Accidental self administration of xylazine in a veterinary nurse

Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports From Front-Line Health Workers in 7 US States

BACKGROUND

Xylazine, an adrenergic alpha-2 agonist increasingly present in the US drug supply, is associated with severe skin ulcers and other harms. Expert knowledge from front-line harm reduction and healthcare professionals is an essential component of evidence-based practice. The purpose of this study is to describe the progression and treatment of xylazine-associated wounds, other xylazine-related health concerns, and the most urgent research priorities as reported by front-line harm reduction and healthcare professionals serving people who use drugs.

METHODS

A convenience sample of 17 healthcare and harm reduction professionals who serve people who use drugs in the US states of Maryland, Massachusetts, Michigan, Minnesota, North Carolina, Pennsylvania, and Texas participated in semi-structured interviews. Participants were asked about the appearance and progression of xylazine-associated wounds; preferred treatment strategies; other xylazine-related harms experienced by people who use drugs; and the most urgent priorities for xylazine-related research.

FINDINGS

Xylazine-associated wounds were broadly described as small lesions appearing mostly on extremities both at and away from injection sites, often within hours or days of exposure, that quickly developed into large, complex, chronic wounds. Reported risk of secondary infection was generally low but appeared more common among unhoused populations. Most participants preferred conservative treatment strategies that included regular wound care, enzymatic debridement, and hygiene. Xylazine-associated wounds and xylazine withdrawal reportedly act as significant barriers to care, including addiction treatment. Participants reported urgent need for scientific research and evidence-based guidance on the management of xylazine-associated wounds and withdrawal.

CONCLUSIONS

High-quality scientific evidence on risk factors for xylazine-associated wounds and on their biologic mechanisms is needed. Such studies could inform new strategies for the prevention and treatment of these wounds. Efforts to improve the management of xylazine withdrawal and to reduce stigma by incorporating harm reduction professionals into healthcare settings may improve access to and retention in care.

Evaluation of the relationship of xylazine and fentanyl blood concentrations among fentanyl-associated fatalities

INTRODUCTION

Illicit fentanyl and fentanyl-analogs have produced a devastating increase in opioid fatalities in the United States. Increasingly, xylazine has been found in the illicit fentanyl supply. The role of xylazine in fentanyl intoxication remains unclear. We reviewed coroner records to evaluate trends and effects associated with xylazine in fentanyl-related fatalities.

METHODS

This is a retrospective cohort study of all deaths reported to the Franklin County Coroner's Office in Ohio from 1 January 2019 to 16 March 2023, in which fentanyl was determined causative or contributory to death. Cases identified as fentanyl-associated fatalities were separated into two groups based on whether or not xylazine was also detected.

RESULTS

There were 3,052 fentanyl-related fatalities during the study period. 4.8 percent of these decedents also tested positive for xylazine. There was no meaningful demographic difference between fentanyl-related fatalities in which xylazine was detected versus those without xylazine detected. There was a mean of 726 fentanyl-associated fatalities per year, with a peak of 846 deaths in 2020 and a decline thereafter. The percentage of fentanyl-related fatalities with xylazine detected increased in linear fashion from 2.7 percent in 2019 to 6.6 percent in 2022. The median fentanyl concentration was 17.0 µg/L (inter-quartile range: 7.9, 27.0) in cases with xylazine detected and 10.0 µg/L (inter-quartile range: 5.6, 18.0) without xylazine. The odds of a fentanyl concentration greater than 40 µg/L in cases with xylazine detected was more than twice as great (odds ratio: 2.41; 95 percent confidence interval: 1.58-3.64) than that in cases without xylazine detected.

CONCLUSIONS

Postmortem fentanyl concentrations were greater in cases with xylazine detected than those without xylazine detected. Though it is unclear why patients who were exposed to xylazine tolerated higher opioid doses prior to succumbing to death, we postulate that xylazine may act to competitively antagonize some degree of mu-opioid receptor binding by opioids.

Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges

Xylazine abuse is emerging globally, while the identification of xylazine lethal cases poses a great challenge in clinical and forensic practice. The non-specific symptoms delay the diagnosis and treatment of xylazine poisoning, the pathological changes and lethal concentration of xylazine in body fluid and organs of fatal xylazine poisoning cases are seldom reported and the other toxins detected in such cases complicate the role of xylazine in the cause of death. Therefore, we carefully reviewed related updated information on xylazine, summarized the knowledge from clinical and forensic perspectives and can thus provide a reference in such cases and throw light on further study in the field of xylazine poisoning.

The New Stealth Drug on the Street: A Narrative Review of Xylazine as a Street Drug

Xylazine is an alpha-adrenergic receptor agonist approved for use only in animals with a prescription from a veterinarian. It is a powerful sedative that is slowly infiltrating the recreational street drug scene and is often used by polysubstance abusers. Known as "tranq," it can be fatal, and xylazine-induced toxicity cannot be reversed with naloxone or nalmefene. Due to its vasoconstrictive effects, chronic use of xylazine is associated with necrotic skin lesions and general deterioration of health. Since xylazine is not approved for human use and is not scheduled as a controlled substance, there are no human studies to provide evidence of drug-drug interactions, lethal doses, or reversal protocols. Xylazine is available online without a prescription. Street drug users may take xylazine knowingly or unknowingly, as it is often combined with other illicit substances such as fentanyl. There are no rapid tests for xylazine, although there are specialty tests that can be ordered. Xylazine represents a major threat to street drug users and another challenge to emergency healthcare workers, first responders, and others who care for those who have taken this "new" street drug.

Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications

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.

Nanocoral-like Polyaniline-Modified Graphene-Based Electrochemical Paper-Based Analytical Device for a Portable Electrochemical Sensor for Xylazine Detection

A portable electrochemical device for xylazine detection is presented for the first time. An electrochemical paper-based analytical device (ePAD) was integrated with a smartphone. The fabrication of the ePAD involved wax printing, low-tack transfer tape, and cutting and screen-printing techniques. Graphene ink was coated on the substrate and modified with nanocoral-like polyaniline, providing an electron transfer medium with a larger effective surface area that promoted charge transfer. The conductive ink on the ePAD presented a thickness of 25.0 ± 0.9 μm for an effective surface area of 0.374 cm². This sensor was then tested directly on xylazine using differential pulse voltammetry. Two linear responses were obtained: from 0.2 to 5 μg mL^-1 and from 5 to 100 μg mL^-1. The detection limit was 0.06 μg mL^-1. Reproducibility was tested on 10 preparations. The relative standard deviation was less than 5%. The applicability of the sensor was evaluated with beverage samples spiked with trace xylazine. Recoveries ranged from 84 ± 4 to 105 ± 2%. The developed sensor demonstrated excellent accuracy in the detection of trace xylazine. It would be possible to develop the portable system to detect various illicit drugs to aid forensic investigations.

Xylazine poisoning: a systematic review

PURPOSE

Xylazine is an alpha-2-adrenergic agonist used for its sedative and analgesic properties in veterinary medicine. While not approved by the Food and Drug Administration for use in humans, anecdotal evidence suggests that exposures in humans is on the rise. We sought to systematically review and synthesize the evidence on xylazine exposure in humans focusing on the clinical presentation, management, and outcomes.

METHODS

We conducted a systematic review of the literature including PubMed, Embase, and Scopus from their inception to September 9, 2021. We searched abstracts from selected emergency medicine and toxicology conferences from 2011 through 2021. We included clinical reports of xylazine exposure in humans. We excluded animal studies, in vitro studies, laboratory studies, or articles in a language other than English. From each included article, we extracted subjective and objective data that focused on clinical presentation, management, and outcomes of patients exposed to xylazine.

RESULTS

We evaluated a total of 1409 records, rendering a final set of 17 articles and 2 abstracts meeting inclusion criteria. We identified a total of 98 patients amongst reports ranging from 1979 to 2020 and across nine countries. The most common types of xylazine exposures reported were unintentional exposure and intentional misuse/abuse. Common symptoms on presentation included hypotension, bradycardia, drowsiness, lethargy, while apnea with intubation and death were less frequently reported.

CONCLUSION

Human exposure to xylazine appears to be a rising concern within the prehospital and emergency medicine setting. Although a standardized treatment algorithm cannot be recommended at this time, further research is needed to improve the care of patients exposed to xylazine.

Electroanalytical Overview: Electrochemical Sensing Platforms for Food and Drink Safety

Robust, reliable, and affordable analytical techniques are essential for screening and monitoring food and water safety from contaminants, pathogens, and allergens that might be harmful upon consumption. Recent advances in decentralised, miniaturised, and rapid tests for health and environmental monitoring can provide an alternative solution to the classic laboratory-based analytical techniques currently utilised. Electrochemical biosensors offer a promising option as portable sensing platforms to expedite the transition from laboratory benchtop to on-site analysis. A plethora of electroanalytical sensor platforms have been produced for the detection of small molecules, proteins, and microorganisms vital to ensuring food and drink safety. These utilise various recognition systems, from direct electrochemical redox processes to biological recognition elements such as antibodies, enzymes, and aptamers; however, further exploration needs to be carried out, with many systems requiring validation against standard benchtop laboratory-based techniques to offer increased confidence in the sensing platforms. This short review demonstrates that electroanalytical biosensors already offer a sensitive, fast, and low-cost sensor platform for food and drink safety monitoring. With continued research into the development of these sensors, increased confidence in the safety of food and drink products for manufacturers, policy makers, and end users will result.

Xylazine, a Veterinary Tranquilizer, Detected in 42 Accidental Fentanyl Intoxication Deaths

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.

A portable electrochemical sensor for detection of the veterinary drug xylazine in beverage samples

A portable electrochemical sensor was developed to determine xylazine in spiked beverages by adsorptive stripping voltammetry (AdSV). The sensor was based on a graphene nanoplatelets-modified screen-printed carbon electrode (GNPs/SPCE). The electrochemical behavior of xylazine at the GNPs/SPCE was an adsorption-controlled irreversible oxidation reaction. The loading of graphene nanoplatelets (GNPs) on the modified SPCE, electrolyte pH, and AdSV accumulation potential and time were optimized. Under optimal conditions, the GNPs/SPCE provided high sensitivity, linear ranges of 0.4-6.0 mg L^-1 (r = 0.997) and 6.0-80.0 mg L^-1 (r = 0.998) with a detection limit of 0.1 mg L^-1 and a quantitation limit of 0.4 mg L^-1. Repeatability was good. The accuracy of the proposed sensor was investigated by spiking six beverage samples at 1.0, 5.0, and 10.0 mg L^-1. The recoveries from this method ranged from 80.8 ± 0.2-108.1 ± 0.3 %, indicating the good accuracy of the developed sensor. This portable electrochemical sensor can be used to screen for xylazine in beverage samples as evidence in cases of sexual assault or robbery.

Xylazine as a drug of abuse and its effects on the generation of reactive species and DNA damage on human umbilical vein endothelial cells

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.

Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature

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.

Human exposures to immobilising agents: results of an online survey

Cases of human exposure to veterinary injectable anaesthetics were reviewed following a literature search and completion of an online questionnaire in an attempt to provide an objective approach to the problem. The modified Glasgow Coma Scale was used to rank cases according to their severity. From the cases examined, results showed that intoxication with potent opioids, such as etorphine, carfentanil and thiafentanil, need to be treated with antagonists such as naloxone, nalmefene or naltrexone, and not with antagonists with agonistic properties, such as diprenorphine. With regard to the alpha(2)-agonists xylazine, detomidine, medetomidine and romifidine, no antagonist is currently accredited for human use. Atipamezole, a specific alpha(2)-antagonist, is widely used in veterinary medicine and has been used experimentally to reverse dexmetomidine in a study in human medicine. The high concentrations of alpha(2)-agonists being used in zoo and wildlife medicine warrant the accreditation of atipamezole for use in cases of human exposure. Knowledge and availability of the appropriate antagonist are essential in cases of human intoxication with injectable anaesthetics. Preventive measures, such as wearing gloves and eye protection, need to be used more regularly to reduce the risk of exposure.

Systemic toxicity after an ocular exposure to xylazine hydrochloride

There are limited reports of human overdose with the animal tranquilizer, xylazine hydrochloride. The reported effects include hypotension, bradycardia, and respiratory depression. Ocular exposures to xylazine have not been previously reported. A 38-year-old man arrived in the Emergency Department, reporting the accidental irrigation of both eyes with approximately 8 mL of xylazine (100 mg/mL) 30 min before arrival. The patient was asymptomatic. The eyes were copiously irrigated with isotonic crystalloid. Two hours after the exposure, the patient developed sinus bradycardia (40-50 beats/min), hypotension (90/60 mm Hg), and a decreased level of consciousness. The patient was admitted for observation, during which the bradycardia and hypotension were noted to persist. He remained otherwise asymptomatic. The symptoms resolved without intervention, other than i.v. fluids, approximately 25 h after the exposure. The patient was discharged home. This case demonstrates that ocular exposure to xylazine can cause systemic central nervous system and cardiovascular effects.

Veterinary pharmacovigilance. Part 4. Adverse reactions in humans to veterinary medicinal products

Although seemingly rare, adverse reactions to veterinary products do occur. These may arise from inadvertent exposure during use or as a result of occupational accidents. They are often mild in nature and include adverse effects such as minor skin reactions. However, more serious reactions may occur, and they are not restricted to the effects of the veterinary medicines themselves. For example, high-pressure injection injuries may occur as a result of accidents occurring during animal vaccination operations. This paper reviews some of these events, mentions where appropriate the regulatory actions taken, and describes some of the measures used to minimise such effects in the future, and serves to bring the issues discussed here to the attention of pharmacologists, pharmacoepidemiologists and others who train those who use veterinary medicinal products.

Drug abuse with inhalated xylazine

Given the difficulty of obtaining traditionally illicit drugs, consumption is turning towards less restricted products. We report the case of an 18-year-old man, who after inhaling xylazine (a non-narcotic sedative used in veterinary medicine for analgesia, hypnosis and muscle relaxation) presented with an episode of chills and dizziness followed by sweating, gait instability, palpitations and two episodes of syncope with bradycardia and hypotension. Ten cases of toxicity caused by xylazine consumption by oral and parenteral administration (intramuscular, subcutaneous, and intravenous) have been documented in humans. In these cases, consumption was either involuntary or for suicidal or homicidal purposes, or used as an agent of drug abuse, occasionally resulting in death. We present the second documented case of toxic effects of drug abuse with inhalated xylazine.

A reported case involving impaired driving following self-administration of xylazine

A case of suspected drug-impaired driving involving self-administration of xylazine (Xyla-Ject), a veterinary tranquilizing agent, and paroxetine is presented. Qualitative and quantitative analysis of xylazine and paroxetine were performed by gas chromatography with a flame-ionization detector (GC-FID) and gas chromatography/mass spectrometry (GC/MS). Whole blood xylazine and paroxetine concentrations were 0.57 and 0.02 microg/ml, respectively.

Volatile Substance and Other Drug Abuse Inhalation in Spain

OBJECTIVE

Inhalant misuse is the intentional inhalation of volatile substances in order to obtain euphoric, disinhibiting, and exciting effects. Solvents, glues, adhesives, paints, varnishes, paint removers, dry cleaning agents, spray paints, nail polish removers, typewriter correction fluids, and aerosol propellants are common sources of volatile substance abuse. In recent years the abuse of inhalant substances, not only among those who abuse other drugs but also in teenagers and younger children, has been reported. We reviewed retrospectively the cases of inhalant misuse reported to the Spanish Poison Control Center.

METHODS

Human intoxications from abuse of inhalant substances registered by our service from 1991 to 2000 were studied. Data analyzed were relative to age, gender, signs and symptoms, drug dependence antecedents, and severity of symptoms of the patients. The type of product and composition were also investigated.

RESULTS

During the study period 109 cases of patients aged from 8 to 50 years were collected. A percentage of 36.6% was less or equal to 20 years old. Seventy percent corresponded to males. Of the patients, 11% presented dependence antecedents to other abuse drugs and 72.5% were symptomatic. In the symptomatic exposures clinical features affected the following systems: CNS (62.8%), gastrointestinal (8.1%), cardiovascular (8.1%), respiratory (2.9%), peripheral nervous system (1.1%), renal (1.1%), haematological (1.1%), hepatic (1.7%), and other (13.1%). The commercial products more frequently inhaled were solvents (34.9%) and glues/adhesives (22.9%). We noted the use of medicines with ethyl chloride-local anaesthetic (8.3%), three cases with aerosol bronchodilator (with fluorocarbons as propellants), and one case of xylazine inhalation. The composition most often involved was aromatic hydrocarbons (46.9%), halogenated hydrocarbons (16.5%), aliphatic hydrocarbons (11.4%), ketones (10.1%), local anaesthetic (ethyl chloride) (8.4%), ethers (2.5%), nitrous oxides (2.5%), and aliphatic nitrites (1.7%). The calls received were 59.6% from health care units and 22% from general public. Only 14% of cases were at home and 48% had moderate to severe clinical effects. Acute intoxications occurred in 82% of cases.

CONCLUSIONS

Inhalation of volatile substance as abuse drugs has been detected in different age groups, including very young people. Although the principal source was industrial products, the use of drugs such as local anaesthetics and aerosol broncodilators was also detected. Based on epidemiological studies in the Spanish population (essentially adolescents and childhood) together with the ability of a Poison Center to detect sentinel-events, the community and authorities should develop strategies to prevent these exposures and the later use of other substances of abuse. In fact, recently a Law on Drug Dependences and Other Addictive Alterations has been approved in Madrid in order to take precautionary measures.

Severe intoxication from xylazine inhalation

We present the first documented case of overdose from xylazine inhalation. The patient developed findings consistent with alpha 2 adrenergic agonist toxicity, eg coma, miosis, apnea, bradycardia, hypothermia, and dry mouth 2 hours after exposure. Standard dose naloxone did not reverse these effects. The patient fully recovered after appropriate supportive measures. A review of prior reports of xylazine exposure is provided.

Parenteral exposure to detomidine and butorphanol

We report a case of intramuscular injection of detomidine and butorphanol in a 36 year-old-man who recovered without sequelae. Detomidine is an alpha 2 adrenergic agonist, similar to clonidine. Detomidine (Domosedan) and butorphanol (Stadol) are commonly used as preanesthetics and to produce chemical restraint, sedation and analgesia in animals, especially horses, but there are no published reports of human toxicity.