PSHP 2026 Residency Conference

PURPOSE: Medetomidine-adulterated fentanyl is associated with complex withdrawal, increasing the need for hospital resources. This research characterizes the use of adjunctive medications to de-escalate the level of care in this population.


METHODS: This retrospective chart review conducted from 1/1/25-9/15/25 included patients admitted for opioid withdrawal receiving intravenous opioids with another adjunctive agent (alpha-2 agonists, benzodiazepines, gabapentin, or antiemetics). Patients were excluded for mechanical ventilation >48 hours; concurrent alcohol or benzodiazepine withdrawal; admission to surgical, trauma, or burn services; or patient-directed discharge prior to ICU discharge. 
Variables were collected throughout ICU course, 72 hours following ICU discharge, and at time of hospital discharge. 
The primary endpoint was the impact of clonidine initiated on day 1 (early initiation) versus after (late initiation) on hospital length of stay (LOS). The impact of high dose (>0.6 mg) clonidine on day 1 compared to low dose (≤0.6 mg) clonidine on hospital LOS was analyzed. The relationship between receipt of additional adjunctive agents and hospital LOS was also analyzed.


RESULTS: One hundred patients were included: median age 42 years, 61% male, and median fentanyl use 10 bags/day. Ninety-three received clonidine, 58 gabapentin, 29 tizanidine, 91 benzodiazepines, and 98 dexmedetomidine. Median ICU LOS was 58 hours and hospital LOS 120 hours. 
Early clonidine was not associated with shorter hospital LOS (p=0.091). In the early clonidine group, patients remained in the ICU for an additional 2 days in the high dose versus 3 days in the low dose group (p=0.14). Dexmedetomidine duration did not differ with clonidine dose or timing. 
For each adjunctive medication added to therapy, there was a 19% decrease in hospital LOS (p=0.018). This relationship was not seen with ICU LOS. Additional analysis is ongoing.


CONCLUSION: Though not statistically significant, early clonidine reduced hospital LOS, while early, high dose clonidine appeared to reduce ICU LOS. Additional adjunctive medications on ICU day 1 significantly reduced hospital LOS. The findings suggest multimodal and early withdrawal management may decrease hospital and ICU LOS. Further research into clonidine dosing strategies is needed to demonstrate impact.