Summary of AAC Panel Discussion on April 9th, 2025 ​

The Impact of Fentanyl and Synthetic Opioids on Withdrawal Management ​

Introduction and Purpose This panel was convened by the Addiction Action Committee (AAC) during its quarterly meeting in response to growing concerns about the evolving toxicity of the street drug supply. ​ Specifically, the increasing presence of fentanyl, xylazine, and medetomidine has led to profound changes in how opioid withdrawal is managed across care settings. ​ Panelists representing provider organizations, emergency medicine, EMS, public health, and Medicaid administration shared their frontline experiences and perspectives. ​ The discussion focused on emerging clinical challenges, system-level responses, policy barriers, and innovative approaches to care coordination and service delivery. ​

Panelists:

• Stefan Zonia, MPP - Northeast Treatment Centers ​
• Dr. Gregory Wanner, DO - Emergency Medicine Physician, Director of ED Public Health & Opioid Treatment at ChristianaCare ​
• Dr. Robert Rosenbaum, MD, FACS - State Medical Director for EMS and Preparedness ​
• Dr. Sherry Nykiel, MD - Behavioral Health Medical Director, Delaware Division of Medicaid and Medical Assistance (DMMA) ​ Moderator: Joanna Champney – Director of Delaware’s Division of Substance Abuse and Mental Health (DSAMH) ​

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Key Themes and Takeaways ​

I. Provider Perspective: Increasing Clinical Complexity ​

• Decline in patients eligible for 3.7 level care: Due to rising symptom severity and unpredictability, fewer patients meet criteria for residential (Level 3.7) withdrawal management. ​ Many now require hospital-level care instead. ​
• Unpredictable symptom presentations: The presence of potent adulterants—particularly medetomidine, now found in up to 92% of tested samples—has drastically altered withdrawal trajectories, making symptom patterns harder to anticipate and manage. ​
• Challenges in demonstrating medical necessity: The variability in how symptoms manifest disrupts typical documentation processes, complicating insurance approvals for residential withdrawal care. ​
• Resource strain in low-census environments: Despite lower patient numbers, facilities are expending more resources per patient—managing acute symptoms, increased biomedical waste, and frequent ER transfers. ​
• Value of 3.5 level care: Programs are finding success with adding clinically managed (Level 3.5) residential treatment to their treatment continuum. ​ The addition of Level 3.5 offers the opportunity to provide extended stabilization, structure, and education. ​ This model supports patients who may not be acutely ill enough for hospitalization and also allows the programs to address not only patients’ substance use but also the contributing social determinants of health. ​ Additionally, it allows for conversations that can’t be had during a 4-day 3.7WM admission in which patients are ill. ​

II. EMS and ED Perspective: Complex Overdoses and Prolonged Sedation ​

• Increase in polysubstance overdoses: Overdoses increasingly involve multiple adulterants (e.g., fentanyl, xylazine, medetomidine), resulting in prolonged sedation and unpredictable toxicologic effects. ​
• Delayed patient responsiveness: Many patients remain nonverbal or minimally responsive for 4–8 hours post-Nalone administration, limiting opportunities for initiating treatment conversations or prehospital buprenorphine. ​
• ED resource strain: Patients often require high-acuity monitoring and longer ED stays, contributing to bed shortages and elevated care complexity. ​
• Rising need for hospital admission: More patients are presenting with withdrawal symptoms severe enough to require inpatient management, including ICU-level care with IV medications. ​
• Data confirms shifting trends: Internal analyses show a 6/7-fold increase in overdose admissions with atypical symptoms like bradycardia and hypotension, reinforcing the term “drug poisoning” over traditional “overdose.” ​

III. Insurance and Policy Perspective: Shifting Definitions of Medical Necessity ​

• Misalignment between policy and clinical realities: Existing insurance coverage criteria have not fully adapted to the complexities introduced by fentanyl and synthetic adulterants. ​
• ASAM Fourth Edition offers progress: Newer guidelines allow for more functional, patient-centered assessments of medical necessity, including risk-based justifications beyond withdrawal symptoms alone. ​
• Coding impacts coverage: Classifying a patient as experiencing “opioid poisoning” rather than “dependence” can shift billing to the medical benefit and remove coverage barriers. ​
• Care continuity is disrupted by administrative rules: Patients requiring IV antibiotics or step-down care are often caught in a coverage gap, unable to participate in substance use treatment while receiving medical care. ​
• Communication is key: Providers are encouraged to engage with MCOs early and often to clarify documentation needs and resolve avoidable denials. ​

IV. Referral and Continuum of Care Challenges ​

• Sedation and withdrawal disrupt referral windows: Long periods of altered mental status post-overdose delay initiation of care pathways and limit engagement opportunities in both EMS and ED settings. ​
• Breakdowns in post-ED linkage: Unpredictable clinical courses make it harder to connect patients to outpatient MOUD programs during the typical discharge window. ​
• Need for centralized referral systems: Delaware is working to streamline referrals to treatment programs across hospitals and agencies, ensuring continuity regardless of entry point. ​
• Integrated models support better transitions: 3.5 level programs have successfully engaged patients following 3.7 care, often by offering on-site transitions and peer support during stabilization. ​

V. Systems-Level Insights and Recommendations ​

• Expand continuum of residential treatment levels of care at one location (e.g., adding 3.5 to 3.7WM), allowing for more flexibility in residential options: These models support a wider range of patients, including those with lower acuity or emerging interest in treatment. ​
• Streamline referral infrastructure: Centralized systems can reduce missed opportunities for care and ease provider burden in the treatment referral process across emergency and outpatient settings. ​
• Adopt ASAM Fourth Edition statewide: Promotes a more accurate, flexible definition of medical necessity, reflecting current withdrawal realities. ​
• Improve SDOH documentation: Systematic capture of social determinants of health (e.g., housing, transportation) is critical for care coordination and should be a focus of future funding advocacy. ​

VI. Emerging Models and Future Considerations ​

• Alternative residential models: 3.1 and 3.7B programs with embedded medical oversight (e.g., wound care, IV antibiotics) offer lower-cost, high-impact solutions for patients with co-occurring medical needs. ​
• Policy and funding innovations: As federal support for SDOH integration declines, states may need to pursue Medicaid waivers, blended funding models, and value-based reimbursement structures. ​
• Regional coordination is essential: Given drug supply trends in neighboring states like Pennsylvania, Delaware’s response will benefit from ongoing collaboration with partners in Philadelphia and Baltimore. ​

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Conclusion

The panel underscored that Delaware’s healthcare and public health systems are navigating a rapidly evolving landscape of opioid use and withdrawal, complicated by adulterants in the drug supply and shaped by unpredictable patient presentations and increasingly complex clinical needs. ​ Providers are managing higher acuity and symptom variability, emergency departments are strained by prolonged sedation and rising admission rates, and payers are being pressed to reconsider outdated definitions of ​medical necessity.

Despite these challenges, the panel highlighted several promising solutions, including the expanded use of 3.5 level care, development of centralized referral systems, and alignment with the ASAM Fourth Edition medical necessity criteria to guide more flexible, risk-based care. Panelists emphasized the importance of sustained cross-sector collaboration, adaptable treatment models, and proactive policy reform to ensure timely, person-centered care for individuals impacted by the changing drug supply.