S3 Ep24: #528 Hospital Addiction Medicine 3.0 with Dr. Maggie LowensteinS3 Ep24: #528 Hospital Addiction Medicine 3.0 with Dr. Maggie Lowenstein
The Curbsiders Addiction Medicine Podcast
Clinicians discuss complex hospital care for people with opioid use disorder, focusing on methadone management, QTc concerns and emerging medetomidine withdrawal. The conversation also covers harm reduction, naloxone use and practical discharge planning for safer transitions of care.
1:18:55•8 Jun 2026
Hospital Addiction Medicine 3.0: Methadone, Medetomidine and Fentanyl’s New Challenges
Episode Overview
- Confirming methadone doses and last administration with OTPs is crucial, but when records are unavailable, clinicians can start cautious yet assertive dosing based on reported use and supplement with short-acting opioids.
- Missed methadone doses should not automatically lead to drastic dose cuts; decisions can factor in ongoing fentanyl use, medical comorbidities and institutional policy, with rapid retitration where safe.
- QTc prolongation around methadone needs careful reassessment, including manual ECG review, correction of electrolytes and trimming unnecessary QT-prolonging drugs before deciding on methadone changes.
- Persistent tachycardia, hypertension and severe nausea despite adequate opioid agonist treatment may suggest medetomidine withdrawal, prompting early, high-dose alpha-2 agonist therapy and strong antiemetic support.
- Discharge planning works best when MOUD follow-up, alpha-2 agonist taper plans, harm reduction supplies and multiple backup options for care are clearly arranged and shared with patients.
“"You can always give more, you can't give less."”
How do people find strength in their journey to sobriety? This episode of The Curbsiders Addiction Medicine podcast zeroes in on the hospital side of that question, with a focus on complex opioid use disorder care and the rapidly changing drug supply. Host doctors Carolyn Chan and Sean Cohen sit down with internist and addiction medicine specialist Dr Maggie Lowenstein from the University of Pennsylvania.
The conversation is aimed squarely at clinicians who care for hospitalised patients with substance use disorders and want practical, evidence-informed tips they can use on their next shift. You’ll hear them break down tricky methadone situations: confirming doses through often clunky OTP systems, deciding what to do when records aren’t available, and handling missed doses without pushing patients into severe withdrawal.
Dr Lowenstein walks through how she balances overdose risk, withdrawal control, and hospital policies, noting that much of this work is still “expert opinion” because the evidence lags behind the reality of fentanyl-heavy use. A big chunk of the chat tackles the emergence of medetomidine in the fentanyl supply and the brutal alpha-2 withdrawal syndrome that can follow.
When a patient still “feels horrible” despite generous opioid agonist dosing, the team talks through recognising medetomidine withdrawal, using high-dose oral alpha-2 agonists like clonidine and guanfacine, aggressive antiemetics, and when to step up to dexmedetomidine in higher-acuity settings. They also stress that naloxone still reverses the opioid component of overdose, even if people don’t fully wake up.
Throughout, there’s a strong emphasis on harm reduction, clear discharge planning, and multiple backup plans for continuity of meds for opioid use disorder. If you care for patients with SUD and feel like the drug supply keeps changing faster than the guidelines, this conversation might be exactly what you need next on your commute. How could these hospital-based strategies change the way you support patients through withdrawal and into ongoing care?
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