As mentioned in prior pearls, xylazine (aka “Tranq”) is alpha-2 adrenergic agonist that has been used as an adulterant of various substances including cocaine, heroin and fentanyl.
Intoxication/Overdose
Usually unintentional: patient’s not knowing the presence of adulterant
Symptoms: CNS depression, bradycardia, hypotension, miosis, anticholinergic effects
Overdose Treatment
Naloxone ineffective against xylazine, but still recommended to use as most overdoses are combination of xylazine and opioid.
Several medications in veterinary medicine are available as alpha-adrenergic antagonists, but not approved for use in humans (atipamezole, tolazoline, yohimbine).
Treatment is largely supportive.
Withdrawal
Symptoms: Anxiety, Restlessness, Depressed mood, Body aches
Withdrawal Treatment (based on case studies):
Alpha-agonists (to decrease noradrenergic activity) including clonidine 0.1-0.3mg q6-8hr (monitor for hypotension), tizanidine 2-8mg q8hr, dexmedetomidine IV infusion in ICU
Benzodiazepines
Gabapentin/Pregabalin
Phenobarbital
Olanzapine
MOUD treatment/withdrawal management: MOUD (suboxone/methadone) + adjunctive medication (Ondansetron, Acetaminophen, NSAIDS, etc.)