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Eger WH, Plesons M, Bartholomew TS, Bazzi AR, Hauschild MH, McElrath CC, Owens C, Forrest DW, Tookes HE, Crable EL. Syringe services program staff and participant perspectives on changing drug consumption behaviors in response to xylazine adulteration. Harm Reduct J 2024; 21:162. [PMID: 39210359 PMCID: PMC11363649 DOI: 10.1186/s12954-024-01082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Xylazine is an increasingly common adulterant in the North American unregulated drug supply that is associated with adverse health outcomes (e.g., skin infections, overdose). However, there are significant knowledge gaps regarding how xylazine was initially identified and how syringe services program (SSP) staff and clients (people who use drugs) responded to its emergence. METHODS From June-July 2023, we conducted qualitative interviews with medical (e.g., clinicians) and frontline SSP staff (e.g., outreach workers) and adult clients with a history of injection drug use at a Miami-based SSP. Inductive memos identified emergent codes; thematic analysis involving team consensus established final themes. RESULTS From interviews with SSP staff (n = 8) and clients (n = 17), xylazine emergence was identified at different times, in various ways. Initially, during summer 2022, clients identified a "tranquilizer-like substance" that worsened sedation and withdrawal and caused wounds. SSP medical staff later identified this adulterant as xylazine by treating new medical cases and through diverse information-sharing networks that included professional societies and news sources; however, frontline SSP staff and clients needed additional educational resources about xylazine and its side effects. With limited guidance on how to reduce harm from xylazine, SSP clients altered their drug consumption routes, reduced drug use, and relied on peers' experiences with the drug supply to protect themselves. Some individuals also reported preferring xylazine-adulterated opioids and increasing their drug use, including the use of stimulants to avoid over sedation. CONCLUSIONS Xylazine's emergence characterizes the current era of unprecedented shifts in the unregulated drug supply. We found that xylazine spurred important behavioral changes among people who use drugs (e.g., transitioning from injecting to smoking). Incorporating these experiences into early drug warning surveillance systems and scaling up drug-checking services and safer smoking supply distribution could help mitigate significant health harms caused by xylazine and other emergent adulterants.
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Affiliation(s)
- William H Eger
- School of Medicine, University of California San Diego, La Jolla, CA, USA.
- School of Social Work, San Diego State University, San Diego, CA, USA.
- , Present address: 9500 Gilman Dr, La Jolla, 92093, CA, USA.
| | - Marina Plesons
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Tyler S Bartholomew
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Maia H Hauschild
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Corbin C McElrath
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Cyrus Owens
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - David W Forrest
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Hansel E Tookes
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Erika L Crable
- School of Medicine, University of California San Diego, La Jolla, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
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Levitas M, Thomas C, Widman C, DeColumna J, Allgaier B, Conley E, deHagen T, Freitas I, Horvath H, Lemberg B, Lemberg D. Qualitative and quantitative determination of xylazine in oral fluid. J Anal Toxicol 2024; 48:482-488. [PMID: 39002106 DOI: 10.1093/jat/bkae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024] Open
Abstract
Xylazine has emerged in recent years as a dangerous adulterant in illicit fentanyl use, and methods for the detection of xylazine in toxicology panels are still lagging. We developed methods for the screening and quantitation of xylazine in oral fluid (OF), a popular testing medium due to its ease of collection and reflection of presence in blood for many classes of drugs. Enzyme-linked immunosorbent assays were employed for the rapid screening of xylazine directly from the collection device buffer with a cutoff of 1 ng/mL. Solid-phase extraction coupled with liquid chromatography-tandem mass spectrometry facilitated the confirmation and quantification of xylazine as low as 0.1 ng/mL and a dynamic range of 0.1-25 ng/mL. Selectivity, ionization suppression, processed sample stability, and dilution effect were also assessed. The method was validated through the American National Standards Institute/American Academy of Forensic Sciences Standards Board (ANSI/ASB) Standard 036, first edition from 2019, and found to be accurate, precise, and robust. Living human subject OF samples collected within substance use disorder and therapeutic drug monitoring clinics received between September 2023 and January 2024, with the specific request to test for xylazine (n = 57), were screened. Presumptive positive samples were confirmed using the validated method. Xylazine confirmed living human subject OF sample concentrations ranged from 1.2 to 23.3 ng/mL.
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Affiliation(s)
- Matthew Levitas
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Christopher Thomas
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Corey Widman
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Joseph DeColumna
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Brandi Allgaier
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Eric Conley
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Troy deHagen
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Isabela Freitas
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Hannah Horvath
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Bridget Lemberg
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Dave Lemberg
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
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3
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Eger WH, Plesons M, Bartholomew TS, Bazzi AR, Hauschild MH, McElrath CC, Owens C, Forrest DW, Tookes HE, Crable EL. Protective or potentially harmful? Altering drug consumption behaviors in response to xylazine adulteration. RESEARCH SQUARE 2024:rs.3.rs-4810429. [PMID: 39149447 PMCID: PMC11326414 DOI: 10.21203/rs.3.rs-4810429/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Background Xylazine is an increasingly common adulterant in the North American unregulated drug supply that is associated with adverse health outcomes (e.g., skin infections, overdose). However, there are significant knowledge gaps regarding how xylazine was initially identified and how syringe services program (SSP) staff and clients (people who use drugs) responded to its emergence. Methods From June-July 2023, we conducted qualitative interviews with medical (e.g., clinicians) and frontline SSP staff (e.g., outreach workers) and adult clients with a history of injection drug use at a Miami-based SSP. Inductive memos identified emergent codes; thematic analysis involving team consensus established final themes. Results From interviews with SSP staff (n = 8) and clients (n = 17), xylazine emergence was identified at different times, in various ways. Initially, during summer 2022, clients identified a "tranquilizer-like substance" that worsened sedation and withdrawal and caused wounds. SSP medical staff later identified this adulterant as xylazine by treating new medical cases and through diverse information-sharing networks that included professional societies and news sources; however, frontline SSP staff and clients needed additional educational resources about xylazine and its side effects. With limited guidance on how to reduce harm from xylazine, SSP clients altered their drug consumption routes, reduced drug use, and relied on peers' experiences with the drug supply to protect themselves. Some individuals also reported preferring xylazine-adulterated opioids and increasing their drug use, including the use of stimulants to avoid over sedation. Conclusions Xylazine's emergence characterizes the current era of unprecedented shifts in the unregulated drug supply. We found that xylazine spurred important behavioral changes among people who use drugs (e.g., transitioning from injecting to smoking). Incorporating these experiences into early drug warning surveillance systems and scaling up drug-checking services and safer smoking supply distribution could help mitigate significant health harms caused by xylazine and other emergent adulterants.
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4
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Allcroft H, Heiman E, Butner JL. Clinical progress note: Xylazine use and its sequelae. J Hosp Med 2024; 19:713-715. [PMID: 38561251 DOI: 10.1002/jhm.13338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 02/25/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Haley Allcroft
- Yale Physician Associate Program, New Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Erica Heiman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jenna L Butner
- Yale School of Public Health, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Habib A, Ali T, Fatima L, Nazir Z, Hafiz AI, Haque MA. Xylazine in illicit drug mixtures: a growing threat and overlooked danger. Ann Med Surg (Lond) 2024; 86:3816-3819. [PMID: 38989224 PMCID: PMC11230776 DOI: 10.1097/ms9.0000000000002190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/08/2024] [Indexed: 07/12/2024] Open
Affiliation(s)
- Ashna Habib
- Dow University of Health Sciences, Mission Road, Karachi
| | - Tooba Ali
- Dow University of Health Sciences, Mission Road, Karachi
| | | | - Zainab Nazir
- Dow University of Health Sciences, Mission Road, Karachi
| | | | - Md Ariful Haque
- Department of Public Health, Atish Dipankar University of Science and Technology
- Voice of Doctors Research School, Dhaka, Bangladesh
- Department of Orthopedic Surgery, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, People's Republic of China
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Jawa R, Murray S, Blakemore S, Ventura AS, Hristova T, Wilder A, Shang M, LaBelle C. Xylazine and Adulterants in the Evolving Drug Supply: Urgent Call for Responsive Education Models. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:168-175. [PMID: 38375666 PMCID: PMC11121508 DOI: 10.1177/29767342241231114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Novel adulterants and synthetic substances are rapidly infiltrating the US drug supply causing new clinical harms. There is an urgent need for responsive education and training to address these evolving harms and mitigate new risks. Since 2020, xylazine, a veterinary tranquilizer, has become increasingly common in the illicit opioid supply, especially alongside fentanyl. Training and technical assistance (TTA) programs employing an adaptive model can quickly disseminate emerging information and provide the tools to respond effectively. We describe our TTA program's experience developing and delivering virtual instructor-led xylazine training to a diverse group of addiction care professionals. The training objectives included the following: (1) introducing epidemiologic trends, pharmacology, and existing literature related to xylazine; (2) reviewing xylazine-associated harms and management; and (3) discussing harm reduction strategies related to xylazine use. We conducted 14 training sessions between October 2022 and July 2023, which were attended by over 2000 individuals across 49 states. We review our experience developing innovative training content and managing flexible training logistics and highlight our lessons learned, including targeting multidisciplinary professionals, leveraging online synchronous delivery methods, and a need for sustainable funding for TTA programs.
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Affiliation(s)
- Raagini Jawa
- Center for Research on Healthcare, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
| | - Stephen Murray
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
| | - Samantha Blakemore
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
| | - Alicia S. Ventura
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
| | - Tavita Hristova
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
| | - Alexa Wilder
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
| | - Margaret Shang
- Center for Research on Healthcare, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colleen LaBelle
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA, USA
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7
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Bowles JM, Copulsky EC, Reed MK. Media framing xylazine as a "zombie drug" is amplifying stigma onto people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 125:104338. [PMID: 38364357 DOI: 10.1016/j.drugpo.2024.104338] [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] [Received: 11/21/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/18/2024]
Abstract
Amid increasing efforts to understand xylazine-associated harms, examining the potentially catastrophic role of stigma resulting from media outlets framing xylazine as the "zombie drug" is imperative. Zombies are cinematically depicted as soulless, dangerous, and required to be killed off entirely for public safety, making the "zombie" analogy especially grave amid the fatal overdose crisis. Xylazine is called the "zombie drug" due to its heavy sedative effect and associated-severely infected skin ulcers. We surmise that wide-scale media framing of xylazine as the "zombie drug" has increased stigmas onto people who use drugs as their likening to zombies reifies subhuman status. The present commentary highlights many media headlines and quotes that use "zombie" terminology when writing about xylazine, and examine how this expansive media framing amplifies stigmas. Xylazine's proliferation in the illicit drug market will likely increase infected ulcers needing medical attention. People who use drugs are often reluctant to seek medical care due to experiences of medically-institutionalized stigma. Based on the media's extensive depiction of xylazine as the "zombie drug," it is plausible that medical practitioners have been exposed to this stigmatizing framing, which could unknowingly detrimentally impact provision of medical care. Strategies to offset harms of xylazine-associated stigmas are proposed, including that medical practitioners undergo evidence-based training to reduce stigmatizing responses to severe xylazine-associated ulcers as any indication of enacted stigma can be internalized by the person seeking treatment, which in turn can perpetuate harms like sepsis or overdose. Author ethnographic observations of xylazine presence are included, which encompass three distinct urban settings that span North America. Finally, we suggest approaches media outlets could adopt to reflect on how referring to xylazine as the "zombie" drug amplifies stigmas onto people already surviving under structural conditions heightening physical and mental trauma, and use language instead that could aid in lessening these harms.
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Affiliation(s)
- Jeanette M Bowles
- British Columbia Centre on Substance Use: Vancouver, BC, Canada; University of British Columbia Department of Medicine: Vancouver, BC, Canada.
| | | | - Megan K Reed
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
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8
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Midthun KM, Nelson BN, Strathmann FG, Browne T, Logan BK. Analysis of umbilical cord tissue as an indicator of in utero exposure to toxic adulterating substances. Front Pediatr 2023; 11:1127020. [PMID: 37025298 PMCID: PMC10070803 DOI: 10.3389/fped.2023.1127020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/27/2023] [Indexed: 04/08/2023] Open
Abstract
In utero drug exposure is a significant public health threat to the well-being and normal development of the neonate. Recently, testing of umbilical cord tissue (UCT) has been employed to measure illicit drug exposure, as drugs used by the mother during the third trimester may be retained in the UCT. Focus has also been given to potential adverse health effects among drug users, resulting from exposure to pharmacologically active adulterants and cutting agents in the street drug supply. The in utero effects of these substances have not been well studied in humans, nor has their presence been demonstrated as a means for assessing adverse health effects in the neonate. Here, we describe the application of a novel test method to analyze UCT for the presence of more than 20 common adulterating/cutting substances via LC/Q-TOF. In total, 300 de-identified UCT samples were analyzed-all had previously tested positive for cocaine or opiates. Generally, the positivity rates of individual compounds were similar between the Cocaine and Opiates Subgroups, apart from levamisole, xylazine, dipyrone (metabolites), and promethazine. Many of the adulterants used in the street drug supply do have legitimate medicinal/therapeutic uses, including several of the compounds most frequently detected in this study. Caffeine and lidocaine were the most frequently identified compounds both individually (>70% each) and in combination with each other. Alternatively, levamisole, an adulterant with no legitimate therapeutic use, was present in 12% of cases. Importantly, this data demonstrates that the detection of traditional drugs of abuse may serve as indicators of potential in utero exposure to toxic adulterating substances during gestation. While there is cause for concern with respect to any unintentional drug exposure, illicit drug use during pregnancy, including uncontrolled dosing, poly-adulterant consumption, and the interactions of these drug mixtures, produces a significant public health threat to the neonate which warrants further study.
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Affiliation(s)
| | | | | | - Thom Browne
- Colombo Plan Secretariat, Colombo, Sri Lanka
| | - Barry K. Logan
- NMS Labs, Horsham, PA, United States
- Center for Forensic Science Research and Education (CFSRE) at the Fredric Rieders Family Foundation, Willow Grove, PA, United States
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Spadaro A, Connor KO, Lakamana S, Sarker A, Wightman R, Love JS, Perrone J. Self-reported Xylazine Experiences: A Mixed Methods Study of Reddit Subscribers. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.13.23287215. [PMID: 36993695 PMCID: PMC10055471 DOI: 10.1101/2023.03.13.23287215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Objectives Xylazine is an alpha-2 agonist increasingly prevalent in the illicit drug supply. Our objectives were to curate information about xylazine through social media from People Who Use Drugs (PWUDs). Specifically, we sought to answer the following: 1) what are the demographics of Reddit subscribers reporting exposure to xylazine? 2) is xylazine a desired additive? and 3) what adverse effects of xylazine are PWUDs experiencing? Methods Natural Language Processing (NLP) was used to identify mentions of "xylazine" from posts by Reddit subscribers who also posted on drug-related subreddits. Posts were qualitatively evaluated for xylazine-related themes. A survey was developed to gather additional information about the Reddit subscribers. This survey was posted on subreddits that were identified by NLP to contain xylazine-related discussions from March 2022 to October 2022. Results 76 posts mentioning xylazine were extracted via NLP from 765,616 posts by 16,131 Reddit subscribers (January 2018 to August 2021). People on Reddit described xylazine as an unwanted adulterant in their opioid supply. 61 participants completed the survey. Of those that disclosed their location, 25/50 (50%) participants reported locations in the Northeastern United States. The most common eoute of xylazine use was intranasal use (57%). 31/59 (53%) reported experiencing xylazine withdrawal. Frequent adverse events reported were prolonged sedation (81%) and increased skin wounds (43%). Conclusions Among respondents on these Reddit forums, xylazine appears to be an unwanted adulterant. PWUDs may be experiencing adverse effects such as prolonged sedation and xylazine withdrawal. This appeared to be more common in the Northeast.
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Affiliation(s)
- Anthony Spadaro
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Karen O’ Connor
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA
| | - Sahithi Lakamana
- Department of Biomedical Informatics, School of Medicine, Emory University, Woodruff Memorial Research Building, 101 Woodruff Circle, 4 Floor East, Atlanta, GA 30322, USA
| | - Abeed Sarker
- Department of Biomedical Informatics, School of Medicine, Emory University, Woodruff Memorial Research Building, 101 Woodruff Circle, 4 Floor East, Atlanta, GA 30322, USA
| | - Rachel Wightman
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Jennifer S Love
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, 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] [Key Words] [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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Affiliation(s)
- Shahana Ayub
- Psychiatry, Cornerstone Family Healthcare, Newburgh, USA
| | | | - Karuna Poddar
- Psychiatry, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Anil K Bachu
- Psychiatry, Baptist Health University of Arkansas for Medical Sciences, North Little Rock, USA
| | | | - Ali M Khan
- Psychiatry, University of Texas Rio Grande Valley, Harlingen, USA
| | - Saeed Ahmed
- Psychiatry and Behavioral Sciences, Rutland Regional Medical Center, Rutland, USA
- Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, USA
- Behavioral Health Sciences, Boston University School of Medicine, Boston, USA
| | - Lakshit Jain
- Psychiatry, University of Connecticut, Hartford, USA
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11
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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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Reed MK, Imperato NS, Bowles JM, Salcedo VJ, Guth A, Rising KL. Perspectives of people in Philadelphia who use fentanyl/heroin adulterated with the animal tranquilizer xylazine; Making a case for xylazine test strips. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100074. [PMID: 36846574 PMCID: PMC9949306 DOI: 10.1016/j.dadr.2022.100074] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022]
Abstract
Background Xylazine is an animal tranquilizer increasingly detected in those who have died of an opioid overdose in Philadelphia, PA and elsewhere. Despite an increasing presence of xylazine in the local fentanyl/heroin drug market and its association with ulcers, there are few perspectives about xylazine from people who use drugs and no data about the utility of a hypothetical xylazine test strip. Methods Between January to May 2021 in Philadelphia, PA, people who used fentanyl/heroin and had previously used fentanyl test strips were queried about xylazine and hypothetical xylazine test strips. Interviews were transcribed and analysis was conducted via conventional content analysis. Results Participants (7 spontaneously, 6 after probing, n = 13) discussed "tranq" (i.e., xylazine) in the fentanyl/heroin supply. None enjoyed tranq or wanted it in their fentanyl/heroin. Participants suspected xylazine saturation of the fentanyl/heroin market, disliked the sensation of the drug, and had safety concerns about xylazine exposure. Participants did not indicate concerns about overdose. All were interested in hypothetical xylazine test strips. While previous literature indicates that some people enjoy tranq in their fentanyl/heroin, our findings differed, with participants expressing concern about the consequences of undesired exposure. The interest expressed for xylazine test strips by people who use fentanyl/heroin is an important opportunity to center their voices in the development of innovations designed to mitigate the harms of unwanted adulterant exposure. Conclusions In the present study, people who use fentanyl/heroin indicated an interest to test their drug for the presence of xylazine prior to use.
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Affiliation(s)
- Megan K. Reed
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PS 19107, United States,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PS, United States,College of Population Health, Thomas Jefferson University, Philadelphia, PS, United States,Corresponding author at: Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PS 19107, United States.
| | - Nicholas S. Imperato
- College of Population Health, Thomas Jefferson University, Philadelphia, PS, United States
| | - Jeanette M. Bowles
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, ON, Canada
| | - Venise J. Salcedo
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PS, United States
| | - Amanda Guth
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PS, United States
| | - Kristin L. Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PS 19107, United States,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PS, United States,College of Nursing, Thomas Jefferson University, Philadelphia, PS, United States
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13
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Teoh WK, Mohamed Sadiq NS, Saisahas K, Phoncai A, Kunalan V, Md Muslim NZ, Limbut W, Chang KH, Abdullah AFL. Vortex-assisted dispersive liquid-liquid microextraction-gas chromatography (VADLLME-GC) determination of residual ketamine, nimetazepam, and xylazine from drug-spiked beverages appearing in liquid, droplet, and dry forms. J Forensic Sci 2022; 67:1836-1845. [PMID: 35616477 DOI: 10.1111/1556-4029.15068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/10/2022] [Accepted: 05/13/2022] [Indexed: 11/29/2022]
Abstract
Presently, investigations of drug-facilitated crimes (DFCs) rely on the detection of substances extracted from biological samples following intake by the victim. However, such detection requires rapid sampling and analysis prior to metabolism and elimination of the drugs from the body. In cases of suspected DFCs, drug-spiked beverage samples, whether in liquid, droplet, or even dried form, can be tested for the presence of spike drugs and used as evidence for the occurrence of DFCs. This study aimed to quantitatively determine three sedative-hypnotics (ketamine, nimetazepam, and xylazine) from drug-spiked beverages using a vortex-assisted dispersive liquid-liquid microextraction-gas chromatography (VADLLME-GC) approach. In this study, a GC method was first developed and validated, followed by the optimization of the VADLLME protocol, which was then applied to quantify the target substances in simulated forensic case scenarios. The developed GC method was selective, sensitive (limit of detection: 0.08 μg/ml [ketamine]; 0.16 μg/ml [nimetazepam]; 0.08 μg/ml [xylazine]), linear (R2 > 0.99), precise (%RSD <7.2%), and accurate (% recovery: 92.8%-103.5%). Higher recoveries were achieved for the three drugs from beverage samples in liquid form (51%-97%) as compared to droplet (48%-96%) and dried (44%-93%) residues. The recovery was not hindered by very low volumes of spiked beverage and dried residues. In conclusion, the developed VADLLME-GC method successfully recovered ketamine, nimetazepam, and xylazine from spiked beverages that are likely to be encountered during forensic investigation of DFCs.
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Affiliation(s)
- Way Koon Teoh
- Forensic Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | | | - Kasrin Saisahas
- Forensic Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Apichai Phoncai
- Division of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Vanitha Kunalan
- Narcotics Division, Forensic Science Analysis Centre, Department of Chemistry, Petaling Jaya, Malaysia
| | - Noor Zuhartini Md Muslim
- Forensic Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Warakorn Limbut
- Division of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, Thailand.,Center of Excellence for Trace Analysis and Biosensors (TAB-CoE), Prince of Songkla University, Hat Yai, Songkhla, Thailand.,Center of Excellence for Innovation in Chemistry, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kah Haw Chang
- Forensic Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Ahmad Fahmi Lim Abdullah
- Forensic Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
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14
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Friedman J, Montero F, Bourgois P, Wahbi R, Dye D, Goodman-Meza D, Shover C. Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis. Drug Alcohol Depend 2022; 233:109380. [PMID: 35247724 PMCID: PMC9128597 DOI: 10.1016/j.drugalcdep.2022.109380] [Citation(s) in RCA: 126] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Sharp exacerbations of the US overdose crisis are linked to polysubstance use of synthetic compounds. Xylazine is a veterinary tranquilizer, long noted in the street opioid supply of Puerto Rico, and more recently Philadelphia. Yet its national trends, geographic distribution, and health risks are poorly characterized. METHODS In this sequential mixed-methods study, xylazine was increasingly observed by ethnographers in Philadelphia among drug-sellers and people who inject drugs (PWID). Subsequently, we systematically searched for records describing xylazine-present overdose mortality across the US and assessed time trends and overlap with other drugs. RESULTS In 10 jurisdictions - representing all four US Census Regions - xylazine was increasingly present in overdose deaths, rising from 0.36% of deaths in 015m 6.7% in 2020. The highest xylazine prevalence data was observed in Philadelphia, (25.8% of deaths), followed by Maryland (19.3%) and Connecticut (10.2%). Illicitly-manufactured-fentanyls were present in 98.4% of xylazine-present-overdose-deaths - suggesting a strong ecological link - as well as cocaine (45.4%), benzodiazepines (28.4%), heroin (23.3%), and alcohol (19.7%). PWID in Philadelphia described xylazine as a sought-after adulterant that lengthens the short duration of fentanyl injections. They also linked it to increased risk of soft tissue infection and naloxone-resistant overdose. CONCLUSIONS Xylazine is increasingly present in overdose deaths, linked to the proliferation of illicitly-manufactured-fentanyls. Ethnographic accounts associate it with profound risks for PWID. Nevertheless, many jurisdictions do not routinely test for xylazine, and it is not comprehensively tracked nationally. Further efforts are needed to provide PWID with services that can help minimize additional risks associated with a shifting drug supply.
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Affiliation(s)
- Joseph Friedman
- Center for Social Medicine and Humanities, University of California, Los Angeles, CA, USA; Medical Informatics Home Area, University of California, Los Angeles, CA, USA.
| | - Fernando Montero
- Department of Anthropology, Columbia University, New York, NY, USA
| | - Phillippe Bourgois
- Center for Social Medicine and Humanities, University of California, Los Angeles, CA, USA.
| | - Rafik Wahbi
- Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Daniel Dye
- Department of Pathology, University of Alabama, Birmingham, AL, USA
| | - David Goodman-Meza
- Division of Infectious Diseases, University of California, Los Angeles, CA, USA
| | - Chelsea Shover
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA.
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15
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Factors That Influence the Interpretations of Analyte Concentrations. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Bowles JM, McDonald K, Maghsoudi N, Thompson H, Stefan C, Beriault DR, Delaney S, Wong E, Werb D. Xylazine detected in unregulated opioids and drug administration equipment in Toronto, Canada: clinical and social implications. Harm Reduct J 2021; 18:104. [PMID: 34645480 PMCID: PMC8511847 DOI: 10.1186/s12954-021-00546-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The North American opioid overdose crisis is driven in large part by the presence of unknown psychoactive adulterants in the dynamic, unregulated drug supply. We herein report the first detection of the psychoactive veterinary compound xylazine in Toronto, the largest urban center in Canada, by the city's drug checking service. METHODS Toronto's Drug Checking Service launched in October 2019. Between then and February 2021, 2263 samples were submitted for analysis. The service is offered voluntarily at harm reduction agencies that include supervised consumption services. Samples were analyzed using gas chromatography-mass spectrometry or liquid chromatography-high resolution mass spectrometry. Targeted and/or untargeted screens for psychoactive substances were undertaken. RESULTS In September 2020, xylazine was first detected by Toronto's Drug Checking Service. Among samples analyzed from September 2020 to February 2021 expected to contain fentanyl in isolation (610) or in combination with methamphetamine (16), xylazine was detected in 46 samples (7.2% and 12.5% of samples, respectively). Samples were predominantly drawn from used drug equipment. Three of the samples containing xylazine (6.5%) were associated with an overdose. CONCLUSION We present the first detection of xylazine in Toronto, North America's fourth-largest metropolitan area. The increased risk of overdose associated with use of xylazine and its detection within our setting highlights the importance of drug checking services in supporting rapid responses to the emergence of potentially harmful adulterants. These data also highlight the clinical challenges presented by the dynamic nature of unregulated drug markets and the concomitant need to establish regulatory structures to reduce their contribution to overdose morbidity and mortality.
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Affiliation(s)
- Jeanette M Bowles
- Centre on Drug Policy Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, Canada
| | - Karen McDonald
- Centre on Drug Policy Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, Canada
| | - Nazlee Maghsoudi
- Centre on Drug Policy Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, 55 College St Room 500, Toronto, ON, Canada
| | - Hayley Thompson
- Centre on Drug Policy Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, Canada
| | - Cristiana Stefan
- Clinical Laboratory and Diagnostic Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Daniel R Beriault
- Department of Laboratory Medicine, St Michael's Hospital, 30 Bond St., Toronto, ON, Canada
| | - Sarah Delaney
- Department of Laboratory Medicine, St Michael's Hospital, 30 Bond St., Toronto, ON, Canada
| | - Ernest Wong
- Clinical Laboratory and Diagnostic Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Dr., La Jolla, CA, USA.
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Kariisa M, Patel P, Smith H, Bitting J. Notes from the Field: Xylazine Detection and Involvement in Drug Overdose Deaths - United States, 2019. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:1300-1302. [PMID: 34529640 PMCID: PMC8445380 DOI: 10.15585/mmwr.mm7037a4] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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White CM, Browne T, Nafziger AN. Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse. J Clin Pharmacol 2021; 61 Suppl 2:S129-S141. [PMID: 34396559 DOI: 10.1002/jcph.1860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/17/2021] [Indexed: 12/25/2022]
Abstract
Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.
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Affiliation(s)
- C Michael White
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA.,HOPES Research Group, UConn and Hartford Hospital, Hartford, Connecticut, USA
| | - Thom Browne
- Rubicon Global Enterprises & Colombo Plan Secretariat, Huachuca City, Arizona, USA
| | - Anne N Nafziger
- Bertino Consulting, Schenectady, New York, USA.,Department of Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Fentanyl epidemic hits the U.S. West Coast: Opioid-related deaths in San Francisco from 2009-2019. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 95:103402. [PMID: 34364179 DOI: 10.1016/j.drugpo.2021.103402] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Opioid-use disorders have led to a nationwide epidemic of accidental overdoses in the United States. In recent years this opioid epidemic has worsened due to the increased availability of fentanyl in the illicit drug market. The increase in fentanyl-related deaths is well known on the U.S. East Coast, however, limited comprehensive information of mortality data exists from major West Coast cities. METHODS Following comprehensive medico-legal death and toxicological investigations, a retrospective cohort study was performed on all accidental opioid overdose deaths (AOOD) from 2009 - 2019 in San Francisco. The sex, age and race of decedents, location, and date and time of death were described and statistically compared by the type of opioid(s) causing death. RESULTS Since 2016, fentanyl deaths started to replace heroin deaths leading to a sharp increase in fatal overdoses involving fentanyl, surpassing heroin and/or medicinal opioids by 2018. Fentanyl contributed to between 3% and 12% of deaths per year from 2009 to 2015, and between 20% and 73% per year from 2016 to 2019. White and Black males represented 91.5% of all AOOD. Age groups younger than 45 died using fentanyl and heroin significantly more often than older populations (60.7% of ≤45 vs. 40.7% of >45 year-olds, χ2p<0.001). CONCLUSIONS This study shows an upward trend in fentanyl fatal accidental overdoses in recent years in a major West Coast U.S. city. These patterns appear to follow patterns seen in eastern states, albeit with an approximate 3-year delay, and may be indicative of other western populations. The described observations provide detailed demographic, chronological and toxicological information to public health and policy-making agencies for drug harm reduction measures.
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20
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Korn WR, Stone MD, Haviland KL, Toohey JM, Stickle DF. High prevalence of xylazine among fentanyl screen-positive urines from hospitalized patients, Philadelphia, 2021. Clin Chim Acta 2021; 521:151-154. [PMID: 34265257 DOI: 10.1016/j.cca.2021.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Xylazine is an α-2 adrenoreceptor agonist used as a sedative/analgesic in veterinary medicine. Xylazine is known to be present within the street supply of opiates in urban Philadelphia. Medical staff at our hospital asked if we could test for xylazine in fentanyl screen-positive urine samples. We developed an LC-MS/MS assay for this purpose, and determined prevalence of xylazine among fentanyl screen-positive urine samples at our hospital. METHODS The LC-MS/MS assay utilized d5-norfentanyl as internal standard (IS). One hundred microliter samples were extracted with 200 µl of MeOH/IS. LC was performed using a Phenomenex Kinetix C18 column (100 A, 5 µm, 50 × 4.6 mm) at 40 °C. Time-variable mobile phases (A = H2O, 0.1% formic acid; B = MeOH, 0.1% formic acid) were used at a fixed flow rate of 0.5 ml/min. MS/MS used positive electrospray ionization, monitoring m/z transitions of 221 > 164 for xylazine (primary), 221 > 90 for xylazine (qualifier), and 238 > 84 for d5-norfentanyl (IS). Retention time was 3.9 min for both xylazine and IS. RESULTS Calibration curve was linear (0-500 ng/ml; r > 0.99). Inter-assay CVs (n = 20) were 5.2% (18 ng/ml) and 6.6% (95 ng/ml). Lower limit of detection was set at 10 ng/ml (CV = 15%). Among 81 urine samples that were screen-positive for fentanyl (Ark Diagnostics immunoassay), 63 (78%) were positive for xylazine (>10 ng/ml). CONCLUSIONS By LC-MS/MS, there was high prevalence (78%) of xylazine in fentanyl screen-positive urine samples submitted to the laboratory. Because α-2 adrenoreceptor agonists may be used in treatment of opioid addiction, knowledge of xylazine exposure may be clinically useful to guide patient management.
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Affiliation(s)
- Warren R Korn
- Department of Pathology, Jefferson University Hospital, Philadelphia, PA, USA
| | - Matthew D Stone
- Department of Pathology, Jefferson University Hospital, Philadelphia, PA, USA
| | - Kaddie L Haviland
- Department of Pathology, Jefferson University Hospital, Philadelphia, PA, USA
| | - Joanne M Toohey
- Department of Pathology, Jefferson University Hospital, Philadelphia, PA, USA
| | - Douglas F Stickle
- Department of Pathology, Jefferson University Hospital, Philadelphia, PA, USA.
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21
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Nunez J, DeJoseph ME, Gill JR. Xylazine, a Veterinary Tranquilizer, Detected in 42 Accidental Fentanyl Intoxication Deaths. Am J Forensic Med Pathol 2021; 42:9-11. [PMID: 33031124 DOI: 10.1097/paf.0000000000000622] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Xylazine is an emerging adulterant with fentanyl in fatal drug intoxications, which has public health, safety, and criminal investigative implications. Xylazine is a nonnarcotic sedative used for analgesia and muscle relaxation exclusively in veterinary medicine. Its chemical structure is similar to clonidine and acts as a central α-2 agonist which may cause bradycardia and transient hypertension followed by hypotension. We report the detection of xylazine in 42 deaths in Connecticut from March to August 2019. Xylazine combined with an opioid or stimulant may affect the toxicity of these drugs. Detection of xylazine may help the forensic pathologist distinguish illicit from prescribed fentanyl, and law enforcement agents track the illicit drugs to a specific drug supplier. Because of its lack of response to naloxone, emergency medicine physicians need to be aware of its potential presence as it may affect therapy.
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22
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Xylazine Identified in the Unregulated Drug Supply in British Columbia, Canada. CANADIAN JOURNAL OF ADDICTION 2020. [DOI: 10.1097/cxa.0000000000000089] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fagiola M, Hahn T, Avella J. Five Postmortem Case Reports with Qualitative Analysis of Cyclopropylfentanyl by LC-MS-MS. J Anal Toxicol 2019; 43:e1-e6. [PMID: 30476101 DOI: 10.1093/jat/bky094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/12/2018] [Accepted: 10/23/2018] [Indexed: 12/29/2022] Open
Abstract
In January 2018, the Drug Enforcement Agency temporarily designated cyclopropylfentanyl as a Schedule I drug. Over the course of 5 months (December 2017-May 2018), the Nassau County Medical Examiner Toxicology Laboratory qualitatively identified and confirmed cyclopropylfentanyl in specimens obtained from five postmortem cases. We describe the five cases and include pertinent autopsy findings and decedent histories, along with results for cyclopropylfentanyl determined in postmortem cardiac blood. Samples were prepared by an alkaline liquid-liquid extraction, with sample pH adjusted to >9 and utilizing an extraction solvent consisting of 90:10 hexane:ethyl acetate. Instrumental analysis was achieved via liquid chromatography tandem mass spectrometry with a dual jetstream electrospray source operating in positive ion mode. Two ion transitions were monitored for each analyte of interest and the internal standard. The estimated concentration range of cyclopropylfentanyl in the reported cases was 5.6 to 82 ng/mL for five postmortem cardiac blood specimens. All five cases included cyclopropylfentanyl in the established cause of death.
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Affiliation(s)
- Michael Fagiola
- Nassau County Medical Examiner, Department of Forensic Toxicology, 2251 Hempstead Turnpike-Building R, East Meadow, NY, USA
| | - Timothy Hahn
- Nassau County Medical Examiner, Department of Forensic Toxicology, 2251 Hempstead Turnpike-Building R, East Meadow, NY, USA
| | - Joseph Avella
- Nassau County Medical Examiner, Department of Forensic Toxicology, 2251 Hempstead Turnpike-Building R, East Meadow, NY, USA
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25
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Matos RR, Martucci MEP, de Anselmo CS, Alquino Neto FR, Pereira HMG, Sardela VF. Pharmacokinetic study of xylazine in a zebrafish water tank, a human-like surrogate, by liquid chromatography Q-Orbitrap mass spectrometry. Forensic Toxicol 2019. [DOI: 10.1007/s11419-019-00493-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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26
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Chuang R, Saleh F, Alyahya B. Pediatric cardiac toxicity associated with fentanyl ingestion. TOXICOLOGY COMMUNICATIONS 2018. [DOI: 10.1080/24734306.2018.1459108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Ryan Chuang
- Department of Emergency Medicine, Alberta Health Services, Calgary, Canada
- Departments of Emergency and Internal Medicine, University of Calgary, Calgary, Canada
| | - Farah Saleh
- Poison and Drug Information Service, Alberta Health Services, Calgary, Canada
| | - Bader Alyahya
- Clinical Pharmacology and Toxicology Program, McGill University, Montreal, Canada
- King Saud University, Riyadh, Saudi Arabia
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Mars SG, Ondocsin J, Ciccarone D. Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore, MD. J Psychoactive Drugs 2017; 50:167-176. [PMID: 29211971 DOI: 10.1080/02791072.2017.1394508] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Since 2001, heroin-related overdose deaths in the United States have risen six-fold, a rise unaccounted for by the expanding user population. Has heroin become a more dangerous drug? Reports of fentanyl and its analogs, often concealed in or sold as heroin, have also increased sharply. This article investigates heroin injectors' perceptions and experiences of changes in the heroin supply in the East Coast city of Baltimore, Maryland, currently facing an epidemic in heroin- and fentanyl-related overdose deaths. Unusually, Baltimore's heroin market is divided between two types: "Raw," believed to be Colombian in origin and relatively pure, and the more adulterated "Scramble" (raw heroin traditionally blended with quinine and lactose). Users reported that Scramble heroin, while gaining market share, has become a highly unstable product, varying dramatically in appearance, intensity of onset, duration of action, and effect. Some considered that Scramble was no longer "heroin," but was heavily adulterated or even replaced, mentioning fentanyl, benzodiazepines, and crushed opioid pills as additives. There was intense awareness of overdose as a present danger in users' lives, which they linked to the recent adulteration of the heroin supply. Responses to this perceived adulteration varied, including information gathering, attraction, avoidance, taking precautions, and acceptance.
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Affiliation(s)
- Sarah G Mars
- a Qualitative Project Director, Heroin in Transition, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
| | - Jeff Ondocsin
- b Ethnographer, Heroin in Transition, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
| | - Daniel Ciccarone
- c Professor of Family and Community Medicine, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
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Rodda LN, Pilgrim JL, Di Rago M, Crump K, Gerostamoulos D, Drummer OH. A Cluster of Fentanyl-Laced Heroin Deaths in 2015 in Melbourne, Australia. J Anal Toxicol 2017; 41:318-324. [DOI: 10.1093/jat/bkx013] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 01/12/2017] [Indexed: 11/13/2022] Open
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Isaacs RC, Harper MM, Miller EC. Analytical challenges in the confirmative identification of dipyrone as an adulterant in illicit drug samples. Forensic Sci Int 2017; 270:185-192. [DOI: 10.1016/j.forsciint.2016.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 08/13/2016] [Accepted: 08/16/2016] [Indexed: 11/28/2022]
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Forrester MB. Xylazine Exposures Reported to Texas Poison Centers. J Emerg Med 2016; 51:389-393. [DOI: 10.1016/j.jemermed.2015.09.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 09/30/2015] [Indexed: 11/30/2022]
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Alexander RT, Hedrick CW, Alexander SD, Jufer-Phipps R, Fowler DR. Epidemic Fentanyl Deaths in Maryland: A Public Health Intervention Involving Geographic Information Systems and Collaboration with the Drug Enforcement Administration. Acad Forensic Pathol 2016; 6:301-314. [PMID: 31239901 DOI: 10.23907/2016.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/24/2016] [Accepted: 03/11/2016] [Indexed: 01/29/2023]
Abstract
An ongoing epidemic of illicit fentanyl overdose deaths started in Maryland in July 2013. The records of the Office of the Chief Medical Examiner for the state of Maryland were searched to identify these deaths from July 2013 to February 2015. A geographic information system was used to map and analyze the spatial and temporal distribution of the deaths in Maryland. A total of 266 fentanyl-related deaths were identified. The number of deaths per month generally increased from July 2013 to June 2014, decreased precipitously in August 2014, and rose steadily until the end of the study in February 2015. Deaths began in Baltimore City and then spread throughout the state. A statistically significant cluster ("hot spot") of deaths was centered in Baltimore City. Greater death densities were also centered on other cities. A high-density band of deaths extended from Baltimore City towards Annapolis. Deaths extended past cities and into the surrounding suburbs; this effect was most pronounced around Baltimore City. Deaths in Baltimore City appeared concentrated in certain neighborhoods. However, the activity moved between various neighborhoods over the course of the study. Review of the above data with the United States Drug Enforcement Administration's Baltimore Office (DEA) allowed some of the above trends to be explained in terms of illicit drug production, transportation and distribution. The DEA is implementing a new strategy to combat illicit narcotic distribution and use in Maryland.
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Mars SG, Fessel JN, Bourgois P, Montero F, Karandinos G, Ciccarone D. Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States. Soc Sci Med 2015; 140:44-53. [PMID: 26202771 PMCID: PMC4587985 DOI: 10.1016/j.socscimed.2015.06.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
Heroin overdose, more accurately termed 'heroin-related overdose' due to the frequent involvement of other drugs, is the leading cause of mortality among regular heroin users. (Degenhardt et al., 2010) Heroin injectors are at greater risk of hospital admission for heroin-related overdose (HOD) in the eastern United States where Colombian-sourced powder heroin is sold than in the western US where black 'tar' heroin predominates. (Unick et al., 2014) This paper examines under-researched influences on HOD, both fatal and non-fatal, using data from a qualitative study of injecting drug users of black tar heroin in San Francisco and powder heroin in Philadelphia Data were collected through in-depth, semi-structured interviews carried out in 2012 that were conducted against a background of longer-term participant-observation, ethnographic studies of drug users and dealers in Philadelphia (2007-12) and of users in San Francisco (1994-2007, 2012). Our findings suggest three types of previously unconsidered influences on overdose risk that arise both from structural socio-economic factors and from the physical properties of the heroin source-types: 1) retail market structure including information flow between users; 2) marketing techniques such as branding, free samples and pricing and 3) differences in the physical characteristics of the two major heroin source forms and how they affect injecting techniques and vascular health. Although chosen for their contrasting source-forms, we found that the two cities have contrasting dominant models of drug retailing: San Francisco respondents tended to buy through private dealers and Philadelphia respondents frequented an open-air street market where heroin is branded and free samples are distributed, although each city included both types of drug sales. These market structures and marketing techniques shape the availability of information regarding heroin potency and its dissemination among users who tend to seek out the strongest heroin available on a given day. The physical characteristics of these two source-types, the way they are prepared for injecting and their effects on vein health also differ markedly. The purpose of this paper is to examine some of the unexplored factors that may lead to heroin-related overdose in the United States and to generate hypotheses for further study.
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Affiliation(s)
- Sarah G Mars
- Department of Family and Community Medicine, University of California, San Francisco, MU337E Box 0900, 500 Parnassus Avenue, San Francisco, CA 94143-0900, USA.
| | - Jason N Fessel
- Department of Anthropology, History and Social Medicine, University of California, San Francisco, 3333 California Street, Suite 485, San Francisco, CA 94143-0850, USA.
| | - Philippe Bourgois
- School of Arts and Sciences, School of Medicine, University of Pennsylvania, 415 Anthropology Museum, 3260 South Street, Philadelphia, PA 19104-6398, USA.
| | - Fernando Montero
- School of Arts and Sciences, School of Medicine, University of Pennsylvania, 415 Anthropology Museum, 3260 South Street, Philadelphia, PA 19104-6398, USA.
| | - George Karandinos
- School of Arts and Sciences, School of Medicine, University of Pennsylvania, 415 Anthropology Museum, 3260 South Street, Philadelphia, PA 19104-6398, USA.
| | - Daniel Ciccarone
- Department of Family and Community Medicine, 500 Parnassus Avenue, MUE3, San Francisco, CA 94143, USA.
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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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Perrin AJ. Intentional misuse of veterinary medications in human suicide. J Vet Pharmacol Ther 2014; 38:209-13. [DOI: 10.1111/jvp.12184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 10/19/2014] [Indexed: 12/01/2022]
Affiliation(s)
- A. J. Perrin
- Research Track Residency; Department of Psychiatry; University of British Columbia; Vancouver BC Canada
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Silva-Torres L, Veléz C, Álvarez L, Zayas B. Xylazine as a drug of abuse and its effects on the generation of reactive species and DNA damage on human umbilical vein endothelial cells. J Toxicol 2014; 2014:492609. [PMID: 25435874 PMCID: PMC4243599 DOI: 10.1155/2014/492609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 10/05/2014] [Accepted: 10/15/2014] [Indexed: 01/14/2023] Open
Abstract
Human xylazine (XYL) abuse among addicts has received great interest due to its potential toxic effects upon addicts and the need to understand the mechanism of action associated with the potential health effects. XYL is an alpha-2 agonist restricted to veterinarian applications, without human medical applications. Our previous work demonstrated that XYL and its combination with cocaine (COC) and/or 6-monoacetylmorphine (6-MAM) induce cell death through an apoptotic mechanism. The aim of this study was to determine the effect of xylazine on the generation of reactive oxygen species (ROS) and reactive nitrogen species (RNS) as well as DNA damage on endothelial cell. Human umbilical vein endothelial cells (HUVEC) were treated with XYL (60 μM), COC (160 μM), 6-MAM (160 μM), camptothecin (positive control, 50 μM), XYL/COC (50 μM), XYL/6-MAM (50 μM), and XYL/COC/6-MAM (40 μM) for a period of 24 hours. Generation of intracellular ROS, RNS, and DNA fragmentation were analyzed using a fluorometric assay. Results reveal that XYL and 6-MAM increase levels of ROS; no induction of RNS production was observed. The combination of these drugs shows significant increase in DNA fragmentation in G2/M phase, while XYL, COC, and 6-MAM, without combination, present higher DNA fragmentation in G0/G1 phase. These findings support that these drugs and their combination alter important biochemical events aligned with an apoptotic mechanism of action in HUVEC.
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Affiliation(s)
- Luz Silva-Torres
- Pharmacology and Toxicology Department, School of Medicine, University of Puerto Rico, Medical Science Campus, P.O. Box 335067, San Juan, PR 00936-5067, USA
- Puerto Rico Institute of Forensic Science, PR, USA
| | - Christian Veléz
- School of Environmental Affairs, Universidad Metropolitana, PR, USA
| | - Lyvia Álvarez
- Pharmacology and Toxicology Department, School of Medicine, University of Puerto Rico, Medical Science Campus, P.O. Box 335067, San Juan, PR 00936-5067, USA
- Puerto Rico Institute of Forensic Science, PR, USA
| | - Beatriz Zayas
- Pharmacology and Toxicology Department, School of Medicine, University of Puerto Rico, Medical Science Campus, P.O. Box 335067, San Juan, PR 00936-5067, USA
- School of Environmental Affairs, Universidad Metropolitana, PR, USA
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Marinetti LJ, Ehlers BJ. A Series of Forensic Toxicology and Drug Seizure Cases Involving Illicit Fentanyl Alone and in Combination with Heroin, Cocaine or Heroin and Cocaine. J Anal Toxicol 2014; 38:592-8. [DOI: 10.1093/jat/bku086] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Deren S, Gelpí-Acosta C, Albizu-García CE, González Á, Des Jarlais DC, Santiago-Negrón S. Addressing the HIV/AIDS epidemic among Puerto Rican people who inject drugs: the need for a multiregion approach. Am J Public Health 2014; 104:2030-6. [PMID: 25211722 DOI: 10.2105/ajph.2014.302114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
High levels of HIV risk behaviors and prevalence have been reported among Puerto Rican people who inject drugs (PRPWID) since early in the HIV epidemic. Advances in HIV prevention and treatment have reduced HIV among people who inject drugs (PWID) in the United States. We examined HIV-related data for PRPWID in Puerto Rico and the US Northeast to assess whether disparities continue. Injection drug use as a risk for HIV is still overrepresented among Puerto Ricans. Lower availability of syringe exchanges, drug abuse treatment, and antiretroviral treatment for PWID in Puerto Rico contribute to higher HIV risk and incidence. These disparities should be addressed by the development of a federally supported Northeast-Puerto Rico collaboration to facilitate and coordinate efforts throughout both regions.
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Affiliation(s)
- Sherry Deren
- Sherry Deren is with the Center for Drug Use and HIV Research, College of Nursing, New York University, New York, NY. Camila Gelpí-Acosta is a postdoctoral fellow at National Development and Research Institutes (NDRI), New York, NY. Carmen E. Albizu-García is with the Graduate School of Public Health, University of Puerto Rico, San Juan. At the time of writing, Ángel González and Salvador Santiago-Negrón were with the Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA; Mental Health and Anti-addiction Services Administration), San Juan. Don C. Des Jarlais is with Mount Sinai Beth Israel, New York, NY
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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: 122] [Impact Index Per Article: 12.2] [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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Gill JR, Lin PT, Nelson L. Reliability of postmortem fentanyl concentrations in determining the cause of death. J Med Toxicol 2013; 9:34-41. [PMID: 22890811 DOI: 10.1007/s13181-012-0253-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Transdermal fentanyl, an opioid used for management of marked pain, also is abused and may cause death. METHODS We reviewed medical examiner reports of 92 decedents who had one or more fentanyl transdermal patches on their body and had fentanyl detected in their postmortem toxicology analysis. RESULTS The manners of death included 40 accidents, 36 natural, 8 suicides, 5 therapeutic complications, and 3 undetermined deaths. Among the accidental fentanyl intoxication deaths, 32 of 37 involved substance abuse. The majority (95 %) of the 37 accidental deaths involving fentanyl were multi-drug intoxications. The substance abuse deaths had a mean fentanyl blood concentration (26.4 ng/ml or μg/L) that was over twice that of the natural group (11.8 ng/ml). Our analysis suggests a relationship between total patch dosage and mean postmortem fentanyl concentration up to the 100-μg/h dose. CONCLUSIONS The very wide and overlapping ranges of postmortem fentanyl concentrations effectively nullify the utility of correlating the dose and expected postmortem concentration for any particular death. Based on the variable relationship between dose and blood concentration, the antemortem dose cannot be reliably predicted based on the postmortem concentration. This does not, however, render the medical examiner/coroner unable to determine the cause and manner of death because the toxicology results are only one datum point among several that are considered. Although there was a weakly positive relationship between body mass index and fentanyl concentration, further research is needed to determine whether adipose tissue represents a significant depot for postmortem release of fentanyl.
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Affiliation(s)
- James R Gill
- New York City Office of Chief Medical Examiner and Department of Forensic Medicine, New York University School of Medicine, New York, NY 10016, USA.
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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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Torruella RA. Xylazine (veterinary sedative) use in Puerto Rico. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2011; 6:7. [PMID: 21481268 PMCID: PMC3080818 DOI: 10.1186/1747-597x-6-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 04/11/2011] [Indexed: 11/30/2022]
Abstract
Human xylazine use in Puerto Rico merits particular attention for its unprecedented scale and depth. Although Puerto Rican injecting drug users (IDUs) have reported using this drug since the early 2000s, little is being done in the research and service delivery sectors as it is claimed that xylazine severely impacts the health of its users. This report provides information on xylazine use and its associated harms. Data from one semi-structured interview collected in New York City (2007-2008) as part of a larger research study with migrant Puerto Rican drug users is presented as a case study. Xylazine, a veterinary sedative, is an adulterant and complement to other drugs and its chronic use is reported to be associated with physical deterioration. Because human xylazine use has been reported in other locations outside of Puerto Rico, this substance could also emerge as an adulterant in other markets to the levels currently experienced in Puerto Rico. Research and interventions are needed to provide adequate services on the island, better understand how the use of xylazine affects its users, and to reduce the possibility of increased xylazine use on the state-side.
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Affiliation(s)
- Rafael A Torruella
- National Development and Research Institutes, Inc and Public Health Solution, 71 West 23rd Street, New York, NY 10010, USA.
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Strano-Rossi S, Alvarez I, Tabernero MJ, Cabarcos P, Fernández P, Bermejo AM. Determination of fentanyl, metabolite and analogs in urine by GC/MS. J Appl Toxicol 2010; 31:649-54. [PMID: 21132842 DOI: 10.1002/jat.1613] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 10/07/2010] [Accepted: 10/07/2010] [Indexed: 11/08/2022]
Abstract
A rapid and sensitive method for the simultaneous determination of alfentanyl, sufentanyl and fentanyl (and its major metabolite norfentanyl) in urine was developed and validated. The method involved a liquid-liquid extraction in alkaline conditions, derivatization with pentafluoropropionic anhydride to improve the sensitivity for norfentanyl and subsequent analysis in GC/MS. The LODs are 0.08 ng ml(-1) for all substances (0.04 ng ml(-1) for alfentanyl). Intra- and inter-day precision coefficient of variation was always below 15%; mean relative error (accuracy) was always below 15%. The method was linear for all analytes, with quadratic regression of calibration curves always higher than 0.99. The method was applied to real samples of subjects who had received therapeutic doses of fentanyl, showing its suitability for the determination of low levels of these substances. The method was also applied to a subject whose death was attributed to fentanyl overdose.
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Verplaetse R, Tytgat J. Development and validation of a sensitive ultra performance liquid chromatography tandem mass spectrometry method for the analysis of fentanyl and its major metabolite norfentanyl in urine and whole blood in forensic context. J Chromatogr B Analyt Technol Biomed Life Sci 2010; 878:1987-96. [DOI: 10.1016/j.jchromb.2010.05.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 05/19/2010] [Accepted: 05/20/2010] [Indexed: 11/29/2022]
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Talu A, Rajaleid K, Abel-Ollo K, Rüütel K, Rahu M, Rhodes T, Platt L, Bobrova N, Uusküla A. HIV infection and risk behaviour of primary fentanyl and amphetamine injectors in Tallinn, Estonia: Implications for intervention. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 21:56-63. [DOI: 10.1016/j.drugpo.2009.02.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Revised: 02/10/2009] [Accepted: 02/27/2009] [Indexed: 11/26/2022]
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Trevorrow P. Launch Editorial. Drug Test Anal 2009; 1:1-3. [DOI: 10.1002/dta.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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