Episode 854: Tranq (xylazine) with Heroin

Contributor: Aaron Lessen, MD

Educational Pearls:

What is Tranq?

• Tranq is the street name for xylazine, a sedative drug typically used in veterinary medicine.

• Xylazine has recently emerged as a recreational drug, often mixed with heroin or fentanyl.

• The mechanism of action of xylazine is similar to dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist.

• At toxic levels, either by itself or when combined with opioids, can cause apnea, bradycardia, coma, and hypotension.

How is it different from other adulterants, such as fentanyl?

• Because It is not an opioid, naloxone (Narcan) does not reverse its effects.

• It may cause local peripheral vasoconstriction leading to necrotic ulcerations at sites of repeated injection.

How do you treat a suspected overdose of Tranq +/- an opioid?

• Consult with a clinical toxicologist.

• Naloxone should still be used despite its limited effect. At the very least it will not make the situation worse.

• Be ready to intubate.

• Provide supportive care.

• Non-selective alpha antagonists are NOT recommended.

References

• Ruiz-Colón K, Chavez-Arias C, Díaz-Alcalá JE, Martínez MA. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int. 2014 Jul;240:1-8. doi: 10.1016/j.forsciint.2014.03.015. Epub 2014 Mar 26. PMID: 24769343.

• Ayub S, Parnia S, Poddar K, Bachu AK, Sullivan A, Khan AM, Ahmed S, Jain L. Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications. Cureus. 2023 Mar 29;15(3):e36864. doi: 10.7759/cureus.36864. PMID: 37009344; PMCID: PMC10063250.

• Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022 Aug 19;14(8):e28160. doi: 10.7759/cureus.28160. PMID: 36148197; PMCID: PMC9482722.

• United States Drug Enforcement Administration. DEA Reports Widespread Threat of Fentanyl Mixed with Xylazine | DEA.gov. (n.d.). https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII