In recent months, the emergence of Medetomidine as a drug of concern has alarmed health professionals and law enforcement agencies across North America. Initially detected in Toronto in 2023, Medetomidine cases have now surged in the United States, particularly in Pennsylvania’s Philadelphia and Pittsburgh areas. The Center for Forensic Science Research & Education (CFSRE) has issued a public Alert due to the increasing instances of hospitalizations and overdose events linked to this potent veterinary tranquilizer.

Understanding Medetomidine

Medetomidine, sold under the brand name Domitor, is primarily approved for veterinary use on canines in the U.S. It belongs to a class of drugs known as alpha-2 adrenergic agonists, which also includes Romifidine and Detomidine. These substances share similar chemical structures and effects, including sedation, analgesia (pain relief), muscle relaxation, and anxiolysis (anxiety reduction). While these effects are beneficial in controlled veterinary settings, their misuse in humans poses significant health risks.

Medetomidine functions by stimulating alpha-2 adrenergic receptors in the central nervous system, leading to a decrease in the release of norepinephrine. This action results in sedation and analgesia. The drug’s potency and efficacy in animals have made it a valuable tool in veterinary medicine. However, these same properties make it particularly dangerous when used improperly in humans.

The rise of Medetomidine misuse began with the first signs observed in Toronto. Since then, the drug has spread to various parts of the U.S., with Pennsylvania being a primary hotspot. In April 2024, Philadelphia witnessed approximately 160 hospitalizations over just a few days, highlighting the drug’s rapid and dangerous impact. Additionally, Chicago has reported mass overdose events, indicating that the issue is not isolated and may soon affect broader regions.

Medetomidine is primarily being used as an additive to street opioids, including Fentanyl, and is also found in counterfeit pills. This trend is particularly concerning because the sedative properties of Medetomidine amplify the effects of opioids, increasing the risk of overdose. Similar to Xylazine, another veterinary tranquilizer misused in the illicit drug market, Medetomidine’s increased potency poses a severe threat to public health.

Reports from hospitals and emergency responders indicate a disturbing pattern of Medetomidine-related incidents. For instance, the surge in Philadelphia hospitalizations is attributed to the drug being mixed with other substances, leading to severe respiratory depression and unconsciousness. Emergency medical services in Chicago have also noted a rise in cases where individuals exhibit extreme sedation and unresponsiveness consistent with Medetomidine exposure.

Challenges in Detection and Treatment

One of the critical challenges in addressing Medetomidine abuse is the lack of effective detection and treatment options. Although it shares similarities with Xylazine, there is currently no instant drug test specifically for Medetomidine. This limitation hampers timely identification and intervention in overdose cases. Furthermore, because Medetomidine is not an opioid, the commonly used overdose reversal drug Narcan (Naloxone) is ineffective against it, complicating emergency response efforts.

Currently, Medetomidine can be detected using advanced laboratory techniques, but these are not readily available in emergency settings. The reliance on comprehensive toxicology screenings means that many cases may go undiagnosed in the initial stages, leading to delayed treatment and increased risk of severe outcomes. Developing rapid testing methods is crucial for improving response times and patient outcomes.

The treatment of Medetomidine overdose focuses primarily on supportive care. This includes maintaining airway patency, providing respiratory support, and monitoring vital signs. In severe cases, mechanical ventilation may be required. The absence of a specific antidote further complicates treatment, emphasizing the need for medical personnel to be well-versed in managing the symptoms associated with alpha-2 adrenergic agonist toxicity.

Public Health Implications, Policy, and Regulatory Considerations

The rise of Medetomidine as a drug of abuse underscores the need for increased vigilance and proactive measures within the public health and law enforcement sectors. Hospitals and emergency responders must be aware of the signs and symptoms of Medetomidine overdose to provide appropriate care. Moreover, the development and deployment of specific drug tests for Medetomidine and similar substances are crucial for early detection and intervention.

Raising public awareness about the dangers of Medetomidine is essential in curbing its spread. Educational campaigns targeting both the general public and healthcare professionals can help disseminate vital information about the risks and signs of Medetomidine misuse. Community outreach programs, informative workshops, and the distribution of educational materials can play significant roles in these efforts.

Addressing the issue of Medetomidine abuse also requires robust policy and regulatory measures. This includes tighter control over the distribution and sale of veterinary tranquilizers and increased surveillance of the illicit drug market. Law enforcement agencies must collaborate with public health officials to monitor and respond to trends in Medetomidine usage and distribution effectively.

Conclusion

Medetomidine represents a growing threat within the landscape of illicit drug use. Its potent effects, combined with its presence as an additive in street opioids and counterfeit pills, make it a significant public health concern. The current lack of effective detection methods and antidotes exacerbates the risk it poses to communities. Addressing this issue requires a coordinated effort between public health officials, law enforcement, and healthcare providers to mitigate the impact of Medetomidine and prevent further harm.

As this situation evolves, staying informed and vigilant is essential. Public awareness and education about the dangers of Medetomidine can play a pivotal role in curbing its spread and ensuring that appropriate measures are taken to protect public health. The development of rapid testing methods and effective treatment protocols is also critical in enhancing the response to Medetomidine-related incidents. By addressing these challenges head-on, we can work towards reducing the incidence of Medetomidine abuse and its associated harms.

Additional Considerations:

Research and Development

Investing in research to better understand Medetomidine’s effects on humans and to develop targeted interventions is crucial. This includes studying its pharmacokinetics and pharmacodynamics in human subjects, as well as exploring potential reversal agents that could mitigate its toxic effects. Collaborative efforts between academic institutions, government agencies, and the pharmaceutical industry can drive advancements in this area.

International Perspectives

While Medetomidine misuse is currently a pressing issue in North America, it is essential to consider its potential impact on a global scale. International cooperation and information sharing can help prevent the spread of Medetomidine abuse to other regions. Learning from the experiences of countries that have successfully managed similar drug crises can provide valuable insights and strategies.

Long-term Public Health Strategies

To combat the rising threat of Medetomidine, long-term public health strategies must be implemented. This includes enhancing substance abuse prevention programs, improving access to addiction treatment services, and addressing the underlying social determinants of drug abuse. A comprehensive approach that combines immediate response efforts with long-term preventive measures can create a more resilient public health system.

Final Thoughts

The emergence of Medetomidine as a drug of abuse highlights the ever-evolving nature of the illicit drug landscape. As new substances enter the market, staying ahead of these trends is essential for protecting public health and safety. By fostering collaboration, investing in research, and prioritizing education and awareness, we can better equip ourselves to handle current and future challenges posed by drugs like Medetomidine. In summary, Medetomidine is a powerful veterinary tranquilizer whose misuse in humans has led to significant public health concerns. Its detection and treatment present unique challenges, necessitating a multi-faceted approach to mitigate its impact. Through concerted efforts across various sectors, we can work towards reducing the harm caused by Medetomidine and safeguarding the health of our communities.

A metabolite is defined as “a substance produced during metabolism, which is the process of digestion and other bodily chemical processes”. Essentially anything you put into your body is metabolized in one way or another. Food, for example, metabolizes into vitamins, proteins, fats, sugars, etc. Some food metabolites are useful chemicals your body needs, and some are discarded and excreted as waste byproducts.

Just like food, some substance metabolites are used by your body for various functions, and some are discarded and excreted as waste byproducts. In almost all cases, the process does not metabolize 100% of whatever was ingested, and to varying degrees is excreted unchanged from what was ingested (we call this the “parent compound”). A good common example of this is when you take too much Vitamin C, some of it is excreted unchanged; this is why we sometimes see bright orange urine when we take Vitamin C.

So why does this matter to us regarding drug testing? Since both the parent and the metabolite compounds are present in urine, it is important for a drug test to detect both. Moreover, the metabolites are detectable in urine much longer than their parents. Because of the longer window of detection, virtually all screens for drugs of abuse use metabolites as their target substance; this target substance is also known as the calibrator. When we talk about the cut-off level of a test, we are referring to the concentration at which the calibrator substance (again, typically the metabolite) will trigger a positive result.

While extremely oversimplified, the chart below gives us an idea of how parents and metabolites are excreted via urine. We can see at the far-left side of our timeline (we’ll call that the “onset” of the window of detection), the level of parent substance being excreted is much higher than the metabolite. Then about halfway through our timeline, we see equal amounts of parent and metabolite. Lastly, toward the “outset” of our window of detection we can still detect the metabolite, but the parent has fallen below the concentration needed for detection. So, for example, when testing for Fentanyl we will be able to detect Norfentanyl – its metabolite – for a much longer period of time after use than the parent Fentanyl.

While instant urine tests for drugs of abuse have improved tremendously over the years, the simple fact that it is still just a method of screening tells us that there are some limitations in the amount of information that they provide. Here we will discuss some of the obvious (and less obvious) reasons why laboratory confirmations should be considered a crucial part of your testing program.

First and foremost, it is part of the manufacturers’ instructions for use; usually worded to the effect of “This assay provides only a preliminary analytical test result. A more specific alternate methodology must be used in order to obtain a confirmed analytical result. Gas chromatography/mass spectrometry (GC/MS) and liquid chromatography/mass spectrometry (LC/MS) are the preferred confirmatory methods”. If I provided no additional reasons beyond this, that it is listed as a “must” in the instructions is a pretty compelling argument.

Let’s discuss some of the reasons that test manufacturers (and the FDA, whose guidance compels these instructions) find this so important…

Firstly, it is no secret that drugs screens – whether an instant device, or a “desktop analyzer” type device – are not 100% accurate. While most panels on our instant tests are greater than 99% accurate, it is this remaining 1% that needs to be accounted for. A good example of this is known cross-reacting substances; using the Fentanyl panel as our example, we know that the medication Buspirone (Buspar) can cause a false positive on the Fentanyl panel. The only way to be sure that the positive result is due solely to the Buspirone would be to have the specimen confirmed via laboratory. There are no cross-reactions on a laboratory confirmation.

Another reason lab confirmations are crucial is the fact that most of the panels on an instant test react with many substances within that drug class. An example I like to use for this instance would be the Benzodiazepine (BZO) panel. Let’s say you have an individual who is prescribed Alprazolam (Xanax), but maybe you have suspicions of other Benzos being used. You would expect to see a positive BZO due to the Xanax, but only a lab confirmation could determine if the positive was from the prescribed BZO, or a different BZO that may have been taken illicitly.

Levels in urine tests don’t provide much (if any) useful information, with one exception: checking for THC level over time. Of course, all instant screens are qualitative (positive or negative) and cannot provide a quantitative result (level). In this instance, with the lab confirmation providing the quantitative result, you are able to check for THC level over time to monitor continued abstinence.

Lastly, I’m sure you have encountered outright denial of use, at least on a couple of occasions; something to the effect of “that can’t be right”, or “your tests are broken”, where they are hoping by some miracle the lab result will confirm their story. Of course, some will admit use after the results of the instant test, reducing the importance of confirming. The other side of the coin here is someone admitting use where nothing shows on the instant. In these instances, the lab will confirm at a lower cut-off level, and will typically show that the concentration of substance was just not high enough to react on the instant.

In summary, while the use of instant tests is a hugely beneficial tool, it can’t always tell the whole story. They do reduce the lost time and cost of having to send every specimen out, but do not completely preclude the need for laboratory testing.

If you’ve watched our “Understanding the Limitations of Drug Testing” webinar or have had conversations with me about that subject, you’ve heard me talk about substances that many people expect to be detected on the tests that they are using, but actually are not.  An excellent example of this that we are all hopefully familiar with is Fentanyl. This synthetic opioid, for a long time, was expected to be detected on an Opiate panel but in fact it is not. As Fentanyl became more problematic, we increased our efforts to ensure that we were giving our customers the knowledge and the tools needed to test for this dangerous substance. Today we will discuss Hydrocodone and Clonazepam. While not nearly as prevalent as Fentanyl, these are two commonly prescribed drugs that do have the potential for abuse and are worth knowing about.

Hydrocodone is an Opioid pain medication, with Vicodin being the most prominent brand name. If you’ve ever had any serious dental work, you have probably heard of this one. Since it is an Opioid, it has a high potential for misuse and addiction, so it is a substance that is important to test for. However, the misconception is that this substance would be detected on the standard Opiate panel, or at least the Oxycodone panel.  Because these substances share a similar molecular structure, there is a possibility that Hydrocodone could be detected on either of those panels. However, the concentration of Hydrocodone in the specimen would have to be much higher than the other substances being detected, and therefore neither of those panels will ever be reliable tools for detecting Hydrocodone. Fortunately, we do have a Hydrocodone specific test, both as separate single-panel dip tests, and also included in select multi-panel cup configurations.

Clonazepam is a Benzodiazepine commonly known by the brand name Klonopin. Benzodiazepines, or Benzos, also have a high potential for misuse and addiction and is also an important substance to test for. Also, like Hydrocodone, it is possible that Clonazepam will trigger a positive on the standard Benzodiazepine panel, but it will not be at all reliable. The Benzodiazepine panel was designed to detect the most common Benzodiazepines. So, a standard test will detect about 20 of the 50+ Benzodiazepines that exist in the world, but Clonazepam is different enough in both molecular structure, and in the way the human body metabolizes it, that it will not be reliably detected. For this reason, such as with Hydrocodone, we do offer a Clonazepam specific test in both a single-panel dip test, and as part of select multi-panel cup configurations.

The big takeaway here is that it is important to know what substances will be detected on the panels you are testing with. While the tests are engineered to detect as many drugs in a specific class as possible, sometimes differences in chemistry and biology make this impossible. Fortunately, in almost all cases, we have the tool available that will fill these “blind spots”.

As always, for additional information or discussion on this topic, please reach out to me or your consultant.