It’s impossible for me to tell this story without context. Supply-side enforcement under the United States’ drug war, as the Iron Law of Prohibition describes, has caused catastrophic effects reminiscent of “bathtub gin” in the 1920s. In recent years this has been seen with the influx of veterinary sedatives like xylazine, and now its more potent big brother, medetomidine.

In 2020, having recovered from heroin addiction years previously, I was working at an outpatient buprenorphine clinic in Kensington, Philadelphia. This was an extremely difficult time: We were learning how to survive during a global pandemic while under occupation by the National Guard. 

As resources dwindled and dried up, many of the folks on my caseload began to disappear or die. At the height of the pandemic, it was impossible to walk two feet without finding a body in Kensington requiring resuscitation. Many of those people were close friends of mine. In that traumatic time, it seemed inevitable that I would start using again.

Over the three-year period that followed, I white-kuckled my way through more than 30 buprenorphine inductions and dozens of precipitated withdrawal events. I eventually found stability with methadone.

The nurse at the clinic refused to dispense my methadone. This, she told me, would “teach me to be on time.”

The sigh of relief from a full agonist was a heavenly turning point in my life. I had finally found recovery again. In the three years it had taken, I’d gone through an epidural abscess and subsequent spinal cord injury requiring multiple surgeries, three months of inpatient rehab for physical therapy and antibiotics; two rounds of sepsis; severe lower-extremity wounds related to xylazine contamination where I faced amputation; and the erosion of most of my teeth from sublingual buprenorphine.

One Saturday morning, six months into my recovery, I had a family issue which caused me to arrive at the methadone clinic seven minutes late. The nurse at the clinic refused to dispense my methadone dose for the day as well as the “gifted” take-home dose for Sunday.

This, she told me, would “teach me to be on time.”

As a rapid metabolizer at a clinic that uses the Methadose formulation, I was already experiencing the onset of withdrawal. I begged her to allow me to dose or perhaps travel to another clinic in the system.

She refused, and before closing the door reminded me to show up on Monday, or else I would be discharged for missing three consecutive doses.

I did my best to tough it out. But about 36 hours into withdrawal, I went to the only source that I knew could give me relief: the street.

This was in May 2024, just about the time that medetomidine was first detected in the Philadelphia drug supply. None of us knew about it. But I knew something was different, because the drugs gave me immediate, severe hallucinations—auditory, visual, and tactile. I also noticed long periods of unusual sedation and memory loss.

I was brought back to the ED critically ill. This was before medetomidine was known to be in the supply.

After three weeks of trying to stabilize on methadone once again, I found that every attempt to feel normal was insufficient. I was profoundly weak, incessantly vomiting and had uncontrolled diarrhea.

I went to the emergency department at a large hospital with a reputation for excellent addiction care. I sat in the waiting room for nine hours. Once withdrawal set in, however, I left.

Two days later, I was brought back to the ED critically ill. This was before medetomidine was known to be in the supply; xylazine was still the hot topic. Xylazine withdrawal was relatively straightforward and could be managed with minimal pharmacological assistance. I was left lying in a pile of my own feces and vomit, too weak to stand or communicate effectively, but aware of what was happening and being said around me.

As the nurses performed tasks, they talked over me as if I didn’t exist, joking about me and other patients and discussing weekend plans. Several of these nurses were former colleagues who knew me personally. The shame I felt while being ridiculed, unable to defend myself, was overwhelming. While my wife was in the room they were professional and provided care. But when they were unsupervised, I was clearly viewed as a nuisance.

The doctor sat down and began discussing end-of-life care and decisions. I spent the next few hours preparing videos for each of my children.

Once blood work started coming back they began to realize how critically ill I was, and I was admitted. I required multiple blood transfusions and long-term antibiotics.

On day three the doctor caring for me sat down and began discussing end-of-life care and decisions. He looked frightened, and explained to me that if my labs did not improve by the next morning, the likelihood of death would increase to 90 percent.

I will never forget that feeling. I spent the next few hours preparing videos for each of my children, telling my story and doing my best to make the case that I was a good father who loved them dearly. I wrote a letter to my wife, declaring my deep love for her and apologizing for not being a stronger and better man. It was a truly heartbreaking and helpless experience.

Miraculously, I turned the corner and everything began to improve. But I kept wondering what was so dramatically different about that experience.

It wasn’t until six months later that I spoke with journalist and harm reductionist Chris Moraff, who told me about his work with PA Groundhogs and the presence of medetomidine in Philadelphia. When I. described the exact block where I purchased the dope and the identifying stamp, he knew without question that I had experienced medetomidine withdrawal, essentially cold turkey—a condition now understood to be so severe that one hospital in Philadelphia has a designated ICU for these cases. Another hospital has a dedicated ambulance to transport medetomidine patients from other hospitals to more specialized care. Most rehabs in the area will now not accept opioid-withdrawal patients before medical clearance.

Prohibition made xylazine less available, at least short-term, but in typical fashion it ushered in a more potent substitute.

Two years ago, xylazine (“tranq”) was the focal point of most medical care, which primarily zeroed in on chronic wound management, limb salvage and infections. At one point xylazine was found in 99 percent of all street samples in Philadelphia. After xylazine was scheduled as a controlled substance in Pennsylvania—temporarily in 2023, then permanently the following year—this dropped to 40 percent, and continues to fall.

Prohibition made xylazine less available, at least short-term, but in typical fashion it ushered in a more potent substitute—the dramatic impacts of which were recently covered by the New York Times.

In fall 2025, I underwent skin graft surgery to finally close my old xylazine wounds. While I was recovering in the burn ICU, I spent a considerable amount of time talking with the physicians and nurses. They were all visibly concerned about medetomidine. Several of the nurses caring for me picked up shifts in the medetomidine-dedicated ICU. They told me they’d never seen so many resource-intensive cases in their entire careers. They appeared beat down and heartbroken, unsure if their work really mattered in the face of such a massive problem.

This story highlights several things. First, there continues to be large-scale ignorance of the detrimental effects of the punitive withholding of methadone in the carceral clinic system. People who take methadone are inherently at risk, and after years of prohibition, the street supply has become so dangerous that a single missed dose can prove fatal. Despite SAMHSA’s recommendations on take-home doses being relaxed in 2024, many (most) clinics have largely ignored these changes and still require daily in-person, observed dosing.

Second, stigma against people who use drugs in health care settings continues, and when it dissuades people from seeking care, it can be deadly.

I will never be the same man as I was prior to 2020. I want those we care for to live long, happy and healthy lives. Our systems stack the odds against them.

Third, my experience shows not only the importance of drug checking, but how it’s critical that changes detected in the drug supply are rapidly communicated to health providers, so they know what they could be dealing with.

And fourth, authorities should have learned long ago that banning drugs and enforcing drug laws may disrupt the supply, but never, in the long-term, for the better. The effects of the Iron Law of Prohibition have accelerated during the current overdose crisis, and our drug supply has long since reached a critical point of danger.

In the past we had the luxury of a supply not without risk, but reliable enough for harm reduction workers to have a sense of predictability and provide a safety net for those in our care. Those days are gone. Today I believe loving harm reduction means not only continuing to provide lifesaving supplies, but also doing everything we can to point people using dope adulterated with xylazine or medetomidine toward a safer supply.

I originally used heroin as a way to manage the ongoing effects of post-traumatic stress, and it did so with precision. I never suffered from abscesses, infections, hospital admissions or long-term complications. However, after using tranq dope for a short period I suffered catastrophic long-term health complications. And then I nearly died after unknowingly using medetomidine.

I will never be the same man as I was prior to 2020. Philly’s current dope is akin to being stood up on prom night by your dream date: empty, cold, lonely and forever painful. Every single time I move my body I am reminded how horrifically tranq is affecting our friends, and of those who have lost their lives after using medetomidine. I want those we care for to live long, happy and healthy lives. Our systems stack the odds against them.

Photograph by Olga Kononenko on Unsplash

The post The Lessons of My Near-Death Experience With Medetomidine appeared first on Filter.

However, these medications are not only restricted for doctors. Nurses can also be mandated to a medication-free—or abstinence-only—form of recovery from opioid use disorder (OUD).

Although health professional monitoring programs vary state-to-state, often operating independently with no oversight, many effectively restrict what is considered the gold standard for treating OUD. They typically create complex systems—requiring expensive and hard-to-obtain neurocognitive testing, for example, to determine impairment—before OUD medications can be approved for nurses. (The jury is out on whether the medications cause any impairment.)

The unspoken primary mechanism creating both this mythological concern for impairment and the general controversy over pharmacotherapy for healthcare professionals with OUD is stigma.

When I called my case manager, her first comment was, “Well, Bill, you know most people who use Suboxone abuse it anyway.”

I am a nurse in sustained recovery from opioid use disorder and a participant in a nurse monitoring program (Pennsylvania Nurse Peer Assistance Program, or PNAP). However, my fight to enter and sustain my recovery has succeeded despite the monitoring program, not because of it.

Nothing in writing outwardly indicates that PNAP prohibits bupe or methadone. But when I called my case manager to inquire, on behalf of another nurse, her first comment was, “Well, Bill, you know most people who use Suboxone abuse it anyway.”

In practice, if a nurse wants to be on buprenorphine and has a clear plan to taper off, PNAP will allow them in the program—and monitor them via drug screens until they taper off, and then continue screens for three years to ensure they stay off. If a person says they want to be on the medication indefinitely, PNAP will not allow them in the program and the nurse will be referred to the licensing board.

My case manager said that the licensing board will require “extensive neurocognitive testing to make sure they aren’t impaired on the medication and this testing is very expensive and difficult to find anyone who does it.” Her tone led me to believe no one would ever be cleared for licensure while taking the medication.

As a person who struggled with opioid addiction during the current age of fentanyl analogues contaminating the drug supply, I was at high risk for fatal overdose. Currently, well over 100 Americans die each day from overdose—a completely preventable cause of death. Opioid agonist medications such as buprenorphine and methadone can reduce this risk by 50 percent.

During my journey to recovery I entered inpatient treatment centers 16 times over an 18-month period. On 13 out of those 16 occasions, I could not abstain from use for more than four-to-six days, and left treatment.

Seven times after I was discharged from treatment, I experienced unmanageable cravings and sought relief, resulting in overdose.

Although I desperately wanted to recover from OUD, the intense cravings I experienced, coupled with unbearable symptoms of physical withdrawal, made it almost impossible for me to navigate these situations. So each time I returned to using opioids, with heightened vulnerability to overdose because of reduced tolerance after my brief period of abstinence.

Seven times after I was discharged from treatment, I experienced unmanageable cravings and sought relief, resulting in overdose. Thankfully, my wife found me on each occasion and administered naloxone.

During most of those inpatient visits, I was offered OUD medications. However, restoring my career was a primary goal for me. As a nurse, my understanding was that methadone and buprenorphine were prohibited—or at least unreachable due to policies and financial commitment.

So I continued to chase the white-knuckle, torturous goal of abstinence.

In addition to limits on medications, monitoring programs often mandate a path of recovery heavily embedded in the 12 Steps of Alcoholics Anonymous—a self-help program, created in 1939, that involves attending meetings, prayer and ridding oneself of “character defects.” Many people find 12-step fellowships helpful, but most don’t—estimates of success rates are very low. People should be free to choose this path if they wish, but not required to follow it.

My program required an initial 90 12-step meetings in 90 days (a typical unscientific practice in these fellowships), followed by three meetings per week for three years. Health professional monitoring programs commonly require this—although Bryon Wood, a former nurse in British Columbia, Canada, recently won his years-long legal fight to get the policy overturned there.

I still have to attend these meetings today, and PNAP tracks my attendance via GPS through my cell phone. Moreover, I am required to submit a monthly progress report outlining my efforts in the program. Each month, I write in these reports how harmful meetings have been to my personal life, yet I am still mandated to continue.

The author’s mandated AA meeting sign-in sheet

PNAP participants are also subject to random drug screens. These screens must be witnessed, which means the person providing the specimen must be physically observed as the urine exits their body by the person collecting the sample. This practice often generates anxiety and shame for the person providing the sample, as I have also stated in my reports for PNAP.

It operates on the assumption that the subject is dishonest, based solely on the myth that people with substance use disorders are liars and thieves. PNAP further perpetuates this discriminatory narrative when educating professionals about “signs” of substance “abuse.”

Behaviors such as dishonesty, when they occur, are not a byproduct of substance use disorder. Rather, they are a complex coping mechanism, related to unjust policy and the shame often imposed by healthcare professionals, reflecting how difficult it is to safely communicate about drug use given severe legal, social or professional consequences.

Testing also comes at an inflated cost, which is not covered by insurance. As the New York Times has reported, urine is a big money-maker in the addiction treatment industry, giving it the nickname “liquid gold.”

In my own case, my wife and I ultimately had to file for bankruptcy as a result of piling debt from treatment costs and monthly fees associated with such monitoring. Being unable to work as a nurse, I had to take a $9/hour retail job, which made it impossible to dig ourselves out of the financial hole.

These programs need to begin developing individually designed, participant-led recovery paths.

Monitoring programs for healthcare professionals are an essential part of public safety. A licensing board carries the great responsibility of ensuring that license holders are safe to practice. However, these programs have an equal responsibility to the nurses and physicians for whom they advocate.

Recovery from substance use disorders is not typically a linear path or a one-size-fits-all prescription. If these programs truly care about public safety—and not just checking off boxes to demonstrate an intervention was completed—they need to begin developing individually designed, participant-led recovery paths.

These options must include standard-of-care medications and evidence-based practices. Twelve-step attendance should never be mandatory, and good-quality therapeutic interventions should be available. Out-of-pocket costs for participants, which are often a barrier, should be eliminated.

Nurses as a group are rarely the subject of policy advocacy, but are severely subjected to stress, mistreatment and discrimination. Those with substance use disorders deserve far better than the restricted, anti-evidence options currently available.

Supporting Nurses Who Use Substances

One illuminating call for a better approach recently came from the Harm Reduction Nurses Association (HRNA) in Canada. The group issued a position statement on February 6, titled “Supporting Nurses Who Use Substances.”

“The prevalence of problematic substance use among nurses is similar to the general population,” it noted. “However, it tends to be underreported largely due to the overly disciplinary and non-supportive approach used by employers, regulatory bodies and unions.”

Indeed, my admittedly anecdotal experience suggests that job-related stress leads to particularly high rates of substance use disorders in this population, masked by a culture of silence.

Five of HRNA’s 13 demands were as follows:

* Nurses should be granted the freedom and autonomy to use psychoactive substances when off work—and not held to a different standard than the general public.

* Nurses with suspected problematic substance use should not automatically be put on leave pending their assessment. Instead, a risk management plan should be developed using the same approach used for other conditions that may result in performance impairment.

* Treatment plans should be individualized, patient-centered, secular and evidence-based, and free from any form of coercion. They should measure up to the best standard of care in the field and be consistent with the quality of health care offered to other citizens.

* Nurses with problematic substance use should not be singled out and subjected to a different level of scrutiny than nurses with other health conditions or injuries. Workplace accommodations should be provided with the same level of consideration and flexibility.

* Complete abstinence from all psychoactive substances should not be used as a treatment goal. Treatment goals should be tailored and developed collaboratively to reflect the state of evidence and principles of harm reduction.

Blocking lifesaving medications for nurses in the US reflects our country’s love affair with the War of Drugs—driven in turn by our Temperance-rooted cultural notion that total abstinence is the only “good” lifestyle.

The requirement that healthcare professionals engage with a program that says we should “turn our will and our lives over” to a masculine god and penitently make amends to every person we have harmed throughout our entire lives has much to do with shaming and nothing to do with science.

In centuries past, we assigned illness to demonic forces and relied upon prayer, or worse, to relieve us of our ailments. It was modern medicine that moved us past such archaic interventions.

How cruelly ironic, then, that in 2020, medical professionals are still forced to pursue a spiritual “remedy” for substance use disorders, and an abstinence-only path that increases their risk of finding not recovery, but death.

Photo by Artur Tumasjan on Unsplash

The post Why Are Nurses Denied Effective Treatment for Opioid Use Disorder? appeared first on Filter.

Bobby, whose last name I’m omitting to protect his family’s privacy, exhibited a genuineness rarely seen in the addiction/recovery world. He brought a childlike perspective into a house of pain, which was a catalyst for healing. It was not uncommon to see men in the house struggling with depression, and Bobby would typically be the guy who showed up with encouraging words and a hug. For some strange reason, he seemed able to enter therapeutic relationships with people the rest of us were excluded from.

A few years back I suffered a recurrence of problematic use (also known as a relapse) and lost touch with Bobby. I later learned that Bobby, like myself, had become a father, and that this event sparked an episode of depression and insecurity that also led him to resume problematic use, as it had with me years earlier.

I eventually found recovery again and began working in the recovery/harm reduction space. This past summer, I ran into Bobby at the local syringe service program in Philadelphia. He described how he had been struggling with opioid use disorder, and subsequently with homelessness.

In the second half of 2019, I began to visit Bobby regularly on the streets of Philadelphia where he was living, discussing available treatment options with him.

Beginning January 1, 2019, city public health officials implemented a ban on smoking at publicly funded addiction treatment programs (including outdoor spaces). Philadelphia ranks second among large US cities for overdose death rates. Advocates have long been concerned about the unintended consequences of this policy—namely, a rise in patients leaving treatment prematurely and increased barriers to their seeking treatment in the first place.

The greatest concern, in the context of Philadelphia’s fentanyl-adulterated drug supply, has been the increased overdose risk for patients who return to use, with lowered opioid tolerance, after a brief period of abstinence.

Every time we spoke, Bobby made it clear that he would not enter a treatment facility which prohibited smoking.

Bobby explained that he had entered a treatment facility in March 2019, three months into the smoking ban. But he had left against medical advice because the struggle to abstain from opioids and nicotine simultaneously had proven too difficult.

Every time we spoke, Bobby made it clear that he would not enter a treatment facility which prohibited smoking. One day I was sitting with him on an abandoned couch in a vacant lot where he lamented not being home with his children.

“I just want to stop. I don’t want to be out here anymore,” he said. “I miss my kids and want to be a good father, but it’s so hard and with this smoking ban, it’s just stupid and too much.” Although replacing cigarettes with vapes would have been a good option for him, the Philadelphia treatment smoking ban, unconscionably, also extends to vaping.

The last time I saw Bobby was late December. He was walking along Kensington Avenue with a large blanket around him, trying to keep warm in the subfreezing temperature. Even in the unbearable cold, he tearfully explained that quitting smoking was too difficult for him to consider while managing his opioid use disorder.

On January 31, I received a call telling me that Bobby had been found unconscious on the street. He was subsequently revived through CPR, but had been down too long without oxygen and suffered irreparable brain damage, resulting in brain death. Bobby then became an organ and tissue donor. He was 28 years old and had a young son and two daughters.

“We are continuing to make a significant investment in health outcomes for Philadelphians,” David T. Jones, the commissioner of Philadelphia’s Department of Behavioral Health and Intellectual Disability Services, told Filter last year. “We know that tobacco utilization is the #1 killer throughout the United States and we’re invested in saving lives.”

Smoking does kill in the long term, but people using fentanyl-adulterated street drugs are at risk of dying right now. In the course of my work, I have heard countless times from people experiencing homelessness and drug addiction that they will not enter treatment if they cannot smoke. They consciously and knowingly accept the risk of continued illicit drug use, preferring to preserve their autonomy rather than enter a nicotine-free facility.

It is impossible to identify how many of the city’s fatal overdose victims refused treatment due to the smoking ban, or how many were patients who left against medical advice. They all matter.

But with Bobby, it was personal for me. He and I had many conversations about going into treatment, and many more about how the restriction on smoking was a deal-breaker. Bobby remained on the streets because of the ban, and he died on those streets as a result.

City officials neglected to consider the slow, progressive nature of personal change—or the absurdly high bar of expecting people to quit nicotine at the same time as other drugs.

His tragic death was entirely preventable, and it is an indictment on policymakers—one that I hope brings humility and repentance.

Harm reduction advocates have been outspoken against the smoking ban since its inception. The opioid-involved overdose crisis claims over 1,100 lives annually in Philadelphia. As Brooke Feldman wrote for Filter last year, this is a time when barriers need to be dismantled—not erected.

Lives depend on this. Children like Bobby’s are relying on obstacles being removed so their parents’ lives can be saved. Banning smoking in treatment programs—an activity in which a large percentage of people struggling with drug addiction engage—is a deeply regressive move that prompts head-scratching from anyone who has spent time in Philadelphia’s drug-user community.

In their zeal for “investing in health outcomes for Philadelphians,” city public health officials neglected to consider the slow, progressive nature of personal change—or the absurdly high bar of expecting people to quit nicotine at the same time as other drugs. In assuming they knew what was best for people, they grossly ignored how personal agency and autonomy are the primary drivers of change.

Their paternalistic decision cost Bobby—among others—his life. It stripped two parents of their son and three small children of their father, and left a woman a single parent.

It is long past due for Philadelphia to repeal this cruel and counterproductive smoking ban.

Photographs of Bobby courtesy of Bill Kinkle/Bobby’s family.

The post My Friend Died Because of Philly’s Addiction-Treatment Smoking Ban appeared first on Filter.