How to Treat Opioid Plus Xylazine Withdrawal

November 7, 2024

Written by Jason Lesnick

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This descriptive study discussed a protocol to treat a fentanyl and xylazine subtype of opiate use withdrawal using one of four pathways. Use of the pathway resulted in lower against medical advice (AMA) dispositions and Clinical Opiate Withdrawal Scale (COWS) scores.

Does treating tranq dope withdrawal make people more tranquil? 
This retrospective observational chart review study of 1284 patients who screened positive for opiate use disorder (OUD) from two Philadelphia hospitals between 9/1/22 and 5/5/23 evaluated AMA rates and COWS scores after an order set was implemented to treat opiate withdrawal. Of the 1284 screened, 270 encounters utilized the order set. A urine drug screen was sent in 214 of these and 100% were positive for fentanyl. The authors reference Philadelphia Department of Public Health data that found 98% of non-medical opioid samples in the area contain both fentanyl and xylazine. 

The authors implemented the below order sets:

Patients who screened positive for OUD when the pathway was used:

• left AMA at a rate of 3.9% compared to 10.7% if not.
• were admitted at a rate of 74.6% compared to 24.2% if not.
• had a median pretreatment COWS score 12 (IQR = 8:18); post-treatment 4 (IQR 2:7) (p <0.001).

How will this change my practice?
These authors expanded my options for treating this emerging clinical entity of fentanyl withdrawal with presumed xylazine co-exposure. I will begin asking my patients about xylazine/tranq dope as a possibility and consider using these pathways in patients who have likely exposure and don’t respond to initial treatment.

Editor’s note: We covered xylazine (Tranq) earlier on JF, and our readers made some important comments at that time. They noted most IV drug users they treated are not intentionally using xylazine and prefer it not be present, as it may cause disfiguring skin necrosis and makes withdrawal symptoms even worse. ~Clay Smith

Source 
Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine.Am J Emerg Med. 2024 Sep 4;85:130-139. doi: 10.1016/j.ajem.2024.08.036. Epub ahead of print. Erratum in: Am J Emerg Med. 2024 Oct 8:S0735-6757(24)00523-0. doi: 10.1016/j.ajem.2024.10.006. PMID: 39260041.