Vancouver Area Network of Drug Users

10/01/2026

An excellent piece on DULF:
“DULF Wins Constitutional Challenge, Judge Applauds Their Work”
“Compassion club co-founders Eris Nyx and Jeremy Kalicum will avoid prison and Canada told to update its drug laws.” by Michelle Gamage
29 Sep 2026 The Tyee
“Drug User Liberation Front co-founders Eris Nyx and Jeremy Kalicum will not face jail time, Justice Catherine Murray ruled this morning.
Nyx, Kalicum and their lawyers have been appearing before Murray in BC Supreme Court for almost a year, first facing trafficking charges and later in a constitutional challenge.
Their ultimate goal has been to push for a novel response to the ongoing public health emergency caused by the unregulated toxic drug supply.
Through the Drug User Liberation Front Nyx and Kalicum had provided tested methamphetamine, co***ne and he**in to DULF members at cost. The idea was to allow people with substance use disorders to understand the makeup of the drugs they were taking to avoid overdose and death.
“You selflessly put yourselves to the side for this cause and that’s something most people wouldn’t do. For that I applaud you. You should be very proud of yourselves,” Murray said, directly addressing the pair in court as she delivered her judgment.
Murray has declared Section 5(2) of the Controlled Drugs and Substances Act unconstitutional and given Ottawa six months to bring the legislation in line with the Charter of Rights and Freedoms.
As a result of this finding, Nyx and Kalicum’s trafficking convictions have been stayed.
If Ottawa doesn’t fix the legislation within the six-month timeframe Murray has mandated, it will no longer be in force.
It’s likely the government will apply for more time to fix the legislation, said Tim Dickson, one of DULF’s lawyers, after the judgment was delivered.
Dickson said today’s judgment was a “vindication” of what DULF was doing.
“The court has declared the prohibition on possession for the purposes of trafficking to be unconstitutional because it violates the Charter rights of individuals who need non-medicalized safer supply to reduce the terrible risks of this toxic drug criss we are suffering under,” Dickson said.
Why DULF was in court
Nyx and Kalicum argued that the law that convicted them both of three counts of trafficking methamphetamine, co***ne and he**in was unconstitutional.
Because the pair had been selling drugs to compassion club members to reduce harms and fatalities caused by the unregulated drug supply, DULF’s lawyers Tim Dickson, Stephanie Dickson and Kaelan Unrau contended that shutting down the club violated Section 7 and Section 15 of its members’ Charter rights.
DULF’s three lawyers smile and pose for a photo in front of the Vancouver courthouse.
Murray delivered a judgment today that aligned with this argument.
Murray agreed that a non-medicalized safer supply program is urgently needed to save lives and found that DULF had been reducing the harms associated with the toxic drug crisis while having no negative impact on the community or public safety.
She also agreed there was no way for a compassion club or non-medical safer supply program to source legal drugs and no legally and practically available safety valves in the Controlled Drugs and Substances Act to support such a program.
She also said Section 5(2) of the Controlled Drugs and Substances Act was unconstitutional because it prevented a non-medicalized safer supply program from operating during the ongoing toxic drug crisis.
This infringed on DULF compassion club members’ rights to life, liberty and security of the person and their right to be treated equally under the law, which are guaranteed under Sections 7 and 15 of the Charter of Rights and Freedoms.
“It’s people like you who make a difference,” Murray told Nyx and Kalicum. “And you just did. So go out and do great things. I have no doubt that you will.”
Starting the Drug User Liberation Front
Nyx and Kalicum met in 2020 and bonded over a shared vision for the future, where no one died after taking unregulated drugs.
As of June the unregulated, toxic drug supply has killed at least 19,906 British Columbians since January 2014, according to the latest data from the BC Coroners Service.
Nyx and Kalicum wanted people who use drugs to be able to access drugs that had some safety protocols.
If people knew what they were taking they wouldn’t have to overdose, Nyx told the court.
The pair began buying and testing drugs, and then giving away tested, labelled drugs for free at rallies.
They applied for a Section 56 exemption to the Controlled Drugs and Substances Act from Health Canada, asking for permission to buy and sell methamphetamine, co***ne and he**in through a compassion club.
They were denied. They decided to open a compassion club anyway.
At the start of the trial, Nyx told the court she has responded to more than 100 overdoses.
“This is a calamity beyond words. This is a horror beyond words. This is a travesty,” Nyx said. “This is gutting my community and killing everyone I know.”
The compassion club welcomed 47 members with previous drug use experience. Members could buy pure, tested drugs at cost.
There was a limit to how much a member could buy in a week.
DULF partnered with Vancouver Coastal Health Authority, which provided funding for DULF to test its drugs, and permission to store, test and package the drugs.
Vancouver Coastal Health Authority also provided DULF with office space in the Downtown Eastside, which it used for storage and a storefront for compassion club members.
But this partnership did not cover the selling or distribution of drugs.
Vancouver Police raided DULF’s office space and arrested Nyx and Kalicum on Oct. 25, 2023. Nyx and Kalicum were both found guilty of three counts of trafficking on Nov. 7.
Launching a constitutional challenge
Two and a half weeks later, DULF launched a constitutional challenge.
DULF’s lawyers argued government action violated Section 7 of the Charter of Rights and Freedoms, which prohibits the state from depriving people of their rights to life, liberty and security of the person, and Section 15, which says all people must be treated equally and have equal protection and benefit from the law.
This case boiled down to the Section 56 exemption DULF had requested from Health Canada.
The federal health minister can grant exemptions under Section 56 of the Controlled Drugs and Substances Act to allow people to violate the legislation in extraordinary cases.
DULF lawyers argued exemptions were not practically available. They said that meant the Controlled Drugs and Substances Act violates Charter rights. Crown counsel disagreed and argued the safety valve was available.
In her judgment Murray agreed with DULF’s lawyers, saying there was no practical way a non-medicalized safer supply program could get a Section 56 exemption. Ottawa will now have to figure out a way to make sure such a safety valve exists in practice.
The Crown has 30 days to appeal Murray’s decision.
Throughout the charter challenge DULF lawyers called 14 witnesses to help explain why DULF chose to open an unsanctioned compassion club.
The compassion club ran what is known as a non-medical safer supply model, where interacting with a doctor is not required to access drugs.
This model is recognized by B.C. experts as a solution to the crisis’s catastrophic death toll.
The BC Centre on Substance Use, Vancouver Coastal Health, Fraser Health and the BC Centre for Disease Control took five years to try and figure out a way to develop a non-medical model, but in the end weren’t able to find a legal way.
Other experts, including Provincial Health Officer Dr. Bonnie Henry, and experts for two death review panels convened by the province’s chief coroner, have called on the province to explore a non-medical safer supply model. So far the province has declined to do so.
Instead the province offers a medical model of safer supply, where a patient gets a prescription from a doctor to use pharmaceutical drugs. This model is extremely limited and only a fraction of the people who could benefit from it can access it.
TJ Felix, who is Secwe̓pemc and uses they/them pronouns, testified about why the services B.C. currently offers to respond to the unregulated toxic drug crisis didn’t work for them.
Using drugs from the unregulated market feels like “a gun always at the back of your head,” but withdrawal from opioids feels “like every nerve ending exploding. It’s like you’re being dragged through a bed of nails,” they said. “It’s indescribable, horrific and painful. You’d do anything you could to avoid it.”
DULF offered stability because members didn’t have to worry about withdrawal or the danger of the unregulated supply, Felix told the court.
Felix said sometimes they would share drugs they had bought from DULF with loved ones.
After seeing a loved one fatally overdose “many times,” Felix said they’d do anything to try and separate their loved ones from the unregulated drug supply.
Giving drugs to someone other than the person they were prescribed or sold to is known as “diversion.”
Politicians critical of safer supply, such as MLA Elenore Sturko, say the risk of diversion outweighs the benefits offered by the program.
But diversion from safer supply programs is minimal at best, testified Lisa Lapointe, who worked as B.C.’s chief coroner for 13 years.
Only three per cent of the Dilaudid dispensed in B.C. in 2024 was for the safer supply program, with the other 97 per cent dispensed for reasons unrelated to safer supply, such as for pain management, Lapointe said.
Patients prescribed Dilaudid for pain do not have to take their medication in front of a pharmacist or provide urine tests to their doctor.
It’s also not clear if Dilaudid pills seized in police drug raids are actually diverted pharmaceuticals or if they’re unregulated knockoffs, Lapointe said.
In 2023 the Vancouver Police Department said Dilaudid made up 0.3 per cent of all drugs seized that year.
DULF is also awaiting the decision in a judicial review where they asked a judge to review Health Canada’s decision to deny them permission to buy, test and distribute unregulated drugs in the name of harm reduction.”

09/30/2026

An explanation of the DULF ruling:
“BC Court Strikes Down Canada’s ‘Possession for the Purpose of Trafficking’ Offence in the DULF Case”
by Kyla Lee Sept 29, 2026
“Today the BC Supreme Court declared one of the most frequently charged drug offences in Canada unconstitutional.
In R v Kalicum, 2026 BCSC 1855, Madam Justice Murray found that section 5(2) of the Controlled Drugs and Substances Act (CDSA), which makes it a crime to possess a controlled substance for the purpose of trafficking, violates sections 7 and 15 of the Charter. She declared the section of no force or effect, then suspended the declaration of invalidity for six months to give Parliament time to respond. She then stayed the convictions of Jeremy Kalicum and Eris Nyx, the co-founders of the Drug User Liberation Front (DULF).
It is the most significant drug law ruling out of this province since the Supreme Court of Canada kept Insite open in 2011. It is also a detailed, evidence-based account of what happens when governments let politics drive their response to a public health emergency.
WHAT DULF DID
Kalicum and Nyx are harm reduction workers in the Downtown Eastside. Between them they have responded to more than 100 overdoses. By 2021 they had watched enough friends, co-workers and neighbours die from a poisoned street supply of drugs that they designed a program to do something about it.
The DULF Compassion Club worked like this. DULF bought he**in, co***ne, and methamphetamine from the dark web. They then had the drugs tested at UBC and UVic for fentanyl, benzodiazepines, and other contaminants, then packaged and labelled them with their contents and health warnings. It sold them, at cost, to screened members who were over 18 and already using those drugs. It bought them on the dark web because no legal source existed. Which is an important part of why the Court ruled the way it did.
DULF knew this was illegal, so it asked permission first. On August 31, 2021, it applied to the federal Minister of Health for an exemption under section 56(1) of the CDSA. That exemption would have allowed them to distribute the drugs lawfully. Health Canada declined the exemption… but it took almost a year to do so. By the time DULF followed up, 1,333 (additional) British Columbians had died from toxic drugs. DULF challenged the refusal in Federal Court. That judicial review was argued in March 2024. As of the last day of the criminal court hearing in July 2026, the Federal Court still had not released a decision.
In the meantime, the province backed DULF. The BC Ministry of Health gave DULF a storefront in the Downtown Eastside at no cost and designated it an overdose prevention site. Vancouver Coastal Health signed a funding agreement worth up to $200,000 a year for DULF’s drug checking and overdose prevention services. The Ministry knew DULF was selling tested drugs to members. So did the Vancouver Police Department. DULF published its results in peer-reviewed journals, gave interviews, and invited officials to visit.
The program worked. In its first year there were no overdoses involving the substances DULF supplied.
THEN THE ECONOMIST RAN A STORY
On September 8, 2023, The Economist published an article about the Compassion Club, with photos of Kalicum and Nyx inside the site. The political reaction was immediate. Pierre Poilievre called it a “disgrace” that the BC NDP would give tax dollars to “illegal drug dealers.” Justice Murray took the time to correct the record. The public funding paid for drug checking and the overdose prevention site, and DULF bought its drugs with money from community donors.
As a result of the political pressure and fallout, the BC Ministry of Health directed Vancouver Coastal Health to pull DULF’s funding and its lease. The VPD drug section, which in the judge’s words “was aware of DULF and the Compassion Club but had turned a blind eye,” opened an investigation.
Six days before the Compassion Club was scheduled to close, police executed a search warrant. They found co***ne, he**in and methamphetamine in two locked safes, mostly in DULF-labelled packages of 0.1 to 1 gram. The drugs were exactly what the labels said, with no fentanyl and no benzodiazepines. That was the whole point of the program.
Kalicum and Nyx were convicted of possessing for the purposes of trafficking in November 2025. The provincial exemptions covered testing, packaging and supervised consumption, but not selling. Their convictions were held in abeyance while they brought this constitutional challenge.
THE ISSUE AT THE CENTER OF THE CASE
The Crown’s position was that DULF’s problem was a failed exemption application, not the law. If DULF wanted to operate legally, it should have gotten an exemption.
Justice Murray found that the exemption was never really available. Section 56 of the CDSA lets the Minister exempt a program from the CDSA. It does not exempt anyone from the Food and Drugs Act, which separately prohibits selling any drug that lacks Health Canada market authorization. The only pharmaceutical he**in in Canada is authorized for one purpose, prescribed and supervised injectable opioid agonist therapy. Using it any other way makes it a “new drug” that needs its own authorization, a process one witness called at trial had been working through for more than a decade, at a cost of millions of dollars. The Food and Drugs Act amendment that would allow person-specific exemptions has never been brought into force.
So a program using illegally sourced drugs violates the Food and Drugs Act even with a CDSA exemption, and a program using legally sourced drugs cannot exist because there are no legally sourced drugs to use. The court called the section 56 exemption “illusory” in this context.
The judge also found a second problem with section 56. It is entirely discretionary. It has no standards, no timelines, and no requirement that the Minister prioritize health and safety. Justice Murray described the toxic drug crisis as “a political hot potato” and agreed that the lack of guardrails leaves the exemption power open to political pressure. An 11-month wait during a declared public health emergency, she noted, was not a failure of the scheme. The scheme allowed it.
An exemption no one can get is not a real meaningful safety valve.
WHY SECTION 5(2) VIOLATES THE CHARTER
The Crown conceded that section 5(2) engages the liberty of anyone who runs a program like DULF’s, because it exposes them to jail. The harder question was whether the law also engages the right to life and security of the person of the people DULF served. The court found it does, relying on the Supreme Court of Canada’s reasoning in Bedford, the s*x work case. Drug use itself is not a criminal offence. A law that stops people from protecting themselves against the risks of a lawful activity deprives them of security of the person, even if other factors also contribute to the harm.
The court then found that the deprivation breaches two principles of fundamental justice. The purpose of the CDSA is to protect public health and public safety. A law that criminalizes a program that saved lives and did not harm public safety captures conduct that advances the law’s own purpose, which makes it overbroad. It is also grossly disproportionate. Justice Murray drew directly on Bedford, where the bawdy-house law stopped s*x workers from moving to a safe indoor location while a suspected serial killer was preying on women on the street. Section 5(2), she wrote, keeps drug users from safer supply “while fentanyl and other highly dangerous contaminants prowl the street drug supply.”
The Crown leaned heavily on R v Lalancette, a 2022 Ontario decision rejecting a similar challenge. The court distinguished it on the facts. Mr. Lalancette delivered five kilograms of street he**in to another dealer, and the judge described him as “for all intents and purposes, a drug trafficker who claimed to have good intentions.” DULF was transparent, publicly supported, studied by researchers, and backed by the health authority.
THE CROWN & THE DEFENSE AGREED THAT SUBSTANCE USE IS A DISABILITY
The court found that by blocking any non-medical source of drugs of known content, section 5(2) has a disproportionate effect on people with severe dependencies, who cannot simply stop using, and pushes them back to a street market that exposes them to overdose, violence and exploitation. The Crown argued the right comparison was between drug users with and without a diagnosed disorder. Relying on the Supreme Court of Canada’s 2026 decision in Kanyinda, Justice Murray called that “an outdated understanding of the test.”THE CROWN BARELY DEFENDED THE LAW
Once a claimant proves a Charter breach, the burden shifts to the government to justify it under section 1. The government has spent years telling the public that non-prescription safer supply is dangerous. In this case it had a months-long hearing, with experts on the other side including the former Chief Coroner, a former Deputy Provincial Health Officer, and a member of Health Canada’s own Expert Advisory Group on Safer Supply. The Crown called no evidence to contradict any of them. The judge described that as being “of marked significance.”
The Crown did not plead justification at all in its outline of position. It gave section 1 a single paragraph in its written argument. The court found the law fails the minimal impairment test, because it criminalizes activity that advances the CDSA’s objectives, not activity that undermines them.
So the Government’s case against safer supply is loud at the megaphone and quiet in the courtroom. When it had to put evidence behind the rhetoric, it called none.
THE REMEDY
Justice Murray declared all of section 5(2) of no force or effect. The Crown asked her to limit the declaration to he**in, co***ne and methamphetamine. She refused, because the problem the case exposed is the absence of any legal pathway to non-medicalized safer supply, whatever the drug.
The Crown asked for a 12-month suspension of the declaration of invalidity. The court gave only six months. “It has been over 11 years since the toxic drug crisis was declared a public health emergency,” she wrote. “It remains an emergency.” The Crown can apply to extend the suspension if Parliament needs more time.
Relying on the Supreme Court of Canada’s decision in Ontario v G, she also granted Kalicum and Nyx individual stays of proceedings. Their convictions are stayed. The Crown had accepted that individual exemptions would be appropriate if the challenge succeeded.
WHAT THIS MEANS IF YOU ARE CHARGED WITH POSSESSION FOR THE PURPOSE OF TRAFFICKING IN BC
Section 5(2) remains fully in force today. The declaration is suspended for six months, and nothing in this decision makes it legal to possess drugs for sale in the meantime. If you have a charge before the courts, it has not gone away. But the door is open to mount a similar constitutional challenge.
Expect the federal Crown to appeal to the BC Court of Appeal, and to ask that the suspension be extended while it does. This case may well end up at the Supreme Court of Canada.
The declaration strikes down the whole section, but the reasoning is built around a transparent, not-for-profit, health-focused program. The court distinguished the ordinary drug dealer in plain terms. Anyone hoping this decision provides a defence to a commercial trafficking case should read Lalancette’s treatment in these reasons carefully. The decision also leaves untouched the separate offences of trafficking under section 5(1) and simple possession under section 4.
Under the Supreme Court of Canada’s decision in R v Sullivan, a superior court’s declaration of invalidity binds the provincial courts in that province. It does not bind courts in other provinces. For now, this is a B.C. ruling.
If you are facing a drug charge, the details of your case matter more than any headline. Talk to a criminal defence lawyer about how this decision, and any appeal, may affect you.
SIX MONTHS
The court said the current law makes it impossible to run a program that every expert panel has recommended, and that the Charter does not allow that. The judge identified the fixes herself. Parliament can amend the Food and Drugs Act regime, and it can give section 56 exemption decisions real structure.
Kalicum and Nyx did in the open what the Coroners Service, the Provincial Health Officer and Health Canada’s own advisors told government to do. Health Canada’s answer took eleven months. The province’s answer took one magazine article. The VPD’s answer was a search warrant. The court’s answer took months of evidence, and it is the only one of the four that was based on any (evidence).”

09/29/2026

09/29/2026

“They were courageous. They were evidence-based.” BC Supreme Court finds. Canadian Drug Policy Coalition
Sept 29, 2026 – “In a landmark ruling that could alter the fabric of drug policy in Canada, the BC Supreme Court has found that the criminal law used to arrest and convict DULF co-founders Jeremy Kalicum and Eris Nyx is unconstitutional. The Court ruled that section 5(2) of the Controlled Drugs & Substances Act violates the Section 7 and Section 15 Charter rights of DULF co-founders and people who use drugs. The Judge declared section 5(2) of the CDSA invalid (of no force or effect), effective six months from today. This delay is to give the opportunity for the legislature to craft a response.
In finding section 5(2) of the CDSA unconstitutional, the Court has issued a “stay of proceedings” against Kalicum and Nyx. This means that no convictions will be entered against them and they cannot be prosecuted again for the DULF compassion club activities that were the subject of this court case.
“They were courageous. They were evidence-based. They pursued their program with no profit, no benefit for themselves at all, always with the sole intention of trying to reduce the terrible rate of death in this crisis,” says Tim Dickson of DULF’s legal team. “Drug policy should not rely on people as courageous as Ms. Nyx and Mr. Kalicum. Governments need to follow the evidence and make the choices to implement programs that…will work to save lives. If we care about saving lives, then we need to follow the evidence. And that is what the Court did in this case.”
Judge Catherine Murray delivered the verdict with oral reasons for judgement, finding that “a non-medical safe supply is urgently needed to save lives” and “the DULF compassion club reduced the harms associated with the toxic drug crisis and did not negatively impact the community or public safety.”
“It’s really encouraging that the court today has recognized some of the harm created by prohibition,” says Aiyanas Ormond of the BC Coalition of Organizations By/For People Who Use Drugs. “We now have an important opportunity to re-think the whole framework of the war on drugs, and consider alternatives, like DULF, that support health, build community, and delink addiction and substance use from the violent harms of criminalization and the black market .”
In court, Judge Murray took time to acknowledge DULF’s co-founders directly. “Mr. Kalicum and Ms. Nyx, you selflessly put yourselves on the line for this cause. I know from watching you through this lengthy process that it has taken a toll…I applaud you for what you have done. You should be very proud of yourselves. Go do great things; I have no doubt that you will.”
“DULF provided life-saving services when no legal alternative was available. This put them on the wrong side of the law: their lawyers argued that given these facts, it is the law, not DULF’s co-founders, that is wrong,” says DJ Larkin, executive director of the Canadian Drug Policy Coalition. “Today, the BC Supreme Court agreed. We are deeply heartened and relieved that the Court has recognized DULF’s lifesaving and selfless work. Thank you to Jeremy, Eris and the legal team led by Tim Dickson, Stephanie Dickson, and Kaelan Unrau for your remarkable and courageous work.”
In November 2025, Eris Nyx and Jeremy Kalicum – two founders of the Drug User Liberation Front (DULF) – were each convicted of three counts of possession for the purpose of trafficking because they sourced diacetylmorphine (he**in), methamphetamine and co***ne from the dark web, rigorously tested it to ensure purity and determine potency, and sold it at cost to members of a strictly controlled compassion club. In doing so, DULF provided its members with a regulated, predictable drug supply as an alternative to the volatile street drug supply that has killed more than 18,000 people in B.C. over the past decade.
But when political winds shifted in September 2023 and several politicians publicly targeted the club and stirred up moral panic, the same government agencies who had previously supported or tacitly permitted the compassion club’s operation abandoned DULF and the club members whose lives and health the club was protecting. On October 25, 2023, the Vancouver Police Department raided DULF and arrested its co-founders, forcing compassion club members back to the dangers of the unregulated drug supply.
“Moms Stop the Harm celebrates the successful outcome of DULF’s Charter challenge and recognizes the extraordinary courage and determination of Eris Nyx, Jeremy Kalicum, their legal team, and everyone who stood behind them,” says J Stewart of Moms Stop the Harm. “At the heart of this case are people’s lives. Canada’s unregulated drug supply continues to cause preventable deaths, and people who use drugs deserve policies grounded in evidence, human rights, dignity and care — not punishment. We are grateful to DULF for having the courage to challenge the status quo.”
As for the future of Canada’s drug laws, Canada now has six months to craft legislation that upholds constitutional rights. It is expected that the Crown will appeal this judgement, which would delay any legislative changes.”

09/29/2026

“What started out with a cordial introduction would, just over two years later, take a quick turn. Within only a few months, Heard would go from meeting with Kalicum to approving a criminal investigation into his actions — an investigation that included tracking Nyx’s phone and trying to put a tracking device on Kalicum’s car.
That investigation would end in raids of DULF’s office and of Kalicum and Nyx’s homes, and possession for the purpose of trafficking charges against the two.”

Court records show the same inspector who encouraged the compassion club’s founders also approved the investigation that led to raids on their homes

09/20/2026

“Improvising in an emergency:
Doctors respond to medetomidine withdrawal with no roadmap” by Hannah Harris Green 08 Sep 2026
“In Pennsylvania, a mystery fentanyl adulterant began causing withdrawal related heart attacks in 2024. Doctors have been rushing to catch up.
One reason Brandie wants to quit street fentanyl is she can't take the “brain zaps,” anymore; “It feels like somebody ringing a bell inside your head, and it goes through your whole body.” The zaps have become routine since late 2024, when medetomidine, a powerful tranquilizer, became the newest adulterant to compromise the Pittsburgh street fentanyl supply. The sensation can be so intense it brings Brandie to her knees.
Brain zaps have become an important signal for both clinicians and for people like Brandie. For Brandie, they’re a sign to either re-dose, get to the hospital, or risk stroke or heart attack. For Dr. Divya Venkat, an addiction and primary care physician in Pittsburgh, brain zaps are the fastest way to determine which patients are withdrawing from fentanyl alone, and which might soon be in critical condition. Rapid urine toxicology panels cannot detect medetomidine. Brain zaps are not a symptom of typical opioid withdrawal, but they are near-universal in medetomidine withdrawal, according to Venkat and other clinicians, as well as several first-hand accounts.
Medetomidine withdrawal patients have been filling Pennsylvania ICU wards for over a year, and the problem has yet to slow down. At the end of August, Pittsburgh’s Poison Control Center received 139 reports of medetomidine related emergencies in the space of just 5 days. Doctors are catching up on the fly—there’s no time for proper scientific procedure. Normally, researchers conduct experiments before landing on a preferred treatment, according to Dr. Michael Lynch, professor of toxicology, addiction and emergency medicine at the University of Pittsburgh Medical Center. They compare new interventions to placebo or an existing treatment, and figure out what’s best. But in a crisis like this one, where inaction can lead to seizures, heart attacks, and strokes, science must wait on doctors’ and patients’ experience, not the other way around. Lynch compared the situation to Covid-19. Before there was evidence, “we needed to do something, because people were very, very sick.”
As new, unpredictable adulterants continue to rotate in and out of the street drug supply, strategies focused on opioid overdose prevention are no longer enough.
Rapid-fire protocol development could, by necessity, become the norm. According to Dr. Nabarun Dasgupta, founder of the Street Drug Analysis Lab, US disruptions to cartel leadership mean that drug manufacturing is currently in a “mix-it-up” phase—it’s hard to predict what’s coming up the pipeline next.
The US has had several decades to figure out how to best tackle the problem of street opioids. But tranquilizers like medetomidine and its predecessor, xylazine, have only become common adulterants in recent years. Pennsylvania made intent to sell xylazine a felony in late 2024. Within weeks, medetomidine took its place, according to an analysis by Dasgupta. Dasgupta’s lab also analyzed street drug samples from Prevention Point Pittsburgh, a local harm reduction organization, to confirm medetomidine in the Pittsburgh fentanyl supply.
THE OPIOD STRATEGY TURNED ON IT’S HEAD
For decades, public health authorities have poured resources into preventing opioid overdoses and addiction. Access to naloxone expanded dramatically, and it’s become common for people who use opioids to carry naloxone and to have many experiences using it to save friends’ lives. The FDA has approved new formulations for people who want to quit opioids in recent years, and the DEA has removed some of the red tape around access.
Fentanyl is by far the most dangerous drug ever to dominate the street supply, but its toll has started to ease, thanks to public health measures and international interdiction efforts specifically designed to tackle the potent synthetic opioid. In 2025, US overdose fatalities declined for the third consecutive year, to fewer than 70,000 for the first time since the pandemic, driven largely by a drop in opioid overdoses.
But in Pennsylvania, where medetomidine has become pervasive in the fentanyl supply, the strategies that helped reduce opioid overdoses have suddenly become less useful. Naloxone can't prevent fatalities related to withdrawal. A key overdose prevention strategy is to get people into substance use treatment with as little friction as possible. Now, anyone wanting to quit fentanyl in Pittsburgh or Philadelphia is strongly advised to go to the hospital first, as withdrawal from medetomidine can quickly become a medical emergency.
“It’s not the use that’s killing people, it’s the stopping that’s killing people,” said Alice Bell, director of Prevention Point Pittsburgh. Bell and Venkat have both observed that while withdrawal related fatalities are rising, overdose deaths have declined since medetomidine appeared in the fentanyl supply. “We're seeing a lot fewer overdose deaths, fewer naloxone administrations,” Bell said.
Fentanyl mixed with medetomidine is more likely to cause extreme sedation than a classic opioid overdose, according to Venkat and Bell's observations, though naloxone is still essential if breathing has dramatically slowed or stopped. “People are not jumping up from being revived like they used to,” said Malcolm Visnich, an overdose prevention specialist at Prevention Point. “Now you just don't know what's going on with them [when they’re lying still.] So you have to really pay attention to their breathing.” Rescue breaths can help ensure that unconscious people continue to get the oxygen they need to avoid brain injury.
CATCHING UP TO THE SCIENCE
Medetomidine is an alpha-2 agonist, a class of drugs that can help calm the sympathetic nervous system, which regulates blood pressure as well as anxiety. While lighter alpha-2 agonists like clonidine and guanfacine can gently regulate anxiety, impulsivity and blood pressure, medetomidine’s strength means small amounts are incapacitating. When someone stops using it, the sudden activation of the sympathetic nervous system constricts the blood vessels, creating rising pressure in the brain that leads to symptoms like the “brain zaps” mentioned earlier, as well as seizures, heart attacks and stroke. The over-activated sympathetic nervous system also leads to unbearable levels of anxiety, worse than withdrawal from opioids alone, Venkat said. “The anxiety we see with opioid withdrawal is awful. But this feels like they're crawling out of their skin.”
Brandie, who is 40, said she and her partner Chris, 36, had been using opioids for seven years, and medetomidine is the worst adulterant they’ve encountered. The fentanyl high is gone—their drugs simply knock them out. And once they wake up, they have to use again in a couple of hours just to “stay well,” Brandie said. It’s expensive, and exhausting. So when Brandie was fed up and ready to quit, she followed public health recommendations and went to the hospital.
The treatment Brandie received when she was withdrawing from medetomidine was available thanks to doctors like Lynch, who cobbled together a protocol by scouring through any and all relevant literature, then closely observing patients to see what works. For example, Lynch was able to figure out that medetomidine dependence and withdrawal both develop with unusual rapidity—thanks to research on dexmedetomidine, a human medication that contains one of the two molecules found in the racemic medetomidine compound that’s taken over the Pittsburgh street supply.
When Brandie arrived at the hospital, she had no severe symptoms, so she just had to wait. Her nurse started to clear the room when Brandie’s heart rate spiked. Brandie asked if everything was alright. “There's just gonna be a lot of people in here really fast,” Brandie recalls the nurse saying, “And she wasn't lying, like ten people got interested in me really quickly. They were taking my blood pressure, my blood sugar.” Brandie heard her own room number over the hospital loudspeaker—it was terrifying.
“They put the shock pads on me. They’re not like in the movies, they’re these big stickers. One’s red and one’s blue." Brandie told the nurse “this doesn’t look good.” “It’s just in case,” she said.
Brandie went to the ICU and received intravenous dexmedetomidine. “I was asleep for two days,” she remembered, “When you wake up, you feel pretty okay. For the next week and a half, Brandie received oxycodone and va**um every four to six hours in the hospital. “They would have never given that type of medication for just fentanyl. They basically have to wean you off the street drugs with op**te medications.”
Lynch’s protocol involves dosing patients with other alpha-2 agonists, analogous to how opioid withdrawal is often treated with other, weaker opioids. Clonidine, a blood pressure medication that is also prescribed for anxiety, and guanfacine, a drug that’s used to treat ADHD related impulsivity as well as high blood pressure, are both starter medications for medetomidine withdrawal. More severe cases can require intravenous administration of dexmedetomidine, the human-approved formulation of the medetomidine molecule, also known by the brand-name Precedex. Dexmedetomidine is typically only available in ICU settings because it is so potent. Lynch published this advice in Annals of Emergency Medicine, but cautioned the paper is “not evidence based in the truest sense,”—there was no carefully planned trial with a control group. Since publishing, Lynch has kept tweaking. “Every time we adjust, we get more aggressive, so doses get higher.”
Lynch said that ideally, once someone’s withdrawal symptoms have been stabilized, they will get started on treatment for opioid use disorder. But a significant percentage of patients end up leaving the hospital early, in what’s called “patient-directed discharge” according to Venkat. “They leave the hospital against physician’s orders because they don’t feel good. They’re scared. And I so wish there was more of a safety net to capture those people.” When people leave the hospital and begin using fentanyl adulterated with medetomidine again, it can mean they'll have to take another trip to the ICU. Brandie's partner Chris had two heart attacks related to medetomidine withdrawal—he said he already had heart health issues. Both times he went to the ICU, it was because he'd been arrested and started withdrawing without access to his drugs. The second heart attack was fatal.
UNANSWERED QUESTIONS
Doctors like Lynch have made it possible for many patients to get through medetomidine withdrawal alive. But there is no established treatment for prolonged medetomidine withdrawal, and many patients end up back on adulterated fentanyl, and, like Chris, back in the ICU. Venkat says this is partly because treatments for opioid use disorder don’t help with prolonged medetomidine withdrawal symptoms.
There is no diagnostic code for medetomidine withdrawal, and there may be many cases where the physician never realizes that's what's going on.
This cycle is exhausting for patients and expensive for hospitals. One study found that withdrawal related costs went up more than tenfold in ICUs where medetomidine had emerged. “We need a different detox model that is cheaper, and we need to be building this now," Dasgupta said. But funding cycles are slow—Lynch worries the next adulterant will already have taken over by the medetomidine research gets funded.
And so long as medetomidine’s true death toll remains obscure, related research may seem less urgent than it is. “That’s going to be a really tricky thing, how do you quantify it?” Bell said. There is no diagnostic code for medetomidine withdrawal, and there may be many cases where the physician never realizes that's what's going on.
The profound sedating effect of medetomidine might lead to deaths that will never be recorded at all. Calla Kainaroi, executive director of Bridge to the Mountains, a Pittsburgh non-profit that connects unhoused people to services, said there have been reports of people hurt or killed while unconscious. Some are assaulted, some roll down the Pittsburgh hills into traffic.
A man who I’ll call Marcus, who uses fentanyl in Pittsburgh, said a friend of his was hit by a train while unconscious. Marcus himself remembers waking up under a car, completely forgetting how he got there—his drugs, money and coat gone in the winter. His fiancée, who I’ll call Ellie, said he’d have frozen to death if his friends hadn’t found him. While Ellie does not use fentanyl herself, she spends a lot of time with people who do.
Since medetomidine, she says, “nobody feels good, not even for a minute. I watch it from the outside looking in and it’s sad. Nobody is enjoying it. They just do it because they don’t want to die.” “

(This reporting was supported by a grant from USC's Impact Fund for Health Journalism)

In 2024, a mystery fentanyl adulterant began causing potentially withdrawal symptoms, like stroke and heart attack, in Pennsylvania.