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Edinoff AN, Sall S, Upshaw WC, Spillers NJ, Vincik LY, De Witt AS, Murnane KS, Kaye AM, Kaye AD. Xylazine: A Drug Adulterant of Clinical Concern. Curr Pain Headache Rep 2024; 28:417-426. [PMID: 38507135 PMCID: PMC11126434 DOI: 10.1007/s11916-024-01211-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE OF REVIEW The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl. RECENT FINDINGS Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.
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Affiliation(s)
- Amber N Edinoff
- McLean Hospital, Division of Alcohol and Drug Addiction, Belmont, MA, 02114, USA.
- Harvard Medical School, Department of Psychiatry, Boston, MA, 02115, USA.
- Louisiana Addiction Research Center, Louisiana State University Health Shreveport, Shreveport, LA, USA.
| | - Saveen Sall
- Louisiana State University Health Sciences Center at Shreveport, Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - William C Upshaw
- Louisiana State University Health Sciences Center at Shreveport, School of Medicine, Shreveport, LA, 71103, USA
| | - Noah J Spillers
- Louisiana State University Health Sciences Center at Shreveport, School of Medicine, Shreveport, LA, 71103, USA
| | - LeighAnn Y Vincik
- Louisiana State Health Sciences Center at Shreveport, Department of Anesthesiology, Shreveport, LA, 71103, USA
| | | | - Kevin S Murnane
- Louisiana Addiction Research Center, Louisiana State University Health Shreveport, Shreveport, LA, USA
- Louisiana State University Health Sciences Center at Shreveport, Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA, USA
- Louisiana State University Health Sciences Center at Shreveport, Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Adam M Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA, 95211, USA
| | - Alan D Kaye
- Louisiana Addiction Research Center, Louisiana State University Health Shreveport, Shreveport, LA, USA
- Louisiana State Health Sciences Center at Shreveport, Department of Anesthesiology, Shreveport, LA, 71103, USA
- Louisiana State University Health Sciences Center at Shreveport, Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Shreveport, Shreveport, LA, USA
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Mai T, Zhang Y, Zhao S. Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges. TOXICS 2023; 11:1012. [PMID: 38133413 PMCID: PMC10748319 DOI: 10.3390/toxics11121012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
Xylazine abuse is emerging globally, while the identification of xylazine lethal cases poses a great challenge in clinical and forensic practice. The non-specific symptoms delay the diagnosis and treatment of xylazine poisoning, the pathological changes and lethal concentration of xylazine in body fluid and organs of fatal xylazine poisoning cases are seldom reported and the other toxins detected in such cases complicate the role of xylazine in the cause of death. Therefore, we carefully reviewed related updated information on xylazine, summarized the knowledge from clinical and forensic perspectives and can thus provide a reference in such cases and throw light on further study in the field of xylazine poisoning.
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Affiliation(s)
- Tingting Mai
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
| | - Youyou Zhang
- Department of Geriatric Neurology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China;
| | - Shuquan Zhao
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
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Turley B, Evans A, Benzio K. Comparative toxicology of syringe exchange and postmortem blood samples in the District of Columbia: Trends and affinity analysis. J Anal Toxicol 2023; 47:588-596. [PMID: 37530762 DOI: 10.1093/jat/bkad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/23/2023] [Accepted: 08/01/2023] [Indexed: 08/03/2023] Open
Abstract
This cross-sectional analysis aimed to understand the similarities and differences between drugs detected in syringes collected from syringe service providers in the District of Columbia and fatal overdose deaths captured by the State Unintentional Drug Overdose Reporting System. Substance exposures for these fatal and non-fatal drug use outcomes have not been previously compared. Substance distributions were examined and a paired significance test was used to compare changes over time. Affinity analysis was employed to reveal substance co-occurrences. Between September 2020 and September 2022, 1,118 postmortem blood samples (PBSs) and 3,646 syringes exchange samples (SESs) were processed, with fatal overdoses increasing 24.1%. Polysubstance use was more commonly found in postmortem blood (82.5%) than in syringe samples (48.6%). Of samples containing opioids, 94.8% of blood samples and 86.3% of syringes contained fentanyl, fentanyl analogs or fentanyl precursors/metabolites. PBSs had double the frequency of co-occurring stimulants and opioids (43.9%) as SESs (21.8%). Major changes in occurrence frequency over time were found for opioid and stimulant exposure in both groups, especially in the increased occurrence of fluorofentanyl (>400%), methamphetamine (>90%) and xylazine (>60%), while the incidence of fentanyl, heroin and metabolite morphine declined. These results indicate that while fatal use and syringe exchange populations have distinct substance exposures, which may contribute to differences in mortality rate, their substance distributions have similar change magnitudes. This study highlights the utility of using multiple data sources to provide a comprehensive description of drug use patterns and discusses the limitations in reporting data from each source.
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Affiliation(s)
- Ben Turley
- DC Department of Health, 899 North Capitol St NE, Washington, DC 20002, USA
- CDC Foundation, 600 Peachtree St NE #1000, Atlanta, GA 30308, USA
| | - Alexandra Evans
- DC Department of Forensic Sciences, 401 E St SW, Washington, DC 20024, USA
| | - Katharine Benzio
- DC Office of the Chief Medical Examiner, 401 E St SW, Washington, DC 20024, USA
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Pergolizzi J, LeQuang JAK, Magnusson P, Miller TL, Breve F, Varrassi G. The New Stealth Drug on the Street: A Narrative Review of Xylazine as a Street Drug. Cureus 2023; 15:e40983. [PMID: 37503500 PMCID: PMC10370501 DOI: 10.7759/cureus.40983] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/25/2023] [Indexed: 07/29/2023] Open
Abstract
Xylazine is an alpha-adrenergic receptor agonist approved for use only in animals with a prescription from a veterinarian. It is a powerful sedative that is slowly infiltrating the recreational street drug scene and is often used by polysubstance abusers. Known as "tranq," it can be fatal, and xylazine-induced toxicity cannot be reversed with naloxone or nalmefene. Due to its vasoconstrictive effects, chronic use of xylazine is associated with necrotic skin lesions and general deterioration of health. Since xylazine is not approved for human use and is not scheduled as a controlled substance, there are no human studies to provide evidence of drug-drug interactions, lethal doses, or reversal protocols. Xylazine is available online without a prescription. Street drug users may take xylazine knowingly or unknowingly, as it is often combined with other illicit substances such as fentanyl. There are no rapid tests for xylazine, although there are specialty tests that can be ordered. Xylazine represents a major threat to street drug users and another challenge to emergency healthcare workers, first responders, and others who care for those who have taken this "new" street drug.
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Affiliation(s)
| | | | | | - Thomas L Miller
- Clinical Development, Enalare Therapeutics, Inc., Princeton, USA
| | - Frank Breve
- Pharmacy, Temple University, Philadelphia, USA
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Rose L, Kirven R, Tyler K, Chung C, Korman AM. Xylazine-induced acute skin necrosis in two patients who inject fentanyl. JAAD Case Rep 2023; 36:113-115. [PMID: 37288443 PMCID: PMC10242481 DOI: 10.1016/j.jdcr.2023.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Affiliation(s)
- Lucy Rose
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Rachel Kirven
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kelly Tyler
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Catherine Chung
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Abraham M. Korman
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Ayub S, Parnia S, Poddar K, Bachu AK, Sullivan A, Khan AM, Ahmed S, Jain L. Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications. Cureus 2023; 15:e36864. [PMID: 37009344 PMCID: PMC10063250 DOI: 10.7759/cureus.36864] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES The opioid overdose epidemic is exacerbated by the emergence of Xylazine as an illicit drug adulterant. Xylazine, a veterinary sedative, can potentiate opioid effects while also causing toxic and potentially fatal side effects. This systematic review aims to assess the impact of Xylazine use and overdoses within the opioid epidemic context. METHOD A systematic search was conducted following PRISMA guidelines to identify relevant case reports, and case series related to Xylazine use. A comprehensive literature search included databases like Web of Science, PubMed, Embase, and Google Scholar, utilizing keywords and Medical Subject Headings (MeSH) terms related to Xylazine. Thirty-four articles met the inclusion criteria for this review. RESULTS Intravenous (IV) administration was a common route for Xylazine use among various methods, including subcutaneous (SC), intramuscular (IM), and inhalation, with overall doses ranging from 40 mg to 4300 mg. The average dose in fatal cases was 1,200 mg, compared to 525 mg in non-fatal cases. Concurrent administration of other drugs, primarily opioids, occurred in 28 cases (47.5%). Intoxication was identified as a notable concern in 32 out of 34 studies, and treatments varied, with the majority experiencing positive outcomes. Withdrawal symptoms were documented in one case study, but the low number of cases with withdrawal symptoms may be attributed to factors such as a limited number of cases or individual variation. Naloxone was administered in eight cases (13.6%), and all patients recovered, although it should not be misconstrued as an antidote for Xylazine intoxication. Of the 59 cases, 21 (35.6%) resulted in fatal outcomes, with 17 involving Xylazine use in conjunction with other drugs. The IV route was a common factor in six out of the 21 fatal cases (28.6%). CONCLUSION This review highlights the clinical challenges associated with Xylazine use and its co-administration with other substances, particularly opioids. Intoxication was identified as a major concern, and treatments varied across the studies, including supportive care, naloxone, and other medications. Further research is needed to explore the epidemiology and clinical implications of Xylazine use. Understanding the motivations and circumstances leading to Xylazine use, as well as its effects on users, is essential for developing effective psychosocial support and treatment interventions to address this public health crisis.
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Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus 2022; 14:e28160. [PMID: 36148197 PMCID: PMC9482722 DOI: 10.7759/cureus.28160] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 11/05/2022] Open
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Kacinko SK, Mohr ALA, Logan BK, Barbieri EJ. Xylazine: Pharmacology Review and Prevalence and Drug Combinations in Forensic Toxicology Casework. J Anal Toxicol 2022; 46:911-917. [PMID: 35770859 DOI: 10.1093/jat/bkac049] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/13/2022] [Accepted: 06/29/2022] [Indexed: 11/14/2022] Open
Abstract
Xylazine, an alpha-2 receptor agonist used in veterinary medicine for its sedative and muscle relaxant effects, has been reported in forensic toxicology casework since the 1980s. It is not approved for human use, but it is used as an adulterant in heroin and illicit fentanyl. The prevalence and concentrations of xylazine in 2.5 years (January 2019-June 2021) of driving-under-the-influence-of-drugs (DUID) and medical-death-investigation (MDI) cases was investigated, including other drugs detected in combination with xylazine. Of over 170,000 cases screened for xylazine, 97% were classified as MDI. Over the course of the study period the prevalence and geographical spread of xylazine increased. Overall, 2.8% of DUID and 2.1% of MDI cases screened positive for xylazine with concentrations of 5.1-450 ng/mL (mean = 36 ng/mL) and 5.0-11,000 ng/mL (mean = 41 ng/mL), respectively. Two MDI cases which had xylazine concentrations of 9,100 and 11,000 ng/mL were drug overdose suicides that did not involve any opioids. Opioids, primarily fentanyl and/or a fentanyl byproduct/metabolite were detected in 100% of DUID and all but two MDI cases. After opioids, stimulants, phyto-cannabinoids and benzodiazepines were the most common drug classes detected in conjunction with xylazine in both DUID and MDI casework. In summary, xylazine exposure continues to increase, mostthrough the adulteration of illicit opioids. There is extensive overlap in the concentrations between living and deceased individuals making it difficult to interpret the role of the drug in MDI or DUID cases without other case information.
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Affiliation(s)
- S K Kacinko
- NMS Labs, 200 Welsh Rd, Horsham, PA 19044, USA
| | - A L A Mohr
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
| | - B K Logan
- NMS Labs, 200 Welsh Rd, Horsham, PA 19044, USA.,Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
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Ball NS, Knable BM, Relich TA, Smathers AN, Gionfriddo MR, Nemecek BD, Montepara CA, Guarascio AJ, Covvey JR, Zimmerman DE. Xylazine poisoning: a systematic review. Clin Toxicol (Phila) 2022; 60:892-901. [PMID: 35442125 DOI: 10.1080/15563650.2022.2063135] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Xylazine is an alpha-2-adrenergic agonist used for its sedative and analgesic properties in veterinary medicine. While not approved by the Food and Drug Administration for use in humans, anecdotal evidence suggests that exposures in humans is on the rise. We sought to systematically review and synthesize the evidence on xylazine exposure in humans focusing on the clinical presentation, management, and outcomes. METHODS We conducted a systematic review of the literature including PubMed, Embase, and Scopus from their inception to September 9, 2021. We searched abstracts from selected emergency medicine and toxicology conferences from 2011 through 2021. We included clinical reports of xylazine exposure in humans. We excluded animal studies, in vitro studies, laboratory studies, or articles in a language other than English. From each included article, we extracted subjective and objective data that focused on clinical presentation, management, and outcomes of patients exposed to xylazine. RESULTS We evaluated a total of 1409 records, rendering a final set of 17 articles and 2 abstracts meeting inclusion criteria. We identified a total of 98 patients amongst reports ranging from 1979 to 2020 and across nine countries. The most common types of xylazine exposures reported were unintentional exposure and intentional misuse/abuse. Common symptoms on presentation included hypotension, bradycardia, drowsiness, lethargy, while apnea with intubation and death were less frequently reported. CONCLUSION Human exposure to xylazine appears to be a rising concern within the prehospital and emergency medicine setting. Although a standardized treatment algorithm cannot be recommended at this time, further research is needed to improve the care of patients exposed to xylazine.
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Affiliation(s)
- Noah S Ball
- Duquesne University School of Pharmacy, Pittsburgh, PA
| | | | | | | | | | - Branden D Nemecek
- Duquesne University School of Pharmacy, Pittsburgh, PA.,UPMC Mercy Hospital, Pittsburgh, PA
| | - Courtney A Montepara
- Duquesne University School of Pharmacy, Pittsburgh, PA.,Allegheny General Hospital, Pittsburgh, PA
| | - Anthony J Guarascio
- Duquesne University School of Pharmacy, Pittsburgh, PA.,Allegheny General Hospital, Pittsburgh, PA
| | | | - David E Zimmerman
- Duquesne University School of Pharmacy, Pittsburgh, PA.,UPMC Mercy Hospital, Pittsburgh, PA
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Thangada S, Clinton HA, Ali S, Nunez J, Gill JR, Lawlor RF, Logan SB. Notes from the Field: Xylazine, a Veterinary Tranquilizer, Identified as an Emerging Novel Substance in Drug Overdose Deaths - Connecticut, 2019-2020. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:1303-1304. [PMID: 34529638 PMCID: PMC8445375 DOI: 10.15585/mmwr.mm7037a5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mulders P, van Duijnhoven V, Schellekens A. Xylazine Dependence and Detoxification: A Case Report. PSYCHOSOMATICS 2016; 57:529-33. [DOI: 10.1016/j.psym.2016.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
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Gao X, Guo H, Du Y, Gu C. Simultaneous Determination of Xylazine and 2,6-Xylidine in Blood and Urine by Auto Solid-Phase Extraction and Ultra High Performance Liquid Chromatography Coupled with Quadrupole-Time of Flight Mass Spectrometry. J Anal Toxicol 2015; 39:444-50. [DOI: 10.1093/jat/bkv040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Silva-Torres LA, Vélez C, Lyvia Alvarez J, Ortiz JG, Zayas B. Toxic effects of xylazine on endothelial cells in combination with cocaine and 6-monoacetylmorphine. Toxicol In Vitro 2014; 28:1312-9. [PMID: 25017475 DOI: 10.1016/j.tiv.2014.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 06/25/2014] [Accepted: 06/26/2014] [Indexed: 11/19/2022]
Abstract
The use of xylazine as a drug of abuse has emerged worldwide in the last 7 years, including Puerto Rico. Clinical findings reported that xylazine users present greater physiological deterioration, than heroin users. The aim of this study was to assess the xylazine toxicity on endothelial cells, as this is one of the first tissues impact upon administration. Human umbilical vein endothelial cells in culture were treated with xylazine, cocaine, 6-monoacetylmorphine (heroin metabolite) and its combinations, at concentrations of 0.10-400 μM, for periods of 24, 48 and 72 h. IC50 were calculated and the Annexin V assay implemented to determine the cell death mechanism. Results indicated IC50 values at 24h as follow: xylazine 62 μM, cocaine 210 μM, 6-monoacetylmorphine 300 μM. When these drugs were combined the IC50 value was 57 μM. Annexin V results indicated cell death by an apoptosis mechanism in cells treated with xylazine or in combination. Results demonstrated that xylazine use inhibits the endothelial cell proliferation, at lower concentrations than cocaine and 6-monoacetylmorphine. These findings contribute to the understanding of the toxicity mechanisms induced by xylazine on endothelial cells.
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Affiliation(s)
- L A Silva-Torres
- University of Puerto Rico, Pharmacology and Toxicology Department, School of Medicine, Medical Science Campus, Puerto Rico; Puerto Rico Institute of Forensic Science, San Juan, Puerto Rico.
| | - C Vélez
- Universidad Metropolitana, School of Environmental Affairs, San Juan, Puerto Rico
| | - J Lyvia Alvarez
- Puerto Rico Institute of Forensic Science, San Juan, Puerto Rico; University of Puerto Rico, School of Health Professions, Medical Science Campus, Puerto Rico
| | - J G Ortiz
- University of Puerto Rico, Pharmacology and Toxicology Department, School of Medicine, Medical Science Campus, Puerto Rico
| | - B Zayas
- University of Puerto Rico, Pharmacology and Toxicology Department, School of Medicine, Medical Science Campus, Puerto Rico; Universidad Metropolitana, School of Environmental Affairs, San Juan, Puerto Rico
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Ruiz-Colón K, Chavez-Arias C, Díaz-Alcalá JE, Martínez MA. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int 2014; 240:1-8. [PMID: 24769343 DOI: 10.1016/j.forsciint.2014.03.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 02/28/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
Abstract
Xylazine is not a controlled substance; it is marketed as a veterinary drug and used as a sedative, analgesic and muscle relaxant. In humans, it could cause central nervous system depression, respiratory depression, bradycardia, hypotension, and even death. There have been publications of 43 cases of xylazine intoxication in humans, in which 21 (49%) were non-fatal scenarios and 22 (51%) resulted in fatalities. Most of the non-fatal cases required medical intervention. Over recent years xylazine has emerged as an adulterant in recreational drugs, such as heroin or speedball (a cocaine and heroin mixture). From the 43 reported cases, 17 (40%) were associated with the use of xylazine as an adulterant of drugs of abuse. Its chronic use is reported to be associated with physical deterioration and skin ulceration. Literature shows some similar pharmacologic effects between xylazine and heroin in humans. These similar pharmacologic effects may create synergistic toxic effects in humans. Therefore, fatalities among drug users may increase due to the use of xylazine as an adulterant. Xylazine alone has proven harmful to humans and even more when it is combined with drugs of abuse. A comprehensive review of the literature of non-fatal and fatal xylazine intoxication cases including those in which the substance was used as adulterant is presented, in order to increase the awareness in the forensic community, law enforcement, and public health agencies.
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Affiliation(s)
- Kazandra Ruiz-Colón
- Puerto Rico Institute of Forensic Sciences, P.O. Box 11878 Caparra Heights Station, San Juan 00922-1878, Puerto Rico.
| | - Carlos Chavez-Arias
- Puerto Rico Institute of Forensic Sciences, P.O. Box 11878 Caparra Heights Station, San Juan 00922-1878, Puerto Rico.
| | | | - María A Martínez
- Instituto Nacional de Toxicología y C. Forenses, Ministerio de Justicia, Las Rozas de Madrid, C/ José Echegaray, 4, 28232 Las Rozas de Madrid, Madrid, Spain.
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Xiao YF, Wang B, Wang X, Du F, Benzinou M, Wang YXJ. Xylazine-induced reduction of tissue sensitivity to insulin leads to acute hyperglycemia in diabetic and normoglycemic monkeys. BMC Anesthesiol 2013; 13:33. [PMID: 24138083 PMCID: PMC4016475 DOI: 10.1186/1471-2253-13-33] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/15/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The α2-adrenoceptor agonist xylazine as an anesthetic has been widely used either alone or in combination with other anesthetics, such as ketamine, in veterinary clinic and research. In the last decade xylazine has been used in drug abusers in certain geographic area. This study investigated the effects of xylazine on blood glucose level and insulin secretion in normoglycemic and insulin-dependent diabetic monkeys. METHODS Both adult cynomolgus (n = 10) and rhesus (n = 8) monkeys with either sex were used in the study. Xylazine (1-2 mg/kg) was administrated intramuscularly. Blood glucose, insulin, glucagon and glucagon-like peptide 1 in overnight-fasted monkeys were measured immediately before and after xylazine administration. The hyperinsulinemic-euglycemic clamp method was used in the study for assessing the potential mechanism of xylazine-induced hyperglycemia. RESULTS Xylazine administration increased the blood glucose levels from 58 ± 3 to 108 ± 12 mg/dL in normoglycemic (n = 5, p < 0.01) and from 158 ± 9 to 221 ± 13 mg/dL in insulin-dependent diabetic (n = 5, p < 0.01) monkeys and was not accompanied by any significant changes in blood insulin, glucagon, and glucagon-like peptide-1. Xylazine-induced hyperglycemia occurred within 10 min and reached the peak at 35 min after injection. Xylazine-induced hyperglycemia declined slowly in diabetic animals. The α2-adrenoceptor antagonist yohimbine was administrated to bring down the elevated glucose level to the pre-xylazine one in 4 out of 5 diabetic animals. To assess the potential mechanism, the hyperinsulinemic-euglycemic clamp was used to maintain a nearly saturated and constant insulin level for minimizing endogenous insulin glucoregulation. Xylazine administration decreased glucose infusion rate, from 14.3 ± 1.4 to 8.3 ± 0.8 mg/min/kg (n = 6, p < 0.01) in normoglycemic rhesus monkeys, which indicates that the glucose metabolic rate (M rate) was decreased by xylazine. In addition, after clamping blood glucose level in a range of 55 to 75 mg/dL for 40 min with constant glucose infusion, xylazine administration still increased blood glucose concentration. CONCLUSIONS We conclude that xylazine administration induces hyperglycemia in normoglycemic and insulin-dependent diabetic monkeys potentially via stimulation of α2-adrenoceptors and then reducing tissue sensitivity to insulin and glucose uptake.
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Affiliation(s)
- Yong-Fu Xiao
- Cardiovascular and Metabolic Disease Research, Crown Bioscience Inc, Science and Technology Park, 6 Beijing West Road, Taicang Economic Development Area, Jiangsu Province 215400, The People's Republic of China.
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Meyer GMJ, Maurer HH. Qualitative metabolism assessment and toxicological detection of xylazine, a veterinary tranquilizer and drug of abuse, in rat and human urine using GC–MS, LC–MS n , and LC–HR-MS n. Anal Bioanal Chem 2013; 405:9779-89. [DOI: 10.1007/s00216-013-7419-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/12/2013] [Accepted: 10/04/2013] [Indexed: 11/30/2022]
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Meyer GM, Meyer MR, Mischo B, Schofer O, Maurer HH. Case report of accidental poisoning with the tranquilizer xylazine and the anesthetic ketamine confirmed by qualitative and quantitative toxicological analysis using GC-MS and LC-MSn. Drug Test Anal 2013; 5:785-9. [DOI: 10.1002/dta.1475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 02/20/2013] [Accepted: 02/26/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Golo M.J. Meyer
- Department of Experimental and Clinical Toxicology; Saarland University; D-66421; Homburg (Saar); Germany
| | - Markus R. Meyer
- Department of Experimental and Clinical Toxicology; Saarland University; D-66421; Homburg (Saar); Germany
| | - Bernhard Mischo
- Department of Pediatrics, Marienhausklinik St. Josef Kohlhof; D-66539; Neunkirchen; Germany
| | - Otto Schofer
- Department of Pediatrics, Marienhausklinik St. Josef Kohlhof; D-66539; Neunkirchen; Germany
| | - Hans H. Maurer
- Department of Experimental and Clinical Toxicology; Saarland University; D-66421; Homburg (Saar); Germany
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Reyes JC, Negrón JL, Colón HM, Padilla AM, Millán MY, Matos TD, Robles RR. The emerging of xylazine as a new drug of abuse and its health consequences among drug users in Puerto Rico. J Urban Health 2012; 89:519-26. [PMID: 22391983 PMCID: PMC3368046 DOI: 10.1007/s11524-011-9662-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
During the last decade, the veterinary anesthetics have gained popularity as recreational drugs. The aim of this study was to document the use of "anestecia de caballo" (xylazine) and its consequences among drug users in Puerto Rico. The study combined a cross-sectional survey with 89 drug users and two focus groups conducted in Mayagüez with frontline drug treatment providers. Drug users were recruited from communities of the San Juan metropolitan area using a variety of ethnographic and outreach strategies. A short questionnaire developed for the study collected information on sociodemographics, xylazine use, and its consequences. The two focus groups were conducted to discuss the details related to xylazine use, its consequences, and utilization awareness. The sample comprised 63 males (70.8%) and 26 females with a mean age of 37.2 years. The mean number of years of drug use was 14.3, with a mean frequency of drug use of 5.9 times daily. More than 65% reported speedball as the principal drug of use. The prevalence of xylazine use was 80.7%. More than 42% of the sample used xylazine in a mixture with speedball. The main route of administration of xylazine was injection but 14% reported the use of xylazine by inhalation. More than 35% of the sample reported skin lesions and 21.1% reported at least one overdose episode. Multiple logistic regression analysis revealed that males (OR = 3.47, CI = 1.10-12.00) and those who reported speedball as their main drug of use (OR = 9.34, CI = 2.51-34.70) were significantly more likely to be xylazine users. Focus groups revealed that drug users claimed to recognize the presence of xylaxine in a mixture of speedball based on its effects, taste, the color of the drug (dark brown), and its odor. In conclusion, the use of xylazine among drug users in Puerto Rico seems to be an emerging trend with potentially serious health consequences.
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Affiliation(s)
- J C Reyes
- Medical Science Campus Universidad de Puerto Rico, San Juan, Puerto Rico.
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Ruiz-Colon K, Martinez MA, Silva-Torres LA, Chavez-Arias C, Melendez-Negron M, Conte-Miller MS, Bloom-Oquendo J. Simultaneous Determination of Xylazine, Free Morphine, Codeine, 6-Acetylmorphine, Cocaine and Benzoylecgonine in Postmortem Blood by UPLC-MS-MS. J Anal Toxicol 2012; 36:319-26. [DOI: 10.1093/jat/bks024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Haymerle A, Fahlman A, Walzer C. Human exposures to immobilising agents: results of an online survey. Vet Rec 2010; 167:327-32. [PMID: 20802186 DOI: 10.1136/vr.c4191] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cases of human exposure to veterinary injectable anaesthetics were reviewed following a literature search and completion of an online questionnaire in an attempt to provide an objective approach to the problem. The modified Glasgow Coma Scale was used to rank cases according to their severity. From the cases examined, results showed that intoxication with potent opioids, such as etorphine, carfentanil and thiafentanil, need to be treated with antagonists such as naloxone, nalmefene or naltrexone, and not with antagonists with agonistic properties, such as diprenorphine. With regard to the alpha(2)-agonists xylazine, detomidine, medetomidine and romifidine, no antagonist is currently accredited for human use. Atipamezole, a specific alpha(2)-antagonist, is widely used in veterinary medicine and has been used experimentally to reverse dexmetomidine in a study in human medicine. The high concentrations of alpha(2)-agonists being used in zoo and wildlife medicine warrant the accreditation of atipamezole for use in cases of human exposure. Knowledge and availability of the appropriate antagonist are essential in cases of human intoxication with injectable anaesthetics. Preventive measures, such as wearing gloves and eye protection, need to be used more regularly to reduce the risk of exposure.
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Affiliation(s)
- A Haymerle
- Research Institute of Wildlife Ecology, University of Veterinary Medicine, A-1160 Vienna, Austria.
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