpatient setting. To address this gap, on May
5, 2026, the Substance Use Response, Guidance,
and Education Program at the Health Federation of
Philadelphia hosted a webinar on outpatient
management of medetomidine withdrawal, “From
REbound to REcovery: Managing the Alpha-2
Agonist Storm in Outpatient Settings,” provided by
experts in primary care, street medicine, opioid
treatment programs, and lived experience. This
Health Update provides a summary of that training,
which can also be accessed here:
https://surge.learn.healthfederation.org/plus/
Disclaimer: the published literature on medetomidine
withdrawal is limited to retrospective cohort studies, case studies, and expert opinion in the inpatient setting. This is
still an emerging clinical presentation. Best practices are based on the experience of outpatient clinicians caring for
people who use drugs in Philadelphia.
Post-hospitalization discharge planning and clonidine tapering
Due to the severity of medetomidine withdrawal, the acute care hospital setting is increasingly where people who use
drugs are receiving withdrawal treatment and being inducted on methadone or buprenorphine for their opioid use
disorder. At hospital discharge, many patients still require high doses of alpha-2-agonist therapy that require tapering
over several months. Clonidine is the most effective alpha-2-agonist therapy for treating medetomidine withdrawal in
the outpatient setting. High doses of clonidine are often used during inpatient admissions, but this should be tapered
during the hospitalization so that patients can be discharged on a safe outpatient dose of clonidine. A clonidine
regimen of 0.3mg three times a day is the maximum dose and frequency for outpatient withdrawal management and
should be a goal for hospital discharge with outpatient follow-up.
After hospital treatment for medetomidine withdrawal, patients need close follow-up for blood pressure monitoring and
medication management. A goal should be for patients to see an outpatient provider within at least 2-5 days of hospital
discharge. Close post-hospitalization follow-up can be facilitated by working with peer navigators, who can
communicate directly with the patient and their follow-up outpatient provider. After post-hospitalization linkage to
•
Patients being discharged from the hospital after
receiving treatment for medetomidine withdrawal to
the outpatient setting should see a provider for follow-
up ideally within 2-5 days for monitoring of vital signs
and medication adjustment.
•
Clonidine dose at hospital discharge for a patient
discharged to the community should not exceed
0.3mg three times a day.
•
Tapering of clonidine post-hospitalization for
medetomidine withdrawal can take up to several
months. At least weekly clinic visits are suggested
initially.
•
Providers should assess for current drug use to
inform clonidine tapering, treatment efficacy, and
educate patients on symptoms of low blood pressure.
•
Clinical factors to consider for referral to inpatient
hospital admission include very elevated blood
pressure, inability to tolerate medications by mouth,
history of previous treatment for medetomidine
withdrawal in the hospital, and underlying co-
morbidities.
SUMMARY POINTS
Message #: PDPH-HAN-00463U-06-22-2026
Philadelphia Department of Public Health
Division of Substance Use Prevention and Harm Reduction ● 123 South Broad St, 11th Floor, Philadelphia, PA 19107
https://www.substanceusephilly.com ● https://www.phila.gov/programs/substance-use-prevention-and-harm-reduction ● https://hip.phila.gov
outpatient care is established, regular weekly visits are necessary to ensure safe and effective tapering of clonidine.
Initially, and at higher clonidine doses, clinicians should prescribe clonidine in 1-week increments to ensure the dose
is safely titrated to blood pressure. (see Table 1)
Table 1: Blood Pressure Parameters for Titrating/Tapering Clonidine Dose for Outpatient Medetomidine Withdrawal
Treatment
Patient Office Presentation
Clonidine Titration/Taper
Low Blood Pressure
Reduce clonidine dose by at least 1/2 to 2/3
Normal Blood Pressure
Keep at the same dose, and plan for a slow
decrease over time (e.g., reduce 0.1mg in 1-2
weeks)
Elevated Blood Pressure
Increase the dose of clonidine or increase
frequency, consider adding guanfacine or tizanidine
Very Elevated Blood Pressure
Consider hospitalization
The use of clonidine patches should be tailored to each patient. Clonidine patches offer the advantage of medication
delivery without requiring adherence to an oral regimen. However, patients will not be able to rapidly change their
clonidine dose in response to changes in substance use or symptoms of high or low blood pressure. In addition,
having a clonidine patch in place may worsen low blood pressure due to non-withdrawal factors such as infection,
dehydration, or return to use. Patches should always be dated, including the time of application and dose.
Blood pressure management and counseling
Clonidine is an anti-hypertensive medication, so it is important to monitor blood pressure weekly initially and titrate
the clonidine dose as described in Table 1 above. Integrating blood pressure management and counseling has not
historically been part of opioid withdrawal management and may require changing clinic workflows. There are several
considerations outpatient clinicians can keep in mind when monitoring blood pressure and using alpha-2-agonists to
manage medetomidine withdrawal that are described in Table 2 below.
Table 2: Clinical Considerations for Alpha-2-agonist Selection in the Outpatient Setting
Clinical Situation
Alpha-2-agonist Selection
Blood pressure/heart rate stable or elevated
Clonidine and Tizanidine
Blood pressure/heart rate low
Tizanidine and Guanfacine
EKG indicating prolonged QTc interval
Guanfacine or Clonidine
Withdrawal symptoms not adequately
controlled with current alpha-2-agonist therapy
Addition of other agents as needed if clonidine has been
maximized to the highest safe outpatient dose, consider inpatient
admission for dexmedetomidine if the patient cannot tolerate
medications by mouth
Importantly, it is not uncommon for patients to continue to use drugs while their medetomidine withdrawal symptoms
are being managed in the outpatient setting. Using fentanyl with medetomidine can lead to marked fluctuations in
blood pressure. (note: “tranq dope” and “tranq” are terms used in reference to illicit fentanyl with medetomidine) Thus,
outpatient providers managing medetomidine withdrawal should regularly have open and non-judgmental
conversations with their patients about their current drug use. Information about patients’ current drug use can inform
clonidine tapering and counseling on blood pressure. Example questions about drug use include:
• Are you using tranq dope or tranq?
• How often do you use tranq dope or tranq?
• How much do you use tranq dope or tranq?
o The amount of drug use is often described in the number of bags or bundles per day. If a patient
describes using a bundle, then clinicians may ask how many bags are typically in a bundle.
• Is that more or less than you used before starting treatment of tranq withdrawal?
Clinicians should monitor the amount and frequency of use to help determine treatment efficacy. When patients
continue to use drugs, a reduction in use is an indication of effective withdrawal treatment. As patients gradually
reduce drug use and plan for complete cessation, alpha-agonist medications will need to be increased, and additional
Message #: PDPH-HAN-00463U-06-22-2026
Philadelphia Department of Public Health
Division of Substance Use Prevention and Harm Reduction ● 123 South Broad St, 11th Floor, Philadelphia, PA 19107
https://www.substanceusephilly.com ● https://www.phila.gov/programs/substance-use-prevention-and-harm-reduction ● https://hip.phila.gov
medications should be considered to treat symptoms of withdrawal. If a patient is using tranq dope/tranq while also
receiving outpatient care for medetomidine withdrawal, then clinicians should consider the following counseling:
• Recommend not taking clonidine if planning to use or have recently used tranq dope/tranq.
• Provide education on symptoms of low blood pressure: lightheadedness or dizziness, fainting (i.e., syncope),
changes in vision (e.g., tunnel vision, blurred vision), and increased confusion.
• Provide anticipatory guidance if a patient is experiencing symptoms of low blood pressure, such as:
o Not taking the next dose of clonidine
o Sitting or lying down to avoid injury
o Increasing intake of salt (e.g., salty snacks) and hydration
o Attempt maneuvers to increase blood pressure, such as squatting or sitting with legs crossed
5
Emerging strategies for outpatient management of co-occurring opioid and alpha-2-agonist withdrawal
To date, medetomidine in the drug supply is nearly always detected with fentanyl. In Q1 2026, medetomidine was
detected in 90% of drug samples where fentanyl was the primary drug in Philadelphia.
6
Thus, successful management
of medetomidine withdrawal requires management of opioid withdrawal. There are two emerging strategies for
outpatient management of both medetomidine and opioid withdrawal:
• The co-management approach has been described in the opioid treatment program setting, where the
induction onto methadone is gradual over several days, but this approach may also be applied to outpatient
buprenorphine micro-inductions. The co-management approach relies on patients reducing use of illicit
substances as the dose of methadone or buprenorphine increases, which can lead to a “self-taper” from
medetomidine that can be supported by prescribing alpha-2-agonists as needed.
• The sequential approach focuses on rapid induction onto buprenorphine, such as direct-to-inject
administration of long-acting injectable buprenorphine for stabilization of opioid use disorder during active drug
use (e.g., Brixadi™, Sublocade™) followed by dedicated management of alpha-2-agonist withdrawal with
clonidine and additional alpha-2-agonists as needed to help reduce drug use. In this approach, patients should
not change their use patterns significantly until they are fully stabilized on buprenorphine. Changing use
patterns before being fully stabilized on buprenorphine will bring on symptoms of medetomidine withdrawal,
which can create confusion given overlapping symptoms of opioid and alpha-2 agonist withdrawal.
In addition to clonidine, the following medications may be used to treat medetomidine withdrawal in the outpatient
setting:
• Alternative/Adunct Alpha-2-agonists to consider in the setting of normal or low blood pressure but ongoing
symptoms of withdrawal or cravings:
o Guanfacine: 0.5–1 mg PO nightly or BID; titrate every 3–7 days; less hypotension/sedation
o Tizanidine: 2–4 mg PO every 6–8h PRN; helpful when BP is lower but patients are still experiencing
symptoms of medetomidine withdrawal; monitor for sedation and liver function tests
• Symptom-targeted adjuvants (short-term):
o Nausea/vomiting: promethazine 12.5–25 mg PO q6h PRN; prochlorperazine 5–10 mg PO q6h PRN
o Severe nausea/agitation: olanzapine 2.5–5 mg PO nightly or BID
o Anxiety: hydroxyzine 25–50 mg PO q6h PRN
▪ Avoid routine benzodiazepines; reserve short courses for select patients with close follow-up
o Sleep/anxiety: gabapentin 300–600 mg PO TID (adjust to renal function)
o Sleep/appetite: mirtazapine 7.5–15 mg PO nightly
Some of these medications can prolong the patient’s QT interval. Depending on the patient’s risk (treatment with
methadone, underlying cardiac comorbidities, propensity for electrolyte abnormalities, etc.), providers can monitor
EKGs to ensure the QT interval is safe.
Clinical factors to consider for inpatient treatment
Patients who are being managed for medetomidine withdrawal in the outpatient setting may need to be referred for
inpatient hospitalization. For example, if their blood pressure is very elevated or they cannot tolerate medications by
Message #: PDPH-HAN-00463U-06-22-2026
Philadelphia Department of Public Health
Division of Substance Use Prevention and Harm Reduction ● 123 South Broad St, 11th Floor, Philadelphia, PA 19107
https://www.substanceusephilly.com ● https://www.phila.gov/programs/substance-use-prevention-and-harm-reduction ● https://hip.phila.gov
mouth because of severe nausea and vomiting (see Table 1 and Table 2). Additional clinical factors that can help
inform when patients may need inpatient treatment include:
• History of requiring admission to the hospital for medetomidine withdrawal in the past, which may be an
indicator that they are more likely to experience severe symptoms requiring intensive care again when they
stop using drugs.
• History of other co-morbidities, such as heart disease, strokes, and seizure disorders, which can increase the
risk of complications from hypertensive urgency and nausea and vomiting associated with medetomidine
withdrawal.
Resources
Medetomidine resources and treatment recommendations: www.substanceusephilly.com/medetomidine
Substance Use Disorder Treatment:
• Behavioral Health Services Initiative (uninsured): 1-215-546-1200
• Community Behavioral Health (Medicaid): 1-888-545-2600
• CareConnect Warmline: 484-278-1679
• DBHIDS Medication Assisted Treatment: https://dbhids.org/services/addiction-services/mat/
• SAMHSA National Helpline: 800-662-HELP (4357)
Recommend patients try not to use alone. If that is what they are doing, then provide resources:
• Never Use Alone: 877-696-1996
• The Brave App – free to download on app stores
• Canary App – free to download on app stores
Learn how to get and use naloxone: www.substanceusephilly.com/get-supplies
Get naloxone and fentanyl test strips shipped to you for free and confidentially: nextdistro.org/philly
Learn how to use fentanyl test strips:
• https://www.substanceusephilly.com/trainings#trainingvideos
• www.cdc.gov/stopoverdose/fentanyl/fentanyl-test-strips.html
• www.youtube.com/watch?v=GmhE6UOZ9YY
Take a wound care training: www.substanceusephilly.com/trainings
Acknowledgment:
The Philadelphia Department of Public Health’s Division of Substance Use Prevention and Harm Reduction would
like to acknowledge Kristina Walker, Judy Chertok, MD, Rachel Truchil, MD, MPH, Keriann Shalvoy, MD, MPH, PMH-
C, and Kara Cohen, CRNP, CWS, for their expertise in developing the content for the training webinar on which this
HAN is based.
Message #: PDPH-HAN-00463U-06-22-2026
Philadelphia Department of Public Health
Division of Substance Use Prevention and Harm Reduction ● 123 South Broad St, 11th Floor, Philadelphia, PA 19107
https://www.substanceusephilly.com ● https://www.phila.gov/programs/substance-use-prevention-and-harm-reduction ● https://hip.phila.gov
References:
1. Philadelphia Department of Public Health. Unintentional Drug Overdose Fatalities in Philadelphia, 2024. CHART
2026; 11(1):1-8.
2. Lynch MJ, Pizon AF, Yealy DM. Emergence of Medetomidine in the Illicit Drug Supply: Implications for Emergency
Care and Withdrawal Management. Ann Emerg Med. Published online January 23, 2026.
doi:10.1016/j.annemergmed.2025.12.004
3. London KS, Durney P, Warrick-Stone T, Alexander K, Kahoud JL. Decreased Effectiveness of a Novel Opioid
Withdrawal Protocol Following the Emergence of Medetomidine as a Fentanyl Adulterant. BioMed. 2025;5(2):2.
doi:10.3390/biomed5020013
4. Penn Medicine Center For Addiction Medicina and Policy - Medetomidine [website].
https://penncamp.org/medetomidine/. Accessed 6/18/2026.
5. Wieling W, Kaufmann H, Claydon VE, et al. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol.
2022;21(8):735-746. doi:10.1016/S1474-4422(22)00169-7
6. Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health. Drug
Checking Findings: January-March 2026. https://www.substanceusephilly.com/drugsupply (Accessed 6/18/2026).