Managing patients taking xylazine-adulterated opioids in emergency, hospital, and addiction care settings.

In response to the rapid escalation in the detection of xylazine in the unregulated drug supply, in April 2023, the White House designated fentanyl contaminated with xylazine an “emerging threat.” The National Institute on Drug Abuse (NIDA) Center for the Clinical Trials Network (CCTN) convened health care professionals and federal partners to review current practices in xylazine-related testing, treatment, and wound care to inform evolving best-practices in the field. This convening focused on the most critical areas of concern with the goal of rapidly identifying current practices and a xylazine-opioid research agenda.

Session 1: Pharmacology and Clinical Manifestations of Withdrawal and Overdose

Presenters focus on current knowledge of xylazine’s pharmacology, clinical outcomes of xylazine-exposed patients who present in the emergency department (ED), and the signs and symptoms of xylazine withdrawal—as well as their treatment.

• Xylazine Pharmacology – Joseph D’Orazio, M.D., Temple University School of Medicine and Giacomo Gianotti, D.V.M., D.V.Sc., DACVAA
• Xylazine Withdrawal, Opioid Withdrawal, and Medication Induction –
  Matthew Salzman, M.D.
• Opioid Overdoses Involving Xylazine in Emergency Department Patients: A Multicenter Study – Jennifer Love, M.D
• Manifestations of Xylazine and Fentanyl Withdrawal in a Hospital Cohort – Maggie Lowenstein, M.D., M.S.H.P., and Ashish Thakrar, M.D.Session 2: Xylazine WoundsLittle is understood about xylazine wounds (generally seen on the arms and legs) or satellite wounds (i.e., distinct injuries not at an injection site). Presenters describe how care is being provided for patients in the community—as individuals with open wounds are often turned away from inpatient drug treatment centers and shelters—and surgical management over the long term.
  • Hands On: Care Provided in the Community –
    Stephanie Klipp, R.N., CARN, CAAP, CRS
  • Surgical: Managing Complex Wounds Long-Term – Lisa Rae, M.D.

  
  Session 3: Testing

  Commercial testing of the illicit drug supply has increased significantly, which raises many questions. Speakers discuss how patients view the usefulness of xylazine tests, a state-wide program that checks the illicit drug supply, and a research collaborative for drug testing with rapid sharing of results.

  • Patient Perspectives and Utility of Xylazine Test Strips – Megan K. Reed, Ph.D., M.P.H.
  • State-wide Drug Testing in Rhode Island: Xylazine –
    Rachel Wightman, M.D.
  • Xylazine Testing for Harm Reduction and Clinical Care –
    Edward R. Sisco, Ph.D.

  
  Roundtable Discussion and Wrap Up

  Drs. Perrone, Haroz, and Thakrar lead a discussion in which participants generate several high-priority research questions in the areas of (1) pharmacology and clinical manifestations of withdrawal and overdose, (2) xylazine wounds, and (3) testing. Aidan Hampson, Ph.D., describes NIDA’s Notice of Special Interest (NOSI), Xylazine: Understanding its Use and the Consequences (NOT-DA-24-009). The purpose of the NOSI is to encourage research on the prevalence and consequences of xylazine use, as well as its treatment—including overdose alone or in combination with other drugs.