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Medetomidine is on the raise in the prairies with Alberta wastewater monitoring showing dramatic increases.
Street sourced fentanyl that contains medetomidine is sometimes referred to as “Tranq” or “Fight club”. Medetomidine, a racemic mixture of the ICU medication dexmedetomidine and its enantiomer levomedetomidine, is an alpha-2 agonist similar to clonidine and xylazine.
Symptoms of acute toxicity include miosis, bradycardia, hypotension, and profound sedation. A clue to exposure would be an opioid overdose that partially responds to naloxone or breathes with naloxone, but does not wake up. Acute intoxication can be difficult to delineate from benzodiazepines in the drug supply, though bradycardia and hypotension are much more common with medetomidine. Management would be entirely supportive with fluids, should respond rapidly to low to norepinephrine if required, and maintaining a broad differential for non-toxicologic causes.
Symptoms of medetomidine withdrawal typically occur within 24-48 hours of last using, and can be difficult to delineate from opioid withdrawal, benzodiazepine withdrawal, and alcohol withdrawal, with many overlapping features. However, intractable vomiting and severe hypertension are clues.
Click below to access the document out of Ontario for further details, but management often includes benzodiazepines for agitation (and treatment of concomitant alcohol or benzodiazepine withdrawal), opioids to manage acute opioid withdrawal, antiemetics including olanzapine or haloperidol, and administration of clonidine or dexmedetomidine infusion.