Josh Trebach, MD

I’m the lucky one ;)

You might be on to something

I still remember some codes

Space heater on HI

got a space heater and I was like “omg it’s so cute its saying hi to us!!” and my husband was like “no u doofus that is the power setting” 🙃

nothing will betray you faster than the front shirt pocket of hospital scrubs

one lean forward and your pens and dignity end up on the floor

ER doc here. I’ve seen patients walk out during heart attacks and other life-threatening emergencies because no one could feed their pets at home. Imagine the lives saved if free emergency pet care existed.

I'll wrap this up here so I don't keep rambling--thanks for reading everyone.

If you are concerned about yourself/someone, please call 911/go to the nearest hospital (pls do not dm/email me asking for medical advice).

(cont.) Good supportive care is key. Acute withdrawal from the opioids should be managed the same way you would normally manage opioid withdrawal (ie, meds like buprenorphine). Medetomidine withdrawal may require introduction of alpha 2 agonists like clonidine to help manage.

HOW DO CLINICIANS TREAT WITHDRAWAL FROM OPIOID/MEDETOMIDINE?

I recommend consulting with tox/poison center/addiction medicine. There's good data on opioid withdrawal treatment, but medetomidine withdrawal has less data and would benefit from expert involvement (see next tweet)

CAN YOU WITHDRAW FROM BOTH OPIOIDS & MEDETOMIDINE?

People can withdraw from opioids which can be incredibly awful to go through. One can withdraw from medetomidine as well and experience effects like tachycardia and encephalopathy. Going through both withdrawals would be awful

TREATMENT FOR OPIOID/MEDETOMIDINE TOXICITY?

For clinicians, treatment = supportive (protect airway, address hypotension with fluids & pressors if needed, etc), give naloxone if concern for opioid toxidrome present/respiratory depression. Calling poison control/tox is recommended

WHAT HAPPENS WHEN SOMEONE USES OPIOIDS + MEDETOMIDINE?

Medetomidine = sedation, bradycardias, hypotension. Some data show hallucinations. Opioids = sedation, bradycardias, hypotension, and life-threatening respiratory depression. Together these are a dangerous combination

CAN YOU TEST SOMEONE FOR MEDETOMIDINE?

Yeah you can do testing to look for medetomidine/metabolite of medetomidine but it’s certainly not a routine test that is quickly done. Usually it would be a test that a hospital would have to send out to specific lab.

WOULD SOMEONE KNOW IF THEIR OPIOIDS HAS MEDETOMIDINE IN IT?

There’s no data (to my knowledge) that says medetomidine has a certain taste/smell/appearance. People may feel their normal opioid hit them harder (or cause hallucinations?) and it may lead to a new withdrawal state

WHY IS MEDETOMIDINE IN THE ILLICIT OPIOID SUPPLY?

Not entirely clear, but possibly bc it can be used to mimic sedative effects of opioids (e.g., fentanyl) while reducing cost for suppliers. There's also market/cost factors $$$$$. Also its high potency may make it appealing

SO DOES THE LEVOMEDETOMIDINE DO ANYTHING?

Short version: eh
Long version: the data we have shows that it doesn’t seem to be cause any effects in dogs/rats at decent dosing; however, there may be some human cell/receptor interactions in some data (PMID 9584224)?

WAIT ISN’T DEXMEDETOMIDINE A HUMAN DRUG?

Ya there’s a drug called Precedex (dexmedetomidine) that is used in humans for sedation. It does not contain levomedetomidine.

WHAT IS MEDETOMIDINE?

Medetomidine is a veterinary anesthetic medication. It’s composed of two different types of molecules called enantiomers: dexmedetomidine and levomedetomidine. The dexmedetomidine is the active component and is an alpha 2 adrenergic agonist.

New York Times headline: A Powerful New Drug Is Creating a 'Withdrawal Crisis' in Philadelphia Medetomidine, a veterinary sedative, mixed into fentanyl has sent thousands to hospitals, not only for overdose but for life-threatening withdrawal. It is spreading to other cities.

Hi, medical toxicologist/ER doctor here 👋

here’s what you need to know about medetomidine in the illicit opioid supply

street fighter xmas sweater

one time I was driving home and I saw a small crowd around someone who looked dead so I pulled my car over and checked for a pulse and then started cpr on the sidewalk and while I was doing cpr a bystander tried to STEAL MY CAR KEYS

nurse: doctor josh can you please tell my son that he shouldn’t eat too much candy

me: ugh yeah one time I ate so much sour candy that my tongue started peeling it was soooo painful

nurse: oh wow how old were you

me: …….yesterday

one time in college I took an exam thinking “wow this is way harder than I expected” and the professor walked by and gasped because she’d given me (AND ONLY ME??) an exam from a different course. Every hard exam since I was like IS IT HAPPENING AGAIN? IT CAN’T HAPPEN TWICE RIGHT?

people named barb are so lucky because they can be like “my name is short for phenobarbital” and no one can argue with them

Social media post where someone is describing putting urine in their eyes and then having their eyes get red and have pus

didn’t think this needed to be said but please don’t put urine in your eyes

At the same time???

I became an attending and work somewhere else now!! My mysterious cookie benefactor did not follow me hehe

when I was a resident, a mysterious ER nurse used to leave a cookie on my desk after I did a good job with a sick patient. Years later, no cookies appear…but after every resuscitation I still crave one….a Pavlovian echo of a kindness that never quite left me 🍪

*be me in med school*

me: ok remember these 3 words—book, cat, potato. I’ll ask again in 5 min to test your memory

patient: ok

*5min later*

patient: book, cat…uhhh…what was the third one?

me: …….

patient: did u forget too

me: …………yeah

Orange cat and grey cat on top of Simpsons arcade cabinet

just Bucket (orange) and Pebble (grey) being gamer kitties