2 weeks Ago By Kiley Koscinski
As lawmakers tighten restrictions on xylazine — a veterinary sedative rapidly spreading among street drugs — medical providers are still learning how best to treat its gruesome side effects, including flesh-rotting wounds. Xylazine has changed the treatment landscape for addiction medicine specialists who must contend with overdose symptoms that may not respond to established care practices. Now, a group of Pittsburgh doctors are sharing their experience with establishing a system-wide treatment protocol to help other providers as xylazine abuse emerges across the country.
“With a rising number of patients presenting with these complex issues, particularly in regions like Western Pennsylvania, there is an urgent need for standardized, evidence-based and trauma-informed approaches to care,” said Raagini Jawa, an addiction medicine and infectious disease physician at UPMC. Jawa also is co-author of the protocols published last week in the peer-reviewed Substance Use and Addiction Journal . Xylazine is primarily used as a tranquilizer in veterinary surgery but has been detected in Pittsburgh’s illegal drug supply for several years.
The sedative — also known as “tranq,” or “tranq dope” — has been mixed into heroin, cocaine and fentanyl to enhance the effects of those drugs. It’s also used to increase the street value of a drug by bulking up the weight, according to the Centers for Disease Control and Prevention. It’s been detected in nearly all 50 states, but Pennsylvania remains a hot spot.
Pittsburgh has seen a five-fold increase in the presence of xylazine among patients with substance use disorder between 2019 and 2021, according to toxicology screening data from UPMC. The adulterant was present in nearly one-third of overdose deaths last year in Allegheny County, according to preliminary data from the county health department. But limited research about the effects of xylazine on humans can leave some health care providers puzzled about how best to treat their patients.
Among the hallmark signs of xylazine use are the scaly, black skin ulcers that can emerge all over the body. The wounds can damage tissue so severely that the bone and tendon become exposed, or an amputation is necessary. Jawa said xylazine wounds are unlike typical injection-related skin wounds because they’re not the result of an infection, but from tissue death.
Still, the wounds can become infected with bacteria if improperly treated, further complicating the wound care required. But many front-line addiction care providers are not adequately trained to provide specialty care to heal xylazine ulcers. That means treatment plans can vary widely, and some patients might ultimately receive lower-quality care than others, according to Alice Bell, director of the overdose prevention at Prevention Point Pittsburgh.
“Depending on where people are going for medical care, there’s tremendous variation in the care that they get,” Bell said. “And if the physicians there are not familiar with the aspects of this particular drug, then they may really be treating the person improperly.” Bell said having a standardized protocol for treatment will lead to better care for people.
Jawa agreed, adding that a lack of consensus can also result in frustration among care providers trying to coordinate treatment. “When formalized protocols don't exist, people are left to either adopt practices that they're not familiar with or they're left on their own,” she said. Jawa has seen the effects of xylazine first-hand.
She said specialty providers treated xylazine-related complications in uncoordinated silos, which can lead to inconsistent care quality because, she said, “not all providers from all specialties get the same competencies and education for wound care.” She and two other internal medicine doctors formed a working group to get providers across the UPMC system on the same page. The resulting guidelines are designed to help clinicians recognize symptoms earlier, coordinate multidisciplinary treatment more effectively, and manage complex wounds.
Perhaps most importantly, Jawa said the protocols mean providers can manage xylazine withdrawal with greater confidence and discharge patients for follow-up visits with the right specialist. Xylazine has been reported to lengthen fentanyl’s euphoric effects, but the sedative can also lead to slowed breathing and heart rate as well as overdose. Opioid overdose-reversal drugs are ineffective against xylazine, but experts still recommend administering naloxone because xylazine overdoses almost always involve opioids and other drugs.
All xylazine-related deaths in Allegheny County last year also involved fentanyl. Experts stress that if an overdose victim does not respond to a naloxone dose, rescue breathing should be tried before rushing to administer more naloxone . The UPMC doctors hope other health systems can adapt the xylazine guidelines to best meet the needs of their patients.
The health system began internally coordinating its xylazine protocol seven months ago, and Jawa said anecdotal evidence shows better symptom control, reduced complications and smoother transitions to outpatient care. Researchers are still gathering data on how the guidelines have so far affected health outcomes. A UPMC statement calls the paper a “critical roadmap for other health systems nationwide, many of which are just beginning to encounter the widespread effects of xylazine in the opioid supply.
” Dr. Brent Rau, medical director of the emergency department at Allegheny General, said Allegheny Health Network is already operating under a similar coordinated care approach. He said he hopes more education about xylazine care can help rural hospitals faced with xylazine patients and far fewer resources to treat them.
“Some of that multidisciplinary approach might not be able to be performed at these smaller, more rural hospitals,” he said. “But knowing that those approaches exist at other sites might lead to quick identification at smaller hospitals,” that can then transfer the patient to a site with more resources. Jawa hopes UPMC’s multidisciplinary approach can be used to confront future adulterants that enter the drug supply.
Northeastern states, where xylazine first emerged in the United States, have already begun detecting medetomidine, another potent veterinary sedative. Providers on the frontlines of addiction treatment are beginning to see medetomidine mixed with xylazine in fentanyl supplies. According to Prevention Point, street drugs have always been mixed with other substances.
But in the earlier years of the opioid epidemic, there would be three or four adulterants; now the supply could include 10 or 12. “The drug supply is changing so rapidly that cutting-edge research is often not even published by the time we need to actually take care of our patients,” Bell said. The guidelines, “give us a mechanism to address the next wave of the changing drug supply and sets a precedent that we all have to be in this together.
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