The Economic Impact of Medetomidine on Critical Care Utilization: A Longitudinal Analysis of Intensive Care Unit Charges for Opioid Withdrawal Across the Adulterated Era

OBJECTIVES: To quantify the impact of the adulterated fentanyl supply, through the eras of xylazine and medetomidine predominance, on critical care charges associated with treatment of opioid withdrawal. METHODS: A longitudinal retrospective analysis was conducted at 2 intensive care units (ICUs) in Philadelphia, PA, USA, from April 1, 2017, to September 30, 2025. Primary outcomes included median per quarter and per patient charges and median quarterly ICU admissions with a primary or secondary ICD-10 diagnosis of opioid withdrawal (F11.23) from Q2 2017 to Q3 2025. These dates were correlated with quarterly drug supply adulterant prevalence reports by the Philadelphia Department of Public Health (PDPH). Secondary outcomes included ICU length of stay. RESULTS: Median quarterly ICU charges for F11.23 increased from $1,383,688 (1,138,614-1,602,562), during the period when the drug supply only included fentanyl (BX), to $2,883,659 (2,625,205-3,466,314) during the period of xylazine dominance (XE), to $17,168,020 (11,302,464-19,963,551) (H=23.50, P<0.001) in the period following the emergence of medetomidine (ME). Increasing cost was driven primarily by an increase in patient admissions (median 62 admissions XE per quarter vs. 261 ME), rather than median charge per patient for (XE $28,336 vs. ME $44,525, P=0.167). CONCLUSIONS: The adulteration of synthetic opioids with medetomidine was associated with a dramatic increase in ICU admissions and charges related to opioid withdrawal diagnoses. These changes represent a substantial public health challenge that may require systematic changes to health system resource allocation and withdrawal protocols.