Broad evidence of xylazine in the UK illicit drug market beyond heroin supplies: Triangulating from toxicology, drug-testing and law enforcement

BACKGROUND AND AIMS

Xylazine is a non-opioid sedative which has spread rapidly throughout the US illicit drug supply. This study aimed to describe the spread of xylazine throughout the UK illicit drug supply.

METHODS

Xylazine detections in human biological samples were collated from toxicology laboratories operating in the United Kingdom with the date, location, case type, xylazine concentration and co-detected drugs (with quantifications where performed) detailed, where permitted, by the corresponding coroner. Drug-testing cases positive for xylazine were collated from the Welsh Emerging Drugs and Identification of Novel Substances (WEDINOS) drug-testing postal service with the date, location, purchase intent and co-detected drugs detailed. Drug seizures made by UK law enforcement were communicated by the Office for Health Improvement and Disparities with the date and location detailed.

RESULTS

By the end of August 2023, xylazine was detected in 35 cases from throughout toxicology, drug-testing and drug seizure sources covering England, Scotland and Wales. There were no cases reported from Northern Ireland. Xylazine was detected in biological samples from 16 people. In most cases where full toxicology results were provided, xylazine was detected with heroin and/or a strong opioid (n = nine of 11), but this polydrug use pattern was not evident in all cases (n = two of 11), suggesting a wider circulation of xylazine in the UK illicit drug market beyond heroin supplies. Evidence from WEDINOS supports this claim, as all 14 drug samples (100%) submitted from across the UK contained xylazine; however, in none of these cases was heroin the purchase intent but rather counterfeit prescription medication tablets (n = 11 of 14), tetrahydrocannabinol (THC) vapes (n = two of 14) or white powder (n = one of 14). Additional evidence for the spread of illicit xylazine comes from five drug seizures made by law enforcement.

CONCLUSIONS

Xylazine has penetrated the UK illicit drug market and is not limited to heroin supplies.

Characteristics of deaths associated with kratom use

BACKGROUND

Kratom (Mitragyna speciosa Korth) use has increased in Western countries, with a rising number of associated deaths. There is growing debate about the involvement of kratom in these events.

AIMS

This study details the characteristics of such fatalities and provides a 'state-of-the-art' review.

METHODS

UK cases were identified from mortality registers by searching with the terms 'kratom', 'mitragynine', etc. Databases and online media were searched using these terms and 'death', 'fatal*', 'overdose', 'poisoning', etc. to identify additional cases; details were obtained from relevant officials. Case characteristics were extracted into an Excel spreadsheet, and analysed employing descriptive statistics and thematic analysis.

RESULTS

Typical case characteristics (n = 156): male (80%), mean age 32.3 years, White (100%), drug abuse history (95%); reasons for use included self-medication, recreation, relaxation, bodybuilding, and avoiding positive drug tests. Mitragynine alone was identified/implicated in 23% of cases. Poly substance use was common (87%), typically controlled/recreational drugs, therapeutic drugs, and alcohol. Death cause(s) included toxic effects of kratom ± other substances; underlying health issues.

CONCLUSIONS

These findings add substantially to the knowledge base on kratom-associated deaths; these need systematic, accurate recording. Kratom's safety profile remains only partially understood; toxic and fatal levels require quantification.

What's being used to spike your drink? Alleged spiked drink cases in inner city London

OBJECTIVES

To determine the incidence and character of drink spiking in an urban population of patients within the UK presenting to an emergency department concerned they had consumed a deliberately contaminated drink.

STUDY DESIGN

Prospective case series determining the presence and quantity of sedative and illicit drugs, and ethanol in biological samples (blood and urine) obtained from consenting patients >18 years of age presenting to a large inner city London emergency department alleging they had consumed a spiked drink within the previous 12 h.

RESULTS

Biological samples were obtained from 67 (blood) and 75 (urine) of 78 study participants. 82% of participants were female, mean age 24 years. Mean time from alleged exposure to biological sampling was 5.9 h (range 1-12 h). Ethanol was detected in 89.7% of participants. Mean serum ethanol concentration was 1.65 g/l (range 0.04-3.1 g/l); 60% of participants had a serum ethanol concentration associated with significant intoxication (>1.5 g/l). Illicit drugs were detected in 12 (15%) participants; 7 denied intentional exposure (3 methylenedioxymethamphetamine, 3 cannabis, 1 gamma-hydroxybutyrate). Medicinal drugs were detected in 13 participants; only 1 exposure was unexplained (benzodiazepine). Overall illicit or medicinal drugs of unexplained origin were detected in 8 (10%) participants. Unexplained sedative drug exposure was detected in only 2 (3%) participants.

CONCLUSIONS

Use of sedative drugs to spike drinks may not be as common as reported in the mainstream media. A large number of study participants had serum ethanol concentrations associated with significant intoxication; the source (personal over-consumption or deliberate drink spiking) is unclear.

Fatality after deliberate ingestion of sustained-release ibuprofen: a case report

INTRODUCTION

Ibuprofen is a nonsteroidal anti-inflammatory drug available over the counter and on prescription for the management of pain and inflammation. Severe toxicity is rare following deliberate self-poisoning with ibuprofen, and patients are usually either asymptomatic or develop only mild gastrointestinal toxicity. Although there have been nine other reported fatalities, co-existent factors have probably contributed to all of these deaths. We report here a fatality from isolated toxicity following self-poisoning with sustained-release ibuprofen.

CASE REPORT

A 26-year-old female presented after deliberate ingestion of up to 105 g sustained-release ibuprofen, with a reduced level of consciousness, severe metabolic acidosis and haemodynamic compromise. Despite intensive supportive management, gut decontamination with multidose activated charcoal and correction of the metabolic acidosis with sodium bicarbonate and haemofiltration, the patient did not survive. The ibuprofen concentration ante mortem on presentation in peripheral blood was 760 mg/l and the concentrations post mortem were 518 mg/l in peripheral blood, 74 mg/kg in liver extract and 116 mg/l in the gastric contents.

DISCUSSION

Most patients with ibuprofen poisoning are either asymptomatic or have mild gastrointestinal symptoms; severe poisoning with ibuprofen is rare. We report the first death related to isolated sustained-release ibuprofen poisoning.

Fatality after deliberate ingestion of the pesticide rotenone: a case report

Rotenone is a pesticide derived from the roots of plants from the Leguminosae family. Poisoning following deliberate ingestion of these plant roots has commonly been reported in Papua New Guinea. However, poisoning with commercially available rotenone in humans has been reported only once previously following accidental ingestion in a 3.5-year-old child. Therefore, the optimal management of rotenone poisoning is not known. After deliberate ingestion of up to 200 ml of a commercially available 0.8% rotenone solution, a 47-year-old female on regular metformin presented with a reduced level of consciousness, metabolic acidosis and respiratory compromise. Metformin was not detected in premortem blood samples obtained. Despite intensive supportive management, admission to an intensive care unit, and empirical use of N-acetylcysteine and antioxidant therapy, she did not survive. Poisoning with rotenone is uncommon but is potentially fatal because this agent inhibits the mitochondrial respiratory chain. In vitro cell studies have shown that rotenone-induced toxicity is reduced by the use of N-acetylcysteine, antioxidants and potassium channel openers. However, no animal studies have been reported that confirm these findings, and there are no previous reports of attempted use of these agents in patients with acute rotenone-induced toxicity.

A pharmacokinetic study of piroxicam in children

Feldene Melt (piroxicam) is commonly used for analgesia following day case surgery. The manufacturer's recommended paediatric dose is 0.4 mg.kg(-1) once daily. In children, plasma piroxicam levels of 3-5 microg.ml(-1) are associated with effective analgesia. However, in adults a single dose of 20 mg piroxicam (0.4 mg.kg(-1) for a 50-kg adult) produces plasma levels of only 1.5-2.2 microg.ml(-1). We therefore studied plasma levels achieved by 0.4 mg.kg(-1) or 1.0 mg.kg(-1) piroxicam in 22 children aged between 3 and 16 years, undergoing elective orthopaedic surgery, in order to investigate the adequacy of single dosing. The first 12 patients received 0.4 mg.kg(-1) Feldene Melt pre-operatively. Following assay of plasma piroxicam levels, a further 10 patients received 1.0 mg.kg(-1) Feldene Melt. In both groups, five blood samples were taken at 2-hourly intervals. The mean (95% CI) piroxicam level following 0.4 mg.kg(-1) was 2.90 (2.33-3.54) microg.ml(-1), compared to 5.87 (4.58-7.16) microg.ml(-1) following 1.0 mg.kg(-1) (p = 0.0003).

Acute poisoning with ibuprofen

1 Seventy five cases of ibuprofen overdose were recorded during a two year survey. 2 Details of the symptoms, treatment and the eventual outcome are known for 64% of the cases. The majority of the patients had no symptoms or only mild symptoms such as nausea or vomiting. 3 In the three cases where more serious symptoms were reported, the role of ibuprofen was not certain. 4 Laboratory analyses available for 13 cases demonstrate that plasma ibuprofen concentrations of up to 704 mg/l could be associated with no symptoms. 5 The data suggest that ibuprofen is of low toxicity in acute overdose and that therapy used should be supportive only.