PURPOSE: To raise awareness of xylazine risk among clinicians and providers serving people who use drugs.
SITUATION: Xylazine is a non-opioid veterinary sedative being detected in combination with fentanyl and other substances in a rising number of overdose deaths, particularly in the northeastern United States. Xylazine, sometimes called “tranq,” can be mixed with opioids to enhance their effect and is not reversed by naloxone. It may be taken by injection, ingestion, or inhalation (eg. smoking or snorting). In humans, xylazine is a quick acting central nervous system (CNS) depressant that causes sedation, amnesia, respiratory depression, bradycardia, and hypotension. Chronic xylazine use has also been associated with necrotic skin wounds. It is an alpha2-adrenergic agonist similar to clonidine and is not approved for human use.
The extent of xylazine use in Alameda County is not known. Testing for xylazine is performed by the County medical examiner for suspected overdose deaths but it has not yet been detected. However, xylazine has been detected along with fentanyl in five recent overdose deaths reported in San Francisco and Santa Clara County. The California Department of Public Health has posted information about xylazine for providers and the public.
ACTIONS REQUESTED OF CLINICIANS AND SERVICE PROVIDERS: Clinicians and providers should educate themselves and people who use drugs about the risks of xylazine use.
- Xylazine is a potentially harmful substance not approved for human use.
- Illicit drugs may be contaminated with xylazine.
- Using xylazine in combination with opioids can lead to life-threatening overdoses that may be difficult to reverse with naloxone; naloxone should still be administered for suspected overdose.
- Xylazine may cause poorly healing skin wounds.
Overdose: Xylazine-involved overdose can present similarly to other opioid overdoses, and naloxone should be administered for all suspected overdoses. Xylazine intoxication is not reversed by naloxone and may be present in situations where naloxone does not result in overdose reversal. Additional respiratory support may be required in such cases. Clinical drug screens are available that detect xylazine or xylazine metabolites, however, even when it is possible to test, the short half-life of xylazine (23-50 minutes) may make it hard to detect.
Withdrawal: Xylazine withdrawal is not well-characterized. Withdrawal may last weeks and may include anxiety, irritability, restlessness, dysphoria, and substantial hypertension. Treating opioid withdrawal may be more complicated in persons also withdrawing from xylazine. The following approaches are being used: replacement therapy with another alpha-2-adrenergic agonist, symptom management (for pain, insomnia, and anxiety) and treatment for opioid withdrawal and opioid use disorder.
Wounds: Chronic xylazine use has been linked to soft tissue wounds characterized by ulceration, necrosis and poor healing. Wounds may be located on the extremities and may or may not be at the site of injection. Wounds may occur even with inhalational use of xylazine. Wound care should involve cleaning with soap and water or saline, covering the wound with a non-adherent dressing, and managing pain. Alcohol and hydrogen peroxide should be avoided. Long-term management may include debridement and use of durable dressings. Antibiotics may be indicated, for example if there is associated purulence, cellulitis, or systemic signs of infection.
Harm Reduction/Safer Drug Use Messages:
- Avoid injecting into wounds.
- Go slow and use less.
- Test your product if you can.
- Snorting or smoking is safer than injecting.
- If using in a group, stagger your use so someone is always alert.
- Carry naloxone and know how to use it. Look out for each other.
- Ensure the airway is open, as breathing may be blocked in slumped positions.
- Avoid using alone. If you use alone, consider having someone check on you. Consider the following resources if you do use alone.
=The Brave App (download for free)
California Department of Public Health (CDPH) Xylazine Information
Food and Drug Administration Xylazine Warning
Drug Enforcement Agency Xylazine Intelligence Report
National Harm Reduction Coalition Xylazine One-Pager