Episode 854: Tranq (xylazine) with Heroin

Jun 5, 2023

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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