Rapid Action Drug Alerts and Response (RADAR) Alert: Xylazine

Public health alert: Xylazine – newly detected drug

This resource has been produced as part of RADAR, Scotland’s drugs early warning system.

Printable summaries of this alert

Summary

Xylazine is a non-opioid tranquiliser used in veterinary medicine as a sedative, muscle relaxant and painkiller. It has been detected in overdoses and deaths in Scotland.

People who take drugs may not be aware of the potential presence of xylazine in the supply. It is most likely to be consumed unintentionally and is usually found as an adulterant in brown powders sold as heroin.

In the UK, it has also been detected in the wider drug supply, including in counterfeit opioid painkillers (codeine and tramadol) and in liquids sold as tetrahydrocannabinol (THC) vapes.

Xylazine is a central nervous system depressant. It reduces breathing, heart rate and blood pressure. Other adverse effects include: sudden collapse, unconsciousness, drowsiness, confusion, loss of coordination, memory loss and nausea.

Xylazine use is associated with the development of severe wounds and skin damage, regardless of how it is administered. The highest risk of wound damage is seen among people who inject drugs. Wounds can appear as spots, blisters or open sores anywhere on the body, and may need medical attention.

As with other new synthetic drugs, the harms associated with xylazine should be considered in the context of polysubstance use (mixing drugs), where the risk of adverse effects is significantly increased.

Xylazine

Wound care

The mechanism by which xylazine causes wound damage is not well understood. Xylazine can cause blood vessels to narrow and reduce the blood supply to the skin which can slow down healing of wounds and increase the chance of skin ulceration, infections and other complications.

People who inject drugs are at the highest risk of harm due to the direct toxic effect of xylazine on the skin, patterns of injection and toxicity of other substances which may be injected at the same time.

Wounds may appear as bruises, spots, blisters, ulcers and black lesions. They are most likely to occur at administration sites but can occur anywhere on the body, including the forearms and lower legs.

First aid should be carried out where necessary. Specific wound care interventions should be provided by trained staff.

Recognising and responding to an overdose

Information for people who take drugs and community members

The unregulated drug supply is increasingly toxic and unpredictable. Getting support and treatment reduces the risk of experiencing harm or dying from an overdose. Speak to your local drug service to get support.

Find a drug service in your area.

Follow harm reduction practices

Actions for high-risk settings

High-risk settings are places where people may take more drugs than average, often at the same time and from shared batches. Places at higher risk include prisons, hostels, supported accommodation, nightlife venues, care homes and educational settings.

People living and working in these settings should:

• Ensure their setting is prepared and ready to respond to overdose situations.
• Be vigilant to opioid use and aware of the signs of an overdose. Encourage people to report overdose signs immediately. In an emergency, stay calm and call 999.
• If appropriate, ensure people have access to hand washing facilities and clean areas to take care of wounds to prevent infection. Offer convenient and discreet access to wound care supplies, such as simple, clean and adhesive dressings (like premierpore or mepore).
• Recognise that levels of consciousness may fluctuate for several hours while under the influence. Even if the person appears alert, this may be temporary. Stay with the person and monitor closely.
• Carry and promote naloxone. Ensure the setting has multiple naloxone kits available and trained people are able to respond. Check that kits have not expired and that they are easy to access.
• Provide regular refresher training on drug-related emergencies, including information on reducing the risk of injection-related injuries, wound care, overdose, basic life support and naloxone.

Where there are concerns about exposure to substances, staff should use appropriate personal protective equipment (PPE) and follow procedures.

Actions for drug and alcohol service staff

• Services, and Alcohol and Drug Partnerships should share this alert with local partners who are likely to be in contact with people who take drugs.
• When asking patients about substance use, explain that the contents of drugs are changing and new substances like nitazenes (synthetic opioids) and xylazine are becoming more common.
• Be vigilant and proactive about asking people if they are injecting and recognise and respond proactively to high-risk injection patterns.
• Have staff members trained in assessing wounds and complications. ACT on wounds – ask, check and treat:
  • Ask: Start a conversation. Explain that xylazine can cause skin damage and infections and offer a safe space to discuss wounds and wound care.
  • Check: Look at sites or areas of concern. Be aware wounds can appear anywhere on the body, not just at injecting sites, and may present in people regardless of their route of administration.
  • Treat: Provide convenient and discreet access to wound care supplies, such as simple, clean and adhesive dressings (like premierpore or mepore). Wounds should be treated onsite wherever possible or referred to a specialist service for treatment.
• Discuss treatment options and harm reduction approaches, including the risk of mixing drugs and the importance of drug checking.
• Service staff can help people access the drug testing service WEDINOS. Staff should not handle substances but can facilitate service access by providing printed submission forms, stamped addressed envelopes and by sharing online results.
• Xylazine test strips can be used to show the presence of xylazine in a sample, but cannot provide information on safety, purity, quantity or other contaminants.
• Xylazine can cause memory impairment. Discuss ways to keep track of appointments such as sending reminders. Make a note of key points at appointments and recap these each time you meet.

Actions for emergency service, clinical and healthcare staff

Staff working in emergency services and healthcare should be vigilant for the presentation of xylazine toxicity, particularly when working with patients who have used opioids, are not responding to naloxone, have wounds, or have low heart rate and blood pressure.

Features may be indistinguishable from concomitant opioid toxicity.

Look out for decreased:

• blood pressure
• consciousness
• mental activity
• pulse
• respiration
• temperature
• blood glucose

The most common clinical features of patients with multi-drug toxicity including xylazine, in the ASSIST emergency department project were reduced consciousness, low heart rate and small pupils.

Be aware that testing used by clinical services is varied and new substances may not be picked up by existing urine and saliva tests. Non-detection of a drug does not mean it is not present, and a person’s clinical history is also important to determine appropriate prescribing and psychosocial interventions.

Build links with your local drug services and liaison team and in all your contacts with patients, encourage them to access support and take-home naloxone.

TOXBASE summary

• The most common features of alpha-2 receptor agonists include drowsiness, coma, bradycardia and hypotension, but signs may be indistinguishable from concomitant opioid toxicity.
• Xylazine may be associated with severe necrotic skin ulceration.
• Xylazine use is also associated with an acute withdrawal syndrome.
• The half-life in humans is around 5 hours. Sedation has been reported to last between 8 and 72 hours in overdose.

For further advice, medical professionals can use the UK National Poisons Information Service 24-hour telephone service on 0344 892 0111, or its online database, TOXBASE.

Recommendations

1. The presence of xylazine as an adulterant in heroin, benzodiazepines, counterfeit pharmaceuticals and in THC vapes indicates widespread availability. Emergency care staff attending suspected incidents of drug intoxication and overdose should consider xylazine as part of their differential diagnosis.
2. Xylazine has largely been identified alongside other substances including heroin and new synthetic opioids, therefore carriage and administration of naloxone remain important harm reduction measures.
3. The potential for xylazine to be used as an adulterant increases the importance and need for drug checking and substance testing services, as well as routine testing within seizures.
4. The highest risk of harm is associated with injection. The risk of skin and wound infections is increased with poor hygiene. This emphasises the need for safe, clean injecting spaces, and a focus on reducing injecting-related injuries.
5. Scottish Government should consider how to support the scale up of wound care packages in primary care, secondary care, drug treatment and harm reduction or low threshold services as part of its urgent response to emergent substances.