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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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Maitland AD, McGriff SA, Glatfelter GC, Schindler CW, Baumann MH. Reinforcing effects of fentanyl analogs found in illicit drug markets. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06641-6. [PMID: 38965085 DOI: 10.1007/s00213-024-06641-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
RATIONALE The potent synthetic opioid fentanyl, and its analogs, continue to drive opioid-related overdoses. Although the pharmacology of fentanyl is well characterized, there is little information about the reinforcing effects of clandestine fentanyl analogs (FAs). OBJECTIVES Here, we compared the effects of fentanyl and the FAs acetylfentanyl, butyrylfentanyl, and cyclopropylfentanyl on drug self-administration in male and female rats. These FAs feature chemical modifications at the carbonyl moiety of the fentanyl scaffold. METHODS Sprague-Dawley rats fitted with intravenous jugular catheters were placed in chambers containing two nose poke holes. Active nose poke responses resulted in drug delivery (0.2 mL) over 2 s on a fixed-ratio 1 schedule, followed by a 20 s timeout. Acquisition doses were 0.01 mg/kg/inj for fentanyl and cyclopropylfentanyl, and 0.03 mg/kg/inj for acetylfentanyl and butyrylfentanyl. After 10 days of acquisition, dose-effect testing was carried out, followed by 10 days of saline extinction. RESULTS Self-administration of fentanyl and FAs was acquired by both male and female rats, with no sex differences in acquisition rate. Fentanyl and FAs showed partial inverted-U dose-effect functions; cyclopropylfentanyl and fentanyl had similar potency, while acetylfentanyl and butyrylfentanyl were less potent. Maximal response rates were similar across drugs, with fentanyl and cyclopropylfentanyl showing maximum responding at 0.001 mg/kg/inj, acetylfentanyl at 0.01 mg/kg/inj, and butyrylfentanyl at 0.003 mg/kg/inj. No sex differences were detected for drug potency, efficacy, or rates of extinction. CONCLUSIONS Our work provides new evidence that FAs display significant abuse liability in male and female rats, which suggests the potential for compulsive use in humans.
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Affiliation(s)
- Alexander D Maitland
- Designer Drug Research Unit (DDRU), National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| | - Shelby A McGriff
- Designer Drug Research Unit (DDRU), National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| | - Grant C Glatfelter
- Designer Drug Research Unit (DDRU), National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| | - Charles W Schindler
- Designer Drug Research Unit (DDRU), National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| | - Michael H Baumann
- Designer Drug Research Unit (DDRU), National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA.
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Quincy Moore P, Ellis K, Simmer P, Waetjen M, Almirol E, Salisbury-Afshar E, Pho MT. Accessibility of Naloxone in Pharmacies Registered Under the Illinois Standing Order. West J Emerg Med 2024; 25:457-464. [PMID: 39028230 PMCID: PMC11254148 DOI: 10.5811/westjem.17979] [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: 03/16/2023] [Revised: 01/24/2023] [Accepted: 02/09/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction To expand access to naloxone, the state of Illinois implemented a standing order allowing registered pharmacies to dispense the drug without an individual prescription. To participate under the standing order, pharmacies were required to opt in through a formal registration process. In our study we aimed to evaluate the availability and price of naloxone at registered pharmacies. Methods This was a prospective, de-identified, cross-sectional telephone survey. Trained interviewers posed as potential customers and used a standardized script to determine the availability of naloxone between February-December, 2019. The primary outcome was defined as a pharmacy indicating it carried naloxone, currently had naloxone in stock, and was able to dispense it without an individual prescription. Results Of 948 registered pharmacies, 886 (93.5%) were successfully contacted. Of those, 792 (83.4%) carried naloxone, 659 (74.4%) had naloxone in stock, and 472 (53.3%) allowed purchase without a prescription. Naloxone nasal spray (86.4%) was the formulation most commonly stocked. Chain pharmacies were more likely to carry naloxone (adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 1.97-5.01, P < 0.01) and have naloxone in stock (aOR 2.72, 95% CI 1.76-4.20, P < 0.01), but no more likely to dispense it without a prescription. Pharmacies in higher population areas (aOR 0.99, 95% CI 0.99-0.99, P < 0.05) and rural areas adjacent to metropolitan areas (aOR 0.5, 95% CI 025-0.98, P < 0.05) were less likely to have naloxone available without a prescription. Associations of naloxone availability based on other urbanicity designations, overdose count, and overdose rate were not significant. Conclusion Among pharmacies in Illinois that formally registered to dispense naloxone without a prescription, the availability of naloxone remains limited. Additional interventions may be needed to maximize the potential impact of a statewide standing order.
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Affiliation(s)
- P. Quincy Moore
- Permanente Medical Group, Oakland, California
- Kaiser Permanente Oakland Medical Center, Department of Emergency Medicine, Oakland, California
| | - Kaitlin Ellis
- Brown University, Department of Obstetrics and Gynecology, Providence, Rhode Island
| | - Patricia Simmer
- University of Chicago, Department of Medicine, Chicago, Illinois
| | - Mweya Waetjen
- University of Chicago Pritzker, School of Medicine, Chicago, Illinois
| | - Ellen Almirol
- University of Chicago, Chicago Center for HIV Elimination, Chicago, Illinois
| | - Elizabeth Salisbury-Afshar
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Family Medicine and Community Health, Madison, Wisconsin
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Population Health Sciences, Madison, Wisconsin
| | - Mai T. Pho
- University of Chicago, Department of Medicine, Section of Infectious Diseases and Global Health, Chicago, Illinois
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Sugarman OK, Shah H, Whaley S, McCourt A, Saloner B, Bandara S. A content analysis of legal policy responses to xylazine in the illicit drug supply in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 129:104472. [PMID: 38852335 DOI: 10.1016/j.drugpo.2024.104472] [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: 03/08/2024] [Revised: 05/01/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Xylazine is a veterinary sedative that is quickly spreading in the U.S. illicit drug supply and is increasingly associated with fatal overdoses and severe wounds. In response, xylazine has been deemed an emerging public health threat and several policy initiatives have been introduced to combat its spread and negative broad health impact. We aimed to synthesize trends in all-time U.S. policy responses to xylazine in the drug supply. METHODS In April 2024, we systematically identified and categorized proposed and enacted policy initiatives that related to human xylazine consumption by searching LexisNexis and Thomas Reuters Westlaw legal databases. RESULTS Of 58 unique policy initiatives, most were introduced in 2023 (n = 37/58, 64 %) and concentrated in Northeastern states. Penalties for xylazine possession, often tied to state drug scheduling changes, were the most common provision (n = 34/58; 59 %) and Schedule III was the most frequently proposed scheduling level (n = 17/30; 57 %). Other provisions included proposals to enhance: test strip access (n = 11/58; 19 %), public awareness and education (n = 3/58; 5 %), xylazine-specific research (n = 4/58; 7 %), and surveillance (n = 8/58; 14 %). CONCLUSION U.S. state and federal policy responses to xylazine grew rapidly in 2023, were most concentrated in states affected most by xylazine, and scheduling was the most commonly proposed policy approach. Research measuring policy effects should be prioritized as policies are implemented.
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Affiliation(s)
- Olivia K Sugarman
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA.
| | - Hridika Shah
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA
| | - Sara Whaley
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA
| | - Alex McCourt
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA
| | - Sachini Bandara
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, Baltimore, MD, USA
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Park JN, Serafinski R, Ujeneza M, McKenzie M, Tardif J, Krotulski AJ, Badea A, Grossman ER, Green TC. Xylazine awareness, desire, use and exposure: Preliminary findings from the Rhode Island community-based drug checking cohort study. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 11:100247. [PMID: 38974777 PMCID: PMC11225690 DOI: 10.1016/j.dadr.2024.100247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/23/2024] [Accepted: 05/30/2024] [Indexed: 07/09/2024]
Abstract
Background Xylazine is an ⍺2 adrenergic receptor agonist and a veterinary sedative that can cause severe health complications yet interventions to detect and treat human exposure remain underdeveloped. Community-based drug checking services (DCS) involve the testing of small amounts of drugs to increase community knowledge of unregulated supplies and decrease harms. This study characterized xylazine awareness, desire, use and exposure among people who use drugs (PWUD) in Rhode Island, US. Methods We analyzed data from an ongoing PWUD cohort study. In 2023, 125 PWUD were enrolled and surveyed. Using point-of-care Fourier Transform infrared spectroscopy (FTIR-S), we tested a drug sample from each participant onsite and confirmed the results offsite at a laboratory. Results were conveyed in real-time, along with harm reduction education, referrals to resources and care. Results Virtually all participants (99.2 %) wanted to avoid xylazine exposure. Half (51.2 %) knew what xylazine was, and a quarter (26.1 %) suspected previous exposure. Xylazine exposure was primarily surmised through sedating (45.2 %) and ulcerative (29.0 %) effects. Only 8.8 % of participants submitted a sample that they expected to contain xylazine. Xylazine was detected in 14.5 % of samples using FTIR-S and in 21.4 % of samples using a dual laboratory approach of gas chromatography mass spectrometry (GC-MS) and liquid chromatography quadrupole-time-of-flight mass spectrometry (LC-QTOF-MS). Participants thought that these xylazine-positive samples were fentanyl (78.3 %), heroin (13.0 %), or Percocet® (8.7 %). Conclusion Implementing point-of-care DCS at harm reduction organizations could be useful in rapidly increasing xylazine awareness and engaging at-risk individuals in prevention, harm reduction, treatment, and rapid care for xylazine-related wounds.
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Affiliation(s)
- Ju Nyeong Park
- Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School, Brown University, Providence, RI, United States
| | | | - Merci Ujeneza
- Rhode Island Hospital, Providence, RI, United States
| | | | | | - Alex J. Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Horsham, PA, United States
| | - Adina Badea
- Rhode Island Hospital, Providence, RI, United States
| | | | - Traci C. Green
- Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School, Brown University, Providence, RI, United States
- Heller School for Social Policy and Management, Brandeis University, United States
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Zheng JX, Randall S, Grimsrud K, Bainbridge S, Tran NK. Not Carfentanil-A Case of Unexpected Xylazine Detection. J Appl Lab Med 2024; 9:629-634. [PMID: 38300830 DOI: 10.1093/jalm/jfad119] [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: 08/28/2023] [Accepted: 10/25/2023] [Indexed: 02/03/2024]
Abstract
Historically, xylazine has been utilized in veterinary medicine for decades as an anesthetic and analgesic sedative to facilitate safe handling, diagnostic testing, and surgical procedures in large animals. Currently, xylazine is an emerging threat to human health. It has been detected in the illicit drug supply chain, often as an adulterant. It has been more commonly added to illicit substances, most notably fentanyl, by drugmakers to enhance drug effect. End users are often unaware of its presence. This is alarming given the large number of xylazine-involved overdose deaths while laboratory detections are deficient and reversal agents are absent. Herein, we present the first documented case of xylazine identified via gas chromatography-tandem mass spectrometry at University of California Davis Health despite a peculiarly mild clinical presentation. We hope to increase awareness of this potentially fatal adulterant that is often missed in evaluation and engender further opportunities to study this ongoing issue.
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Affiliation(s)
- Jasper X Zheng
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Shelby Randall
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Kristin Grimsrud
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Scott Bainbridge
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
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Soderquist M, Delgado G, Abdelfattah H, Thoder J, Solarz M. Necrotic Upper-Extremity Infections in People Who Inject Drugs: A Case Series. J Hand Surg Am 2024; 49:459-464. [PMID: 37178065 DOI: 10.1016/j.jhsa.2023.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/15/2023] [Accepted: 04/05/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Our institution has noted an increase in severe upper-extremity infections within the last 2 years. These patients have required transhumeral amputation. This case series demonstrates some of the catastrophic outcomes of these infections in people who inject drugs, which has been postulated to be related to the addition of xylazine to injectable drugs in our community. METHODS The study included patients presenting with severe upper-extremity infections resulting from intravenous drug use and requiring upper-extremity amputation between January 1, 2020 and September 30, 2022 at a single, urban, level 1 trauma center. Patient information and clinical images were collected through retrospective chart review. RESULTS Eight patients were identified at our institution with extensive necrosis of the skin and soft tissues in the forearm and hand, resulting in exposure of the radius and ulna. None of these patients had viable motor function in the hand and presented with a lack of sensation. All underwent transhumeral amputations, including bilaterally in one case. CONCLUSIONS The patients in this case series self-reported injection of tranquilizer-containing drugs, and xylazine has been reported to be present in 91% of heroin and fentanyl samples in our community. Although more studies are needed to confirm that xylazine is the definitive cause of the extensive tissue necrosis seen in these patients, we have found the severity of these infections to be noteworthy, given the likely expansion of xylazine to drug samples beyond our region. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Melissa Soderquist
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA.
| | - Gabriel Delgado
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Hesham Abdelfattah
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
| | - Joseph Thoder
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
| | - Mark Solarz
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
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Sue KL, Hawk K. Clinical considerations for the management of xylazine overdoses and xylazine-related wounds. Addiction 2024; 119:606-608. [PMID: 37939387 DOI: 10.1111/add.16388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Kimberly L Sue
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Sociobehavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Kathryn Hawk
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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Galust H, Seltzer JA, Hardin JR, Friedman NA, Salamat J, Clark RF, Harmon J. Adulterants present in the San Diego county fentanyl supply: a laboratory analysis of seized law enforcement samples. BMC Public Health 2024; 24:923. [PMID: 38553721 PMCID: PMC10981322 DOI: 10.1186/s12889-024-18459-0] [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: 07/04/2023] [Accepted: 03/26/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND The opioid overdose crisis is one of the worst public health crises ever to face the US and emerging evidence suggests its effects are compounded by the presence of drug adulterants. Here we report our efforts to characterize the adulterants present within the local fentanyl supply of San Diego County, obtained from undifferentiated drug samples seized by local law enforcement over the calendar year 2021. METHODS Thirty-two participating local law enforcement agencies across San Diego submitted 4838 unknown individual illicit drug samples (total of 312 kg) to the San Diego County Sheriff's Department Regional Crime Laboratory for identification. RESULTS Qualitative analysis of these samples via FTIR and GC-MS identified methamphetamine (38.7%), fentanyl (20.8%), diacetylmorphine (heroin) (10.2%), codeine (5.8%) and alprazolam (4.3%) as the most common illicit substances and the presence of 52 unique adulterants. The most common adulterants included 4-methylaminoantipyrine (4-MAAP) (10.9%), mannitol (9%), acetaminophen (8.5%), methamphetamine (4.2%), diacetylmorphine (heroin) (3.6%), tramadol (1.9%), and xylazine (1.7%). Several additional pharmacologically active adulterants and contaminants of interest were also identified. CONCLUSION This analysis is vital for public health use and harm reduction efforts at the level of the individual consumer. Continued direct surveillance of the drug supply is necessary for the detection of potentially harmful adulterants that may pose serious threats to the public.
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Affiliation(s)
- Henrik Galust
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA.
- VA San Diego Healthcare System, San Diego, CA, USA.
- California Poison Control System, San Diego, CA, USA.
| | - Justin A Seltzer
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Jeremy R Hardin
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Nathan A Friedman
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Jeff Salamat
- San Diego County Sheriff's Crime Laboratory. John F. Duffy Administrative Center, 9621. Ridgehaven Ct, 92123, San Diego, CA, USA
| | - Richard F Clark
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Jennifer Harmon
- San Diego County Sheriff's Crime Laboratory. John F. Duffy Administrative Center, 9621. Ridgehaven Ct, 92123, San Diego, CA, USA
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German D, Genberg B, Sugarman O, Saloner B, Sawyer A, Glick JL, Gribbin M, Flynn C. Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore. Harm Reduct J 2024; 21:18. [PMID: 38254198 PMCID: PMC10804796 DOI: 10.1186/s12954-024-00940-z] [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: 10/18/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Addressing xylazine harms are now a critical harm reduction priority, but relatively little epidemiological information exists to determine prevalence, magnitude, and correlates of xylazine use or related outcomes. METHODS We conducted a rapid behavioral survey among people who inject drugs (n = 96) in Baltimore November-December 2022. Using a novel indicator of self-reported presumed xylazine effects, we examined prevalence and sociodemographic correlates of past year presumed xylazine effects and association with overdose and wound-related outcomes. Chi-square and descriptive statistics were used to examine bivariate associations overall and separately for those who reported xylazine by name and by reported fentanyl use frequency. RESULTS Almost two-thirds (61.5%) reported experiencing xylazine effects. There were no differences by socio-demographics, but xylazine effects were more commonly reported among those who reported injecting alone (66% vs 38%%, p < 0.007) and daily fentanyl use (47% vs 24% p < 0.003). Those reporting xylazine exposure was three times as likely to report overdose (32% vs 11%, p < 0.03) and twice as likely to have used naloxone (78% vs 46%, p < 0.003). They also more commonly reported knowing someone who died of an overdose (92% vs 76%, p < 0.09) and to report an abscess requiring medical attention (36% vs 19%, p < 0.80). These associations were higher among respondents who specifically named xylazine and those who used fentanyl more frequently, but fentanyl frequency did not fully explain the heightened associations with xylazine effects. CONCLUSIONS This study provides insight into the scope of xylazine exposure and associated health concerns among community-based PWID and suggests measures that may be instrumental for urgently needed research.
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Affiliation(s)
- Danielle German
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | - Becky Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Olivia Sugarman
- Department of Health, Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Brendon Saloner
- Department of Health, Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anne Sawyer
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Jennifer L Glick
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore, MD, 21205, USA
| | | | - Colin Flynn
- Maryland Department of Health, Baltimore, MD, USA
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Kiyatkin EA, Choi S. Brain oxygen responses induced by opioids: focus on heroin, fentanyl, and their adulterants. Front Psychiatry 2024; 15:1354722. [PMID: 38299188 PMCID: PMC10828032 DOI: 10.3389/fpsyt.2024.1354722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024] Open
Abstract
Opioids are important tools for pain management, but abuse can result in serious health complications. Of these complications, respiratory depression that leads to brain hypoxia is the most dangerous, resulting in coma and death. Although all opioids at large doses induce brain hypoxia, danger is magnified with synthetic opioids such as fentanyl and structurally similar analogs. These drugs are highly potent, act rapidly, and are often not effectively treated by naloxone, the standard of care for opioid-induced respiratory depression. The goal of this review paper is to present and discuss brain oxygen responses induced by opioids, focusing on heroin and fentanyl. In contrast to studying drug-induced changes in respiratory activity, we used chronically implanted oxygen sensors coupled with high-speed amperometry to directly evaluate physiological and drug-induced fluctuations in brain oxygen levels in awake, freely moving rats. First, we provide an overview of brain oxygen responses to physiological stimuli and discuss the mechanisms regulating oxygen entry into brain tissue. Next, we present data on brain oxygen responses induced by heroin and fentanyl and review underlying mechanisms. These data allowed us to compare the effects of these drugs on brain oxygen in terms of their potency, time-dependent response pattern, and potentially lethal effect at high doses. Then, we present the interactive effects of opioids during polysubstance use (alcohol, ketamine, xylazine) on brain oxygenation. Finally, we consider factors that affect the therapeutic potential of naloxone, focusing on dosage, timing of drug delivery, and contamination of opioids by other neuroactive drugs. The latter issue is considered chiefly with respect to xylazine, which strongly potentiates the hypoxic effects of heroin and fentanyl. Although this work was done in rats, the data are human relevant and will aid in addressing the alarming rise in lethality associated with opioid misuse.
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Affiliation(s)
- Eugene A. Kiyatkin
- Behavioral Neuroscience Branch, National Institute on Drug Abuse–Intramural Research Program, National Institutes of Health, DHHS, Baltimore, MD, United States
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Cano M, Daniulaityte R, Marsiglia F. Xylazine in Overdose Deaths and Forensic Drug Reports in US States, 2019-2022. JAMA Netw Open 2024; 7:e2350630. [PMID: 38180756 PMCID: PMC10770774 DOI: 10.1001/jamanetworkopen.2023.50630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/17/2023] [Indexed: 01/06/2024] Open
Abstract
Importance Xylazine is increasingly reported in street drugs and fatal overdoses in the US, yet state-level data are limited, hampering local public health responses. Objective To gather available state-level data on xylazine involvement in overdose deaths and in forensic drug reports. Design, Setting, and Participants This cross-sectional study was a secondary analysis of 2019 to 2022 data from the National Forensic Laboratory Information System (NFLIS), National Center for Health Statistics, and individual states' medical examiner or public health agency reports. Data were analyzed from August to October 2023. Exposure State. Main Outcomes and Measures Yearly xylazine-related overdose deaths per 100 000 residents; xylazine NFLIS drug reports, both per 100 000 residents and as a percentage of all NFLIS drug reports (from samples of drugs seized by law enforcement and analyzed by NFLIS-participating laboratories). Results A total of 63 state-years were included in analyses of mortality rates, while 204 state-years were included in analyses of NFLIS reports. According to the publicly available data compiled in this study, at least 43 states reported at least 1 xylazine-related overdose death from 2019 to 2022, yet yearly totals of xylazine-related deaths were available for only 21 states. Of states with data available, xylazine-involved overdose death rates were highest in Vermont (10.5 per 100 000 residents) and Connecticut (9.8 per 100 000 residents) in 2022. In 2019, 16 states had zero xylazine reports included in NFLIS reports; in 2022, only 2 states had zero xylazine reports and all but 3 states had recorded an increase in xylazine's representation in NFLIS reports. In 2022, xylazine represented 16.17% of all NFLIS reports in Delaware and between 5.95% and 7.00% of NFLIS reports in Connecticut, Maryland, District of Columbia, New Jersey, and Rhode Island, yet less than 1.0% of NFLIS reports in 35 different states. Conclusions and Relevance In this cross-sectional study of publicly available data on fatal overdoses and drugs analyzed by forensic laboratories, xylazine's reported presence in overdose deaths and forensic reports was concentrated in the eastern US yet extended across the country to encompass nearly all states. In spite of xylazine's geographic reach, yearly state-level numbers of xylazine-related overdose deaths were publicly available for less than half of all states.
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Affiliation(s)
- Manuel Cano
- School of Social Work, Arizona State University, Phoenix
| | | | - Flavio Marsiglia
- School of Social Work, Arizona State University, Phoenix
- Global Center for Applied Health Research, Arizona State University, Phoenix
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Hays HL, Spiller HA, DeRienz RT, Rine NI, Guo HT, Seidenfeld M, Michaels NL, Smith GA. Evaluation of the relationship of xylazine and fentanyl blood concentrations among fentanyl-associated fatalities. Clin Toxicol (Phila) 2024; 62:26-31. [PMID: 38353935 DOI: 10.1080/15563650.2024.2309326] [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: 06/22/2023] [Accepted: 01/18/2024] [Indexed: 03/01/2024]
Abstract
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.
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Affiliation(s)
- Hannah L Hays
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rebecca T DeRienz
- Franklin County Coroner's Office, Franklin County Forensic Science Center, Columbus, OH, USA
| | - Natalie I Rine
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Han-Tian Guo
- Franklin County Coroner's Office, Franklin County Forensic Science Center, Columbus, OH, USA
| | - Meagan Seidenfeld
- Department of Chemistry, University of South Florida, Tampa, FL, USA
| | - Nichole L Michaels
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Gary A Smith
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Mai T, Zhang Y, Zhao S. Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges. TOXICS 2023; 11:1012. [PMID: 38133413 PMCID: PMC10748319 DOI: 10.3390/toxics11121012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
Xylazine abuse is emerging globally, while the identification of xylazine lethal cases poses a great challenge in clinical and forensic practice. The non-specific symptoms delay the diagnosis and treatment of xylazine poisoning, the pathological changes and lethal concentration of xylazine in body fluid and organs of fatal xylazine poisoning cases are seldom reported and the other toxins detected in such cases complicate the role of xylazine in the cause of death. Therefore, we carefully reviewed related updated information on xylazine, summarized the knowledge from clinical and forensic perspectives and can thus provide a reference in such cases and throw light on further study in the field of xylazine poisoning.
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Affiliation(s)
- Tingting Mai
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
| | - Youyou Zhang
- Department of Geriatric Neurology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China;
| | - Shuquan Zhao
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
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15
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Sisco E, Nestadt DF, Bloom MB, Schneider KE, Elkasabany RA, Rouhani S, Sherman SG. Understanding sensitivity and cross-reactivity of xylazine lateral flow immunoassay test strips for drug checking applications. Drug Test Anal 2023. [PMID: 38043944 DOI: 10.1002/dta.3612] [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: 09/01/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023]
Abstract
The continued prevalence of xylazine in the illicit drug market has necessitated development of quick and simple methods for identification, including lateral flow immunoassays (also known as "test strips"), like those frequently used to detect fentanyl. This study explored the drug checking applicability of the first publicly available xylazine test strips (XTS) using four sub-studies: reproducibility (i.e., consistency of positive results in a highly-concentrated xylazine solution); limit of detection on a calibration curve of xylazine concentrations; cross-reactivity against 77 commonly encountered drugs, cutting agents, and other structurally similar compounds; and applicability for analyzing community-acquired samples-where 100 drug residue samples were analyzed using XTS, direct analysis in real time mass spectrometry (DART-MS), and gas chromatography tandem mass spectrometry (GC-MS/MS). XTS consistently detected xylazine at concentrations ≥2.5 μg/ml, and XTS results were reproducible. Sensitivity and specificity of XTS were calculated by comparing expected versus obtained results based on xylazine concentration of community-acquired samples measured by GC-MS/MS. XTS consistently detected xylazine in samples with concentration >2 μg/ml and yielded a sensitivity of 0.974, specificity of 1.00, and overall accuracy of 0.986. Cross-reactivity with lidocaine, a common cutting agent, and lack of XTS reactivity with other α2 -agonists found in the illicit drug supply highlight the need to offer consumers comprehensive drug checking services that identify a range of substances and better inform them about drug contents.
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Affiliation(s)
- Edward Sisco
- National Institute of Standards and Technology, Gaithersburg, Maryland, USA
| | - Danielle F Nestadt
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Madeline B Bloom
- Department of Forensic Sciences, George Washington University, Washington, DC, USA
| | - Kristin E Schneider
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rae A Elkasabany
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Saba Rouhani
- Department of Epidemiology, New York University School of Global Public Health, New York, New York, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Mumba MN, Tice J, Brown W. Xylazine: The Drug Taking the World By Storm: What You Need to Know. J Psychosoc Nurs Ment Health Serv 2023; 61:7-10. [PMID: 38051681 DOI: 10.3928/02793695-20231109-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Xylazine has taken the world by storm and proactive strategies are urgently needed to combat its negative impacts on population health. Xylazine is an unscheduled non-opioid indicated as a veterinary tranquilizer, also known as "Tranq." This drug is commonly used in combination with other drugs, such as heroin, fentanyl, and cocaine. Xylazine can be used orally, intranasally, sniffed, smoked, and injected, but is mostly used intravenously. Adverse effects of xylazine are secondary to central nervous system (CNS), cardiovascular, and respiratory function depression. When alpha-2-receptors in the cardiovascular and respiratory systems are stimulated, physiological effects include bradycardia, hypotension, and respiratory and CNS depression. There are currently no U.S. Food and Drug Administration-approved medications for the treatment of xylazine withdrawal or reversal of its overdose. Therefore, it is imperative that health care providers are trained to recognize these signs and symptoms and intervene proactively. [Journal of Psychosocial Nursing and Mental Health Services, 61(12), 7-10.].
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Vohra V, Stroh-Steiner GK, Jones P. Qualitative and quantitative characteristics of xylazine-associated deaths detected using a post-mortem toxicology testing program. Clin Toxicol (Phila) 2023; 61:1040-1046. [PMID: 38088581 DOI: 10.1080/15563650.2023.2288540] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/22/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION The United States drug overdose crisis continues to evolve. Xylazine has been increasingly identified as an adulterant in illicit opioid supplies. The incorporation of novel adulterants, like xylazine, into the illicit drug supply adds complexity to post-mortem toxicology testing, public health messaging, substance use mitigation, and the treatment of people who use drugs. METHODS We assessed trends, decedent characteristics, drug co-detection, and blood concentrations of xylazine-positive post-mortem cases in Michigan. We utilized a toxicology testing program capable of detecting several opioids and non-opioids in post-mortem blood samples within 72 hours. RESULTS A total of 279 deaths were xylazine-positive between October 2019 and June 2023, with 100 percent positive for fentanyl. Only 30 percent of xylazine-involved samples were positive for naloxone, while 21.2 percent of xylazine-negative and opioid-positive samples were positive for naloxone. The percentage of xylazine-positive deaths increased from 3.2 percent in 2021 to 4.7 percent in January-June 2023. A median of five total drug groups were present among xylazine-positive deaths. Post-mortem xylazine concentrations for 55 decedent blood samples ranged from 5.2 to 200 µg/L. DISCUSSION Our study demonstrated increases in xylazine detection among post-mortem cases. Our findings are consistent with national trends of increasing xylazine presence among drug-involved deaths. Our range of detected post-mortem xylazine blood concentrations was consistent with what has been reported in previous literature. Fentanyl was detected in 100 percent of xylazine-positive overdose deaths. Naloxone detection was relatively low, highlighting the continued importance of increasing naloxone access and distribution. Deaths associated with xylazine often involved multiple other drugs. Limited human clinical xylazine research precludes accurate interpretation and attribution of causality from these data. CONCLUSIONS Overdose-related deaths with xylazine detection are increasing in Michigan and across the United States. Further clinical and toxicological research can help contextualize the clinical significance of xylazine in opioid overdose, clarify epidemiologic and clinical research, and inform appropriate public health messaging.
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Affiliation(s)
- Varun Vohra
- Department of Emergency Medicine, Michigan Poison & Drug Information Center, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Prentiss Jones
- Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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18
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Dowd WN. The effect of untargeted naloxone distribution on opioid overdose outcomes. HEALTH ECONOMICS 2023; 32:2801-2818. [PMID: 37670413 DOI: 10.1002/hec.4755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/06/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Abstract
Opioid overdose has claimed the lives of over 340,000 Americans in the last decade. Over that same period, policymakers have taken steps to increase the availability of naloxone-an opioid antagonist used to rescue overdose victims-to people in the community. Previous studies, most of which have examined the effects of state laws designed to facilitate access to naloxone, have reached mixed conclusions about the effects of naloxone access on fatal and non-fatal overdoses. This paper exploits a unique policy experiment provided by two naloxone giveaways intended to increase naloxone possession among the general public in Pennsylvania to estimate the causal impact of naloxone distribution on fatal overdoses and opioid-related emergency department (ED) visits. Using a difference-in-differences design, I find evidence that opioid overdose deaths fell immediately following the first giveaway but increased following the second giveaway and discuss these apparently contradictory findings in the context of the changing composition of the opioid supply. I also find some evidence of a decline in opioid overdose-related ED visits following the giveaways. This study is the first to examine the effects of untargeted naloxone distribution and has implications for other novel, naloxone distribution efforts currently underway.
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Affiliation(s)
- William N Dowd
- Public Health Division, RTI International, Research Triangle Park, North Carolina, USA
- Division of Health Research, Lancaster University, Lancaster, UK
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19
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Hoffman RS. Closing the xylazine knowledge gap. Clin Toxicol (Phila) 2023; 61:1013-1016. [PMID: 38270058 DOI: 10.1080/15563650.2023.2294619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
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20
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Noonan G, Sethi R. Xylazine Use in Pregnancy: The Effects of the Fentanyl Adulterant Xylazine on Pregnant Patients and the Developing Fetus. Kans J Med 2023; 16:277-279. [PMID: 37954882 PMCID: PMC10635681 DOI: 10.17161/kjm.vol16.20624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/02/2023] [Indexed: 11/14/2023] Open
Abstract
Objective A literature review was completed to outline the effects of xylazine on the pregnant patient while raising awareness of the increasing prevalence of opioid use disorder in pregnancy and the increase in adulterants in non-prescribed controlled substances. Data Sources PubMed and Google Scholar were searched using the key words "xylazine, adulterant," "xylazine, humans," "xylazine, pregnancy," and "xylazine, placenta" to identify the studies evaluating xylazine's effects on humans and the pregnant patient. Study Selection Studies were included if they provided information on symptoms of xylazine exposure, the prevalence of xylazine in pregnant humans and the hemodynamic effects of xylazine on both human and animal pregnant populations. Animal studies were included given the limited data on xylazine in pregnant humans. Four studies were utilized for background data and five studies were included in the final review of the effects of xylazine on pregnancy. Results Studies involving humans show that xylazine toxicity can cause respiratory depression, bradycardia, and central nervous system depression. There is evidence of xylazine in human umbilical cord tissue, showing that the fetus is exposed to xylazine. Animal studies show decreased uterine blood flow, increased uterine vascular resistance, and decreased fetal growth in response to xylazine. Conclusions Due to the limited studies on the effects of xylazine on pregnant populations, providers rely on animal studies for knowledge on xylazine's effects throughout pregnancy. Animal studies suggest an increased risk of adverse effects during pregnancy in response to xylazine. Future studies should focus on the pregnancy outcomes in patients exposed to xylazine to create more robust recommendations for treatment and pregnancy surveillance.
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Affiliation(s)
- Grace Noonan
- University of Kansas School of Medicine, Kansas City, KS
| | - Roopa Sethi
- University of Kansas School of Medicine, Kansas City, KS
- Department of Psychiatry and Behavioral Sciences
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Quijano T, Crowell J, Eggert K, Clark K, Alexander M, Grau L, Heimer R. Xylazine in the drug supply: Emerging threats and lessons learned in areas with high levels of adulteration. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104154. [PMID: 37574646 DOI: 10.1016/j.drugpo.2023.104154] [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] [Received: 05/29/2023] [Revised: 07/22/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Xylazine, a sedative analgesic drug approved as an animal tranquilizer but not for human use, has become an adulterant in the illicit opioid marketplace in North America. Recently declared an emerging health threat in the U.S., the prevalence of xylazine in overdose deaths increased 5.5-fold between 2019 and 2021. More information is needed about the impact of xylazine on opioid users and harm reduction service providers. METHODS The impact of xylazine adulteration was triangulated through examination of (1) opioid overdose fatalities in Connecticut between 2017 and 2021 reported by the Office of the Chief Medical Examiner data, (2) a convenience survey of people in Connecticut who use drugs (PWUD) regarding their knowledge of and attitude about the local illicit drug supply, and (3) semi-structured interviews of harm reduction service providers in Connecticut and Philadelphia in response to prompts on the impacts of and responses to xylazine adulteration. RESULTS The presence of fentanyl or its analogues in fatal opioid overdoses was a statistically significant predictor of xylazine presence [OR = 25.0, 95%CI (10.7,81.1)] as was being Hispanic [OR = 1.36, 95%CI (1.03,1.77)]. A survey of people who used drugs revealed that 43% (n = 286) were concerned that the drug supply was always unpredictable. Three-quarters of respondents were aware of xylazine and two-thirds would use a xylazine test strip if one was available. Respondents who identified as White, Hispanic were most likely to be aware of xylazine, to have used a fentanyl test strip, and to be interested in a xylazine test strip. Respondents who injected drugs were 3.6-fold more likely than those who did not inject to endorse an interest in a xylazine test strip. Harm reduction service providers were cognizant of a range of problems surrounding the use and injection of xylazine. Although they reported implementing practices to better respond to xylazine harms, they recognized the absence of solutions to many of the problems encountered. CONCLUSION The prevalence of xylazine has expanded, especially in combination with fentanyl. Harm reduction education efforts with fidelity to best practices have emerged, but the harms persist and community prevention needs are largely unmet.
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Affiliation(s)
- Thomas Quijano
- Yale School of Public Health, New Haven, CT, United States.
| | - Jason Crowell
- Sex Workers and Allies Network, New Haven, CT, United States
| | - Kathryn Eggert
- APT Foundation, New Haven, CT, United States; Antioch University Graduate School of Leadership and Change, Yellow Springs, OH, United States
| | - Katie Clark
- Clark Health Education and Research Solutions, Branford, CT, United States
| | - Marcus Alexander
- Yale Institute for Network Science, New Haven, CT, United States
| | - Lauretta Grau
- Yale School of Public Health, New Haven, CT, United States
| | - Robert Heimer
- Yale School of Public Health, New Haven, CT, United States
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Zhu DT. Public health impact and harm reduction implications of xylazine-involved overdoses: a narrative review. Harm Reduct J 2023; 20:131. [PMID: 37700329 PMCID: PMC10498612 DOI: 10.1186/s12954-023-00867-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION Xylazine, an α2-adrenoceptor agonist sedative commonly used in veterinary medicine, is not approved for human use. Nevertheless, xylazine-involved overdose rates have surged in recent years, fueled by an increasingly toxic and synthetic illicit drug supply in North America. METHODS This narrative review assessed major epidemiological trends in xylazine-involved overdoses in North America, aiming to identify harm reduction priorities. A literature search was conducted using four bibliographic databases (PubMed, Scopus, Embase, and ScienceDirect) and three preprint servers (medRxiv, bioRxiv, and Europe PMC) on May 28, 2023, to capture articles related to combinations of keywords such as "xylazine", "opioid", and "harm reduction". RESULTS Xylazine emerged as an adulterant in Puerto Rico in 2001, likely diverted from veterinary supplies. By the mid-2010s, it began proliferating across unregulated US drug markets, often contemporaneously with illicitly manufactured fentanyl (IMF), displaying characteristics of a syndemic. Initially concentrated in Northeastern regions (e.g., Philadelphia, Connecticut, Maryland), xylazine-involved overdoses later extended to the Rust Belt, Southern, and Western regions of the USA in the late 2010s and early 2020s. During this time, xylazine-involved overdoses also surged in Canada, particularly in Western provinces (British Columbia and Alberta) and Ontario with established IMF-dominated unregulated drug markets. DISCUSSION Over the past two decades, xylazine-involved overdoses have been rapidly rising in North America and exhibit few signs of slowing down, representing a serious public health epidemic. Numerous factors may have contributed to this, including limited epidemiological surveillance and drug checking for xylazine and emerging novel adulterants; further, barriers to comprehensive, trauma-informed, non-stigmatizing treatment and social services have also exacerbated this issue. While several epidemiological and ethnographic studies have assessed these factors in the USA, limited evidence is available in Canada where xylazine emerged more recently. This underscores the need for additional research and harm reduction measures. CONCLUSION Harm reduction-informed public health guidelines and programs are urgently needed to promote a safer supply, strengthen the healthcare system capacity to prevent and respond to xylazine-involved overdoses, and address social and structural disparities in health outcomes.
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Affiliation(s)
- David T Zhu
- Medical Scientist Training Program, School of Medicine, Virginia Commonwealth University, 1201 E Marshall St, Richmond, VA, 23298, USA.
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Zibbell JE, Aldridge A, Grabenauer M, Heller D, Clarke SD, Pressley D, McDonald HS. Associations between opioid overdose deaths and drugs confiscated by law enforcement and submitted to crime laboratories for analysis, United States, 2014-2019: an observational study. LANCET REGIONAL HEALTH. AMERICAS 2023; 25:100569. [PMID: 37583649 PMCID: PMC10423896 DOI: 10.1016/j.lana.2023.100569] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
Background The overdose epidemic in the United States (US) continues to generate unprecedented levels of mortality. There is urgent need for a national data system capable of yielding high-quality, timely, and actionable information on existing and emerging drugs. Public health researchers have started using law enforcement forensic laboratory data to obtain surveillance information on illicit drugs. This study is the first to use drug reports from the entire US to examine correlations between a changing drug supply and increasing opioid-involved overdose deaths (OOD) on a national scale. Methods This study is observational and investigates associations between law enforcement drug reports and OOD for the US from 2014 to 2019. OOD data are from the Centers for Disease Control and Prevention's National Vital Statistics System restricted-use multiple cause of death files. The US Drug Enforcement Administration's National Forensic Laboratory Information System (NFLIS) contains forensic laboratory-tested drug exhibit information for the entire US (NFLIS-Drug). Counts of forensic laboratory reports and OOD were aggregated for each state by month, quarter, and year. A difference-in-differences framework was used to estimate contemporaneous and lagged associations. Findings Between 2014 and 2019 in the US, 249,522 OOD were reported, with the annual number nearly doubling from 28,723 to 50,179. OOD involving illicitly manufactured fentanyls (IMF) also increased substantially during this period, from 19.4% to 72.9%. In addition, 3,817,438 forensic laboratory reports in the US that were reported to NFLIS-Drug contained an opioid, stimulant, or benzodiazepine. Reports of fentanyl and fentanyl-related compounds (FFRC) had the strongest association with OOD. Each additional FFRC exhibit was associated with a 2.97% (95% CI: 1.7%, 4.1%) increase in OOD per 100,000 persons per quarter. Interpretation Adding to the emerging consensus, protracted growth in IMF supply was more strongly associated with OOD than all other illicit drugs reported to NFLIS-Drug over the study time period. Findings demonstrate NFLIS-Drug data usefulness for research that require proxy indicators for the illicit drugs supply. A concerted effort between public health and public safety to make NFLIS-Drug more timely could strengthen its utility as a national, public health, drug surveillance system. Funding Sangeetha Arctic Slope Mission Services, LLC, ASMS Contract No. ASM5-00017.
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Cano M, Daniulaitye R, Marsiglia F. Xylazine in Drug Seizure Reports and Overdose Deaths in the US, 2018-2022. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.24.23294567. [PMID: 37662345 PMCID: PMC10473811 DOI: 10.1101/2023.08.24.23294567] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Xylazine is increasingly reported in street drugs and fatal overdoses in the United States (US), often in combination with synthetic opioids, yet state-level xylazine data are limited, hampering local public health responses. The present study analyzed 2018-2022 state-level data from the National Forensic Laboratory Information System (xylazine-positive reports of seized drugs analyzed by forensic laboratories), the Centers for Disease Control and Prevention (population estimates, synthetic opioid overdose mortality rates), and individual states' medical examiner/public health agency reports (numbers of xylazine-involved overdose deaths). An ordinary least squares regression model predicted state-level synthetic opioid overdose mortality rates by xylazine seizure report rates, adjusting for US Census Region. In 2018, relatively low rates of xylazine seizure reports were observed, with 21 states reporting zero xylazine seizures. In 2022, only three states reported zero xylazine seizures, and the highest xylazine seizure report rates (per 100,000 residents) were observed in New Jersey (30.4), Rhode Island (22.7), Maryland (18.9), Virginia (15.5), New Hampshire (13.0), and Ohio (10.9). Data on 2019-2022 xylazine-involved overdose deaths were available for 21 states/DC (60 state-years), with the highest 2022 xylazine-involved overdose death rates (per 100,000 residents) in Vermont (10.5) and Connecticut (9.8). Finally, in 2021, at the state level, each additional reported xylazine seizure per 100,000 residents was associated with a 2% higher synthetic opioid overdose mortality rate (b=0.02, robust standard error=0.01; p=0.049). Overall, study results emphasize xylazine's increasing involvement in US law enforcement drug seizure reports and overdose deaths, primarily in the East, yet also extending across the country.
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Affiliation(s)
- Manuel Cano
- School of Social Work, Arizona State University, United States
| | | | - Flavio Marsiglia
- School of Social Work, Arizona State University, United States
- Global Center for Applied Health Research, Arizona State University, United States
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Holt AC, Schwope DM, Le K, Schrecker JP, Heltsley R. Widespread Distribution of Xylazine Detected Throughout the United States in Healthcare Patient Samples. J Addict Med 2023; 17:468-470. [PMID: 37579111 PMCID: PMC10417214 DOI: 10.1097/adm.0000000000001132] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/05/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Xylazine is a tranquilizer commonly added into the illicit drug supply and a likely contributor to overdoses because it does not respond to naloxone reversal. The objective of this study was to perform a retrospective data analysis on xylazine-positive samples collected from patients in various outpatient healthcare settings to illustrate geographic distribution and common copositive substances, which may also contribute to risk of adverse events. METHODS Samples for which providers ordered testing for xylazine were subjected to enzymatic hydrolysis, extracted, and analyzed using liquid chromatography-tandem mass spectrometry. Retrospective analysis was performed on xylazine-positive samples collected from April 2021 to March 2022, to include geographic location and copositive substances. RESULTS Xylazine was identified in 413 of 59,498 samples from adults aged 20-73 years and originated from 25 of the 39 states where xylazine testing was ordered. The most common routine substances detected with xylazine were fentanyl, buprenorphine, naloxone, cocaine, d -methamphetamine, and delta-9-tetrahydrocannabinol. The most common designer drugs detected included fentanyl analogs, isotonitazene, and designer benzodiazepines. CONCLUSIONS Xylazine is geographically spread throughout the United States, indicative of a wide incorporation into the illicit drug supply. These findings differ from previous studies in that these samples originated from healthcare providers in routine care settings, where other reports typically involve overdose deaths. This analysis illustrates that routine testing for xylazine in outpatient settings can afford providers the opportunity to educate individuals and adjust harm reduction measures to potentially mitigate overdose risk.
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Choi S, Irwin MR, Kiyatkin EA. Xylazine effects on opioid-induced brain hypoxia. Psychopharmacology (Berl) 2023; 240:1561-1571. [PMID: 37340247 PMCID: PMC10775769 DOI: 10.1007/s00213-023-06390-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/17/2023] [Indexed: 06/22/2023]
Abstract
RATIONALE Xylazine has emerged in recent years as an adulterant in an increasing number of opioid-positive overdose deaths in the United States. Although its exact role in opioid-induced overdose deaths is largely unknown, xylazine is known to depress vital functions and cause hypotension, bradycardia, hypothermia, and respiratory depression. OBJECTIVES In this study, we examined the brain-specific hypothermic and hypoxic effects of xylazine and its mixtures with fentanyl and heroin in freely moving rats. RESULTS In the temperature experiment, we found that intravenous xylazine at low, human-relevant doses (0.33, 1.0, 3.0 mg/kg) dose-dependently decreases locomotor activity and induces modest but prolonged brain and body hypothermia. In the electrochemical experiment, we found that xylazine at the same doses dose-dependently decreases nucleus accumbens oxygenation. In contrast to relatively weak and prolonged decreases induced by xylazine, intravenous fentanyl (20 μg/kg) and heroin (600 μg/kg) induce stronger biphasic brain oxygen responses, with the initial rapid and strong decrease, resulting from respiratory depression, followed by a slower, more prolonged increase reflecting a post-hypoxic compensatory phase, with fentanyl acting much quicker than heroin. The xylazine-fentanyl mixture eliminated the hyperoxic phase of oxygen response and prolonged brain hypoxia, suggesting xylazine-induced attenuation of the brain's compensatory mechanisms to counteract brain hypoxia. The xylazine-heroin mixture strongly potentiated the initial oxygen decrease, and the pattern lacked the hyperoxic portion of the biphasic oxygen response, suggesting more robust and prolonged brain hypoxia. CONCLUSIONS These findings suggest that xylazine exacerbates the life-threatening effects of opioids, proposing worsened brain hypoxia as the mechanism contributing to xylazine-positive opioid-overdose deaths.
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Affiliation(s)
- Shinbe Choi
- Behavioral Neuroscience Branch, National Institute On Drug Abuse Intramural Research Program, National Institutes of Health, DHHS, Baltimore, MD, 21224, USA
| | - Matthew R Irwin
- Behavioral Neuroscience Branch, National Institute On Drug Abuse Intramural Research Program, National Institutes of Health, DHHS, Baltimore, MD, 21224, USA
| | - Eugene A Kiyatkin
- Behavioral Neuroscience Branch, National Institute On Drug Abuse Intramural Research Program, National Institutes of Health, DHHS, Baltimore, MD, 21224, USA.
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Delcher C, Anthony N, Mir M. Xylazine-involved fatal overdoses and localized geographic clustering: Cook County, IL, 2019-2022. Drug Alcohol Depend 2023; 249:110833. [PMID: 37352735 DOI: 10.1016/j.drugalcdep.2023.110833] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/11/2023] [Accepted: 06/11/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Xylazine, a veterinary analgesic sedative, is circulating in the illicit drug markets of at least 23 states including Illinois. We conducted a geographic analysis to better identify the spatial distribution of xylazine-involved fatal overdoses in Cook County, IL. METHODS Cook County Medical Examiner Office's (CCMEO) publicly available data was used to identify xylazine-involved fatal overdoses from January 1, 2019, to June 30, 2022. Xylazine-positive (cases) to xylazine-negative groups with drug mixtures involving fentanyl, alcohol and stimulants (controls) were matched on age, race, sex, and year of death. Ripley's K-function was used to examine the likelihood of case clustering compared to controls with the Bernoulli spatial scan deployed to identify specific geographic clusters. RESULTS Almost all (94.4%) xylazine-positive overdoses contained fentanyl. Using coordinate-based matching, we found that approximately 3% of xylazine overdose incidents were co-located with other overdoses. Xylazine cases clustered to from 0 to 16.1 miles (max=10.6 miles). Results of the Bernoulli spatial scan varied by control group with two high-risk clusters found relative to alcohol and stimulants and a low-risk cluster relative to fentanyl. Differences in co-occurring drugs were found between xylazine and fentanyl groups like the absolute number of drugs (4.6v 3.4, p<0.0001) and fentanyl analog types. CONCLUSIONS Xylazine fatal overdose incident locations exhibited localized clustering relative to fentanyl overdoses but clusters were not precisely detected at these scales. Even so, our results, especially relative to repeat overdose micro "hot spots", offer insight on targeting harm reduction and other services at the neighborhood-level.
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Affiliation(s)
- Chris Delcher
- College of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky, United States; Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, United States.
| | - Nicholas Anthony
- College of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky, United States; Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, United States
| | - Mojde Mir
- Cook County Medical Examiner's Office, Chicago, IL, United States
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Wei J, Wachuku C, Berk-Krauss J, Steele KT, Rosenbach M, Messenger E. Severe cutaneous ulcerations secondary to xylazine (tranq): A case series. JAAD Case Rep 2023; 36:89-91. [PMID: 37274146 PMCID: PMC10232457 DOI: 10.1016/j.jdcr.2023.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Affiliation(s)
- Jenny Wei
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Juliana Berk-Krauss
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine T. Steele
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Messenger
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Stopka TJ, Larochelle MR, Li X, Bernson D, Li W, Ackerson LK, Bayly R, Dammann O, Bauer C. Opioid-related mortality: Dynamic temporal and spatial trends by drug type and demographic subpopulations, Massachusetts, 2005-2021. Drug Alcohol Depend 2023; 246:109836. [PMID: 36931131 PMCID: PMC10121848 DOI: 10.1016/j.drugalcdep.2023.109836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Fatal opioid-related overdoses (OOD) present significant public health challenges. Intuitive and replicable analytical approaches are needed to inform targeted public health responses. METHODS We obtained fatal OOD data for 2005-2021 from the Massachusetts Registry of Vital Records and Statistics. We conducted heatmap analyses to assess trends in fatal OOD rates per 100,000 residents, visualizing rates by death year and decedent age at one-year intervals, stratifying by race/ethnicity, sex, rurality, and involved substances. We calculated Getis-Ord Gi* statistics to identify spatial clusters of OOD rates. RESULTS Among 20,774 fatal OODs, rates were higher among males, and highly variable by race/ethnicity, age group, and rurality. While fatal OOD rates increased in urban before rural communities, rates were higher in rural communities by 2018-2019. Stimulant-related fatal OODs were elevated in 2020 and 2021. Fatal OOD rates involving fentanyl and stimulants increased precipitously and simultaneously in the non-Hispanic Black population in 2020 and 2021, with a bimodal age distribution peaking among those in their 40s and 60s. Elevated rates among 30-to-60 year old Hispanic residents were largely tied to synthetic opioids from 2015 to 2021. Spatial clusters were detected for prescription opioids, heroin, and stimulants in western Massachusetts. For synthetic opioids, hotspots became more ubiquitous across the state from 2016 to 2021, intensifying in southeastern Massachusetts. CONCLUSION Our novel approach uncovered new time varying and spatial patterns in fatal OOD rates not previously reported. Identified shifts in fatal OOD rates by sex, age, and race/ethnicity can inform location-specific field actions targeting subpopulations at disproportionally high risk.
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Affiliation(s)
- Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States.
| | - Marc R Larochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, United States
| | - Xiaona Li
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Dana Bernson
- Office of Population Health, Department of Public Health, Commonwealth of Massachusetts, Boston, MA, United States
| | - Wenjun Li
- Center for Health Statistics and Department of Public Health, University of Massachusetts Lowell, Lowell, MA, United States
| | - Leland K Ackerson
- Center for Health Statistics and Department of Public Health, University of Massachusetts Lowell, Lowell, MA, United States
| | - Ric Bayly
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States; Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Cici Bauer
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Sibbesen J, Abate MA, Dai Z, Smith GS, Lundstrom E, Kraner JC, Mock AR. Characteristics of xylazine-related deaths in West Virginia-Xylazine-related deaths. Am J Addict 2023; 32:309-313. [PMID: 36504413 PMCID: PMC10121736 DOI: 10.1111/ajad.13365] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/11/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The involvement of xylazine, a veterinary drug, in West Virginia (WV) human drug-related deaths was examined. METHODS WV drug deaths from 2019 (when xylazine was first identified) to mid-2021. Characteristics including toxicology findings were compared between xylazine and nonxylazine deaths. RESULTS Of 3292 drug deaths, 117 involved xylazine, and the proportions of deaths with it have increased (1% [2019] to 5% [mid-2021)]. Xylazine decedents had more cointoxicants, with fentanyl (98%) predominant followed by methamphetamine. Xylazine decedents had a significantly greater history of drug or alcohol misuse and hepatic disease. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE In one of the largest analyses of xylazine-involved deaths in a predominantly rural state, identification of xylazine was increasing with multiple cointoxicants (especially fentanyl), and was present in a few deaths with only one other substance involved. Health professionals should be aware of possible enhanced toxicity from xylazine ingestion especially since naloxone does not reverse xylazine's adverse effects.
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Affiliation(s)
- Julie Sibbesen
- Department of Clinical Pharmacy, School of Pharmacy, West Virginia University, West Virginia, Morgantown, USA
| | - Marie A Abate
- Department of Clinical Pharmacy, School of Pharmacy, West Virginia University, West Virginia, Morgantown, USA
| | - Zheng Dai
- Health Affairs Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Gordon S Smith
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, West Virginia, Morgantown, USA
| | - Eric Lundstrom
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, West Virginia, Morgantown, USA
| | - James C Kraner
- West Virginia Department of Health and Human Resources, West Virginia Office of the Chief Medical Examiner, Charleston, West Virginia, USA
| | - Allen R Mock
- West Virginia Department of Health and Human Resources, West Virginia Office of the Chief Medical Examiner, Charleston, West Virginia, USA
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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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Love JS, Levine M, Aldy K, Brent J, Krotulski AJ, Logan BK, Vargas-Torres C, Walton SE, Amaducci A, Calello D, Hendrickson R, Hughes A, Kurt A, Judge B, Pizon A, Schwarz E, Shulman J, Wiegan T, Wax P, Manini AF. Opioid overdoses involving xylazine in emergency department patients: a multicenter study. Clin Toxicol (Phila) 2023; 61:173-180. [PMID: 37014353 PMCID: PMC10074294 DOI: 10.1080/15563650.2022.2159427] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Illicit opioids, consisting largely of fentanyl, novel synthetic opioids, and adulterants, are the primary cause of drug overdose fatality in the United States. Xylazine, an alpha-2 adrenergic agonist and veterinary tranquilizer, is being increasingly detected among decedents following illicit opioid overdose. Clinical outcomes in non-fatal overdose involving xylazine are unexplored. Therefore, among emergency department patients with illicit opioid overdose, we evaluated clinical outcome differences for patients with and without xylazine exposures. METHODS This multicenter, prospective cohort study enrolled adult patients with opioid overdose who presented to one of nine United States emergency departments between 21 September 2020, and 17 August 2021. Patients with opioid overdose were screened and included if they tested positive for an illicit opioid (heroin, fentanyl, fentanyl analog, or novel synthetic opioid) or xylazine. Patient serum was analyzed via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect current illicit opioids, novel synthetic opioids, xylazine and adulterants. Overdose severity surrogate outcomes were: (a) cardiac arrest requiring cardiopulmonary resuscitation (primary); and (b) coma within 4 h of arrival (secondary). RESULTS Three hundred and twenty-one patients met inclusion criteria: 90 tested positive for xylazine and 231 were negative. The primary outcome occurred in 37 patients, and the secondary outcome occurred in 111 patients. Using multivariable regression analysis, patients positive for xylazine had significantly lower adjusted odds of cardiac arrest (adjusted OR 0.30, 95% CI 0.10-0.92) and coma (adjusted OR 0.52, 95% CI 0.29-0.94). CONCLUSIONS In this large multicenter cohort, cardiac arrest and coma in emergency department patients with illicit opioid overdose were significantly less severe in those testing positive for xylazine.
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Affiliation(s)
- Jennifer S Love
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Levine
- Department of Emergency Medicine, University of California, Los Angeles, CA, USA
| | - Kim Aldy
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation Willow Grove, Willow Grove, PA, USA
| | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation Willow Grove, Willow Grove, PA, USA
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara E Walton
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation Willow Grove, Willow Grove, PA, USA
| | | | - Diane Calello
- Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | | | | | - Anita Kurt
- Lehigh Valley Health Network, Bethlehem, PA, USA
| | | | - Anthony Pizon
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evan Schwarz
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Joshua Shulman
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy Wiegan
- University of Rochester Medical Center, Rochester, NY, USA
| | - Paul Wax
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Alex F Manini
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Spadaro A, Faude S, Perrone J, Thakrar AP, Lowenstein M, Delgado MK, Kilaru AS. Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series. J Am Coll Emerg Physicians Open 2023; 4:e12880. [PMID: 36704210 PMCID: PMC9871399 DOI: 10.1002/emp2.12880] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self-directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.
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Affiliation(s)
- Anthony Spadaro
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sophia Faude
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency MedicineGrossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Jeanmarie Perrone
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ashish P. Thakrar
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- National Clinician Scholars ProgramUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Margaret Lowenstein
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal MedicineDepartment of Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - M. Kit Delgado
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Austin S. Kilaru
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Rich KM, Solomon DA. Medical Complications of Injection Drug Use - Part I. NEJM EVIDENCE 2023; 2:EVIDra2200292. [PMID: 38320040 DOI: 10.1056/evidra2200292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Medical Complications of Injection Drug Use - Part IDuring the past 2 decades, the risk of death and the prevalence of hospitalizations in the United States have increased substantially among people who inject drugs, in large part because of the opioid epidemic. This article reviews the complications observed in people who inject drugs as well as strategies to reduce harm.
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Affiliation(s)
| | - Daniel A Solomon
- Harvard Medical School, Boston
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston
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Affiliation(s)
- David Love
- United States Drug Enforcement Administration, Special Testing and Research Laboratory, USA
| | - Nicole S. Jones
- RTI International, Applied Justice Research Division, Center for Forensic Sciences, 3040 E. Cornwallis Road, Research Triangle Park, NC, 22709-2194, USA,70113th Street, N.W., Suite 750, Washington, DC, 20005-3967, USA,Corresponding author. RTI International, Applied Justice Research Division, Center for Forensic Sciences, 3040 E. Cornwallis Road, Research Triangle Park, NC, 22709-2194, USA.
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Deutsch SA, De Jong AR. Xylazine Complicating Opioid Ingestions in Young Children. Pediatrics 2023; 151:190352. [PMID: 36550066 DOI: 10.1542/peds.2022-058684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 12/24/2022] Open
Abstract
The authors of this report present 3 cases of synthetic opioid intoxication complicated by the concomitant presence of the additive xylazine, a nonopioid sedative analgesic and muscle relaxant used in veterinary medicine that potentiates respiratory depression associated with the opioid toxidrome. Three exposed children presented with severe signs and symptoms, 2 of whom experienced cardiac arrest, a need for continuous naloxone infusion or multiple naloxone doses, or mechanical ventilation to treat respiratory failure after their exposures. Additives were detected in urine studies only through the performance of specialized toxicology testing. Detection of xylazine among adult overdose deaths has recently increased sharply, particularly across the northeastern United States. Adulteration by xylazine is an emerging public health threat nationally. Our report reveals that pediatricians should be aware of sentinel drug trends among adults, including the emerging types of illicit, synthetic, or counterfeit formulations of recreational substances, because children may be harmed because of accidental or intentional exposure. Children exposed to dangerous substances also need child protection services that may entail safe relocation outside of the home and the referral of affected caregivers to necessary substance use treatment services. Given epidemic drug use among adults, pediatricians should be competent to recognize common toxidromes and be aware that signs and symptoms may be potentiated by synergistic novel additives or polysubstance exposures. Importantly, standard urine drug screens may not detect synthetic opioid derivatives or contributing additives, so that diagnosis will require specialized toxicology testing.
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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)
- Kari M. Midthun
- NMS Labs, Horsham, PA, United States
- Correspondence: Kari M. Midthun
| | | | | | - 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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Rising abuse of veterinary drugs. Nursing 2022; 52:34-37. [PMID: 36259903 DOI: 10.1097/01.nurse.0000872420.88590.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT There has been a significant increase in veterinary drugs found on toxicology screens and postmortem analyses, especially in the Northeast region of the US. This article details the effects and treatment of two common culprits: xylazine and tiletamine-zolazepam.
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Macmadu A, Yolken A, Frueh L, Toussaint JR, Newman R, Jacka BP, Collins AB, Marshall BDL. Characteristics of events in which police responded to overdoses: an examination of incident reports in Rhode Island. Harm Reduct J 2022; 19:116. [PMID: 36258209 PMCID: PMC9578237 DOI: 10.1186/s12954-022-00698-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Narrow or non-existent Good Samaritan Law protections and harsh drug selling statutes in the USA have been shown to deter bystanders from seeking medical assistance for overdoses. Additionally, little is known about the actions that police take when responding to overdose events. The objectives of this study were to assess the prevalence and correlates of naloxone administration by police, as well as to examine overdose events where arrests were made and those in which the person who overdosed was described as combative. Methods We analyzed incident reports of police responding to an overdose between September 1, 2019, and August 31, 2020 (i.e., 6 months prior to and during the COVID-19 pandemic), from a city in Rhode Island. We examined characteristics of incidents, as well as individual characteristics of the person who overdosed. Correlates of police naloxone administration were assessed using Wilcoxon rank sum tests and Fisher’s exact tests, and we examined incidents where arrests occurred and incidents in which the person who overdosed was described as combative descriptively. Results Among the 211 incidents in which police responded to an overdose during the study period, we found that police administered naloxone in approximately 10% of incidents. In most incidents, police were the last group of first responders to arrive on scene (59%), and most often, naloxone was administered by others (65%). Police were significantly more likely to administer naloxone when they were the first professionals to arrive, when naloxone had not been administered by others, and when the overdose occurred in public or in a vehicle. Arrests at overdose events were rarely reported (1%), and people who overdosed were rarely (1%) documented in incident reports as being ‘combative.’ Conclusions Considering these findings, ideally, all jurisdictions should have sufficient first responder staffing and resources to ensure a rapid response to overdose events, with police rarely or never dispatched to respond to overdoses. However, until this ideal can be achieved, any available responders should be dispatched concurrently, with police instructed to resume patrol once other professional responders arrive on scene; additionally, warrant searches of persons on scene should be prohibited. Supplementary Information The online version contains supplementary material available at 10.1186/s12954-022-00698-2.
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Affiliation(s)
- Alexandria Macmadu
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA
| | | | - Lisa Frueh
- Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA
| | - Jai'el R Toussaint
- Department of Africana Studies, Brown University Churchill House, 155 Angell Street, Providence, RI, USA
| | - Roxxanne Newman
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA
| | - Brendan P Jacka
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA
| | - Alexandra B Collins
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA.
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Alexander RS, Canver BR, Sue KL, Morford KL. Xylazine and Overdoses: Trends, Concerns, and Recommendations. Am J Public Health 2022; 112:1212-1216. [PMID: 35830662 PMCID: PMC9342814 DOI: 10.2105/ajph.2022.306881] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/04/2022]
Abstract
Xylazine is a nonopioid veterinary anesthetic and sedative that is increasingly detected in the illicit drug supply in the United States. Data indicate a striking prevalence of xylazine among opioid-involved overdose deaths. The emergence of xylazine in the illicit drug supply poses many unknowns and potential risks for people who use drugs. The public health system needs to respond by increasing testing to determine the prevalence of xylazine, identifying its potential toxicity at various exposure levels, and taking mitigating action to prevent harms. Currently, there is little testing capable of identifying xylazine in drug supplies, which limits the possibility of public health intervention, implementation of harm reduction strategies, or development of novel treatment strategies. (Am J Public Health. 2022;112(8):1212-1216. https://doi.org/10.2105/AJPH.2022.306881).
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Affiliation(s)
- Ryan S Alexander
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
| | - Bethany R Canver
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
| | - Kimberly L Sue
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
| | - Kenneth L Morford
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
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Gelpí-Acosta C, Cano M, Hagan H. Racial and ethnic data justice: The urgency of surveillance data disaggregation. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100082. [PMID: 36712292 PMCID: PMC9881686 DOI: 10.1016/j.dadr.2022.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Disease and overdose surveillance across industrialized countries, including the United States (US), have historically relied upon racial and ethnic classifications such as Non-Hispanic Black, White, Asian and Hispanic/Latinx to characterize the populations it describes. These categories underestimate significant HIV, hepatitis C (HCV) and drug overdose variance within these groups, by both place of birth and ethnicity. For socioeconomically disadvantaged people of color in the US, frontline workers (i.e., harm reduction outreach workers, case managers, etc.) are a medullar entry point to the HIV, HCV, and drug misuse care continuums. Racial/ethnic data aggregates fail to characterize vulnerable groups in ways that can increase these workers’ efficacy. HIV, HCV, and overdose data disaggregation is urgent to end HIV and to control HCV and drug overdoses more effectively, and to also move closer to an anti-racist epidemiology.
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Affiliation(s)
- Camila Gelpí-Acosta
- LaGuardia Community College, City University of New York, USA,Corresponding author.
| | - Manuel Cano
- School of Social Work, Arizona State University, USA
| | - Holly Hagan
- School of Global Public Health, Center for Drug Use and HIV/HCV Research, NYU, 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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Chhabra N, Mir M, Hua MJ, Berg S, Nowinski-Konchak J, Aks S, Arunkumar P, Hinami K. Notes From the Field: Xylazine-Related Deaths - Cook County, Illinois, 2017-2021. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:503-504. [PMID: 35358161 PMCID: PMC8979597 DOI: 10.15585/mmwr.mm7113a3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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