Management of Xylazine Withdrawal in a Hospitalized Patient: A Case Report

Ehrman-Dupre, Rachel; Kaigh, Caroline; Salzman, Matt; Haroz, Rachel; Peterson, Lars-Kristofer; Schmidt, Ryan

doi:10.1097/adm.0000000000000955

Cited by 43 publications

(57 citation statements)

References 11 publications

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“…Case studies included: Ehrman-Dupre et al [ 16 ], Stillwell et al [ 17 ], Elejalde et al [ 18 ], Liu CM et al [ 19 ], Deutsch SA et al [ 20 ], Andreson-Streicht et al [ 21 ], Mulders et al [ 22 ], Bayramoglu A et al [ 23 ], Spoerke et al [ 24 ], Carruthers et al [ 25 ], Samanta et al [ 26 ], Ganapathy et al [ 27 ], Shapses et al [ 28 ], Miller et al [ 29 ], Hoffman et al [ 30 ], Velez et al [ 31 ], Krongvorakul et al [ 32 ], Gallanosa et al [ 33 ], Capraro et al [ 34 ], Wolowich et al [ 35 ], Meyer et al [ 36 ], Poklis et al [ 37 ], Arican et al [ 38 ], Mccloskey et al [ 39 ], Snow et al [ 40 ], Choon et al [ 41 ], Ramon et al [ 42 ], Lewis et al [ 43 ], Haigh et al [ 44 ], Wong et al [ 45 ], Chavez et al [ 46 ], Barroso et al [ 47 ], Briellman et al [ 48 ], and Mittelman et al [ 49 ]. See Table 1 .…”

Section: Reviewmentioning

confidence: 99%

“…Though there are no established guidelines or protocols for treating Xylazine overdose, case studies have documented a variety of approaches. These include the administration of naloxone in the presence of co-occurring opioids, supportive care such as intubation and mechanical ventilation, and the use of medications like clonidine, tizanidine, dexmedetomidine, and others [ 16 , 72 , 73 ]. However, because Xylazine is often co-used with opioids, naloxone is typically administered as the first step in management [ 72 ].…”

Section: Reviewmentioning

confidence: 99%

See 1 more Smart Citation

Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications

Ayub¹,

Parnia²,

Poddar³

et al. 2023

Cureus

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Introduction and objectives: The opioid overdose epidemic is exacerbated by the emergence of Xylazine as an illicit drug adulterant. Xylazine, a veterinary sedative, can potentiate opioid effects while also causing toxic and potentially fatal side effects. This systematic review aims to assess the impact of Xylazine use and overdoses within the opioid epidemic context. Method: A systematic search was conducted following PRISMA guidelines to identify relevant case reports, and case series related to Xylazine use. A comprehensive literature search included databases like Web of Science, PubMed, Embase, and Google Scholar, utilizing keywords and Medical Subject Headings (MeSH) terms related to Xylazine. Thirty-four articles met the inclusion criteria for this review. Results: Intravenous (IV) administration was a common route for Xylazine use among various methods, including subcutaneous (SC), intramuscular (IM), and inhalation, with overall doses ranging from 40 mg to 4300 mg. The average dose in fatal cases was 1,200 mg, compared to 525 mg in non-fatal cases. Concurrent administration of other drugs, primarily opioids, occurred in 28 cases (47.5%). Intoxication was identified as a notable concern in 32 out of 34 studies, and treatments varied, with the majority experiencing positive outcomes. Withdrawal symptoms were documented in one case study, but the low number of cases with withdrawal symptoms may be attributed to factors such as a limited number of cases or individual variation. Naloxone was administered in eight cases (13.6%), and all patients recovered, although it should not be misconstrued as an antidote for Xylazine intoxication. Of the 59 cases, 21 (35.6%) resulted in fatal outcomes, with 17 involving Xylazine use in conjunction with other drugs. The IV route was a common factor in six out of the 21 fatal cases (28.6%). Conclusion: This review highlights the clinical challenges associated with Xylazine use and its co-administration with other substances, particularly opioids. Intoxication was identified as a major concern, and treatments varied across the studies, including supportive care, naloxone, and other medications. Further research is needed to explore the epidemiology and clinical implications of Xylazine use. Understanding the motivations and circumstances leading to Xylazine use, as well as its effects on users, is essential for developing effective psychosocial support and treatment interventions to address this public health crisis.

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Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications

Ayub¹,

Parnia²,

Poddar³

et al. 2023

Cureus

View full text Add to dashboard Cite

show abstract

“…Experts have recently proposed a role for short-acting opioids in the treatment of acute opioid withdrawal, an approach not listed in the guidelines studied here but that will rise in importance as fentanyl increasingly contaminates the opioid supply 31,32 . As other adulterants such as xylazine become common, the effectiveness of OAT for the resulting withdrawal syndrome will be further challenged 33,34 . In addition, drivers such as housing concerns, stigma from staff, and the restrictive hospital environment have been shown to contribute to PDD; none of these challenges are addressed by withdrawal management 11,15 …”

Section: Discussionmentioning

confidence: 99%

“…31,32 As other adulterants such as xylazine become common, the effectiveness of OAT for the resulting withdrawal syndrome will be further challenged. 33,34 In addition, drivers such as housing concerns, stigma from staff, and the restrictive hospital environment have been shown to contribute to PDD; none of these challenges are addressed by withdrawal management. 11,15 The observational study design limits the attempt to describe the impact of the intervention on outcomes.…”

Section: Discussionmentioning

confidence: 99%

Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management

et al. 2022

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Objectives: Rising rates of hospitalization for patients with opioid use disorder (OUD) result in high rates of patient-directed discharge (PDD, also called "discharge against medical advice") and 30-day readmissions. Interdisciplinary addiction consult services are an emerging criterion standard to improve care for these patients, but these services are resource-and expertise-intensive. A set of withdrawal guidelines was developed to guide generalists in caring for patients with opioid withdrawal at a hospital without an addiction consult service. Methods: Retrospective chart review was performed to determine PDD, 30-day readmission, and psychiatry consult rates for hospitalized patients with OUD during periods before (July 1, 2017, to March 31, 2018) and after (January 1, 2019, to July 31, 2019) the withdrawal guidelines were implemented. Information on the provision of opioid agonist therapy (OAT) was also obtained. Results: Use of OAT in patients with OUD increased significantly after guideline introduction, from 23.3% to 64.8% (P < 0.001). Patientdirected discharge did not change, remaining at 14% before and after. Thirty-day readmissions increased 12.4% to 15.7% (P = 0.05065). Receiving any OAT was associated with increased PDD and readmission, but only within the postintervention cohort. Conclusions: A guideline to facilitate generalist management of opioid withdrawal in hospitalized patients improved the process of care, increasing the use of OAT and decreasing workload on the psychiatry consult services. Although increased inpatient OAT has been previously shown to decrease PDD, in this study PDD and readmission rates did not improve. Guidelines may be insufficient to impact these outcomes.

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“…Non-opioid analgesic adjuvants, gabapentinoinds, and opioid withdrawal adjuvants such as clonidine, ondansetron, and loperamide were administered regularly. Benzodiazepines and antispasmodics were also administered to more than one-third of patients concurrently with short-acting opioids to manage opioid or xylazine withdrawal symptoms and anxiety [40].…”

Section: Intervention Detailsmentioning

confidence: 99%

Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder

Thakrar

Uritsky

Christopher

et al. 2023

Addict Sci Clin Pract

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Background Patients with opioid use disorder (OUD) frequently leave the hospital as patient directed discharges (PDDs) because of untreated withdrawal and pain. Short-acting opioids can complement methadone, buprenorphine, and non-opioid adjuvants for withdrawal and pain, however little evidence exists for this approach. We described the safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with OUD at an academic hospital in Philadelphia, PA. Methods From August 2021 to March 2022, a pharmacist guided implementation of a pilot sOAT protocol consisting of escalating doses of oxycodone or oral hydromorphone scheduled every four hours, intravenous hydromorphone as needed, and non-opioid adjuvants for withdrawal and pain. All patients were encouraged to start methadone or buprenorphine treatment for OUD. We abstracted data from the electronic health record into a secure platform. The primary outcome was safety: administration of naloxone, over-sedation, or a fall. Secondary outcomes were PDDs and respective length of stay (LOS), discharges on methadone or buprenorphine, and discharges with naloxone. We compared secondary outcomes to hospitalizations in the 12 months prior to the index hospitalization among the same cohort. Results Of the 23 cases, 13 (56.5%) were female, 19 (82.6%) were 40 years or younger, and 22 (95.7%) identified as White. Twenty-one (91.3%) regularly injected opioids and four (17.3%) were enrolled in methadone or buprenorphine prior to hospitalization. sOAT was administered at median doses of 200–320 morphine milligram equivalents per 24-h period. Naloxone administration was documented once in the operating room, over-sedation was documented once after unsanctioned opioid use, and there were no falls. The PDD rate was 44% with median LOS 5 days (compared to PDD rate 69% with median LOS 3 days for prior admissions), 65% of sOAT cases were discharged on buprenorphine or methadone (compared to 33% for prior admissions), and 65% of sOAT cases were discharged with naloxone (compared to 19% for prior admissions). Conclusions Pilot implementation of sOAT was safe. Compared to prior admissions in the same cohort, the PDD rate was lower, LOS for PDDs was longer, and more patients were discharged on buprenorphine or methadone and with naloxone, however efficacy for these secondary outcomes remains to be established.

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Management of Xylazine Withdrawal in a Hospitalized Patient: A Case Report

Cited by 43 publications

References 11 publications

Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications

Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications

Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management

Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder

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