Enhance EMS Response to Overdose Emergencies: Xylazine & MOUD

Overdose emergencies, and fatalities from overdose, have risen drastically throughout the past 20 years. This growth could be attributed to several factors—mental health disorders or limited access to care—but a primary reason could be the rise in opioids mixed with xylazine.

The National Overdose Prevention Leadership Summit, developed in partnership with SUOPT Western States Opioid and Stimulant Summit and San Diego Imperial HIDTA, aimed to tackle some of the key challenges and share strategies for first responders to improve pre-hospital care for these types of emergencies.

Background & Challenges of Xylazine

Xylazine is an FDA-approved sedative and analgesic for veterinary use. Bayer developed it in 1962 and had been previously withdrawn from human trials. Xylazine in humans, specifically after xylazine poisoning, can lead to bradycardia, CNS/respiratory depression, hypothermia, and transient to persistent hypertension. It can also exacerbate the sedative and respiratory depressive effect of opioids.

In a presentation on the challenges of xylazine, speaker Paul Wax, MD, FACMT, Executive Director of the American College of Medical Toxicology, and Rachel Culbreth, Ph.D., MPH, Research Director of the Toxicology Investigators Consortium, explore the epidemiology of xylazine overdose and the primary obstacles to xylazine overdose treatment.

Some of the obstacles include the following:

• Difficulty differentiating between mixed opioids and xylazine may lead to naloxone only particularly reversing opioid and xylazine overdoses.
• Wound care can be challenging, especially because wounds have been reported in areas other than typical injection sites, and it may lead to delayed healing, surgical debridement, or even amputation.
• Xylazine may complicate withdrawal management from opioids.
• And there’s no reversal agent approved for humans.

Provider Obstacles

Outside of the complications of the opioid itself, providers and first responders face several obstacles to care.

In another session, Gerard Carroll, MD, FAAEM, FAEMS, EMT-P, Division Head of EMS and Disaster Medicine at Cooper University Healthcare, explored some of the challenges that come from his team’s work in Camden, NJ, where drug overdose rates are some of the highest in the state.

Cooper EMS administered naloxone to 1,279 patients in 2019 alone.

While EMS providers continue administering large amounts of naloxone nationwide, many providers face frequent refusals. And beyond that, this type of working environment can lead to frequent burnout.

Many of these patients also suffer from opioid use disorder, which is defined as a “physical and psychological reliance on opioids, a substance found in certain prescription pain medications and illegal drugs like heroin.” This type of dependency often requires advanced life support.

Evaluating Medication-Assisted Treatment

According to the study, “Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association with Mortality: A Cohort Study,” medications for opioid use disorder (MOUD) may be an effective strategy to prevent an overdose emergency.

The study looked at three types of MOUD: methadone maintenance treatment (MMT), buprenorphine, and naltrexone. According to the results, MMT and buprenorphine were associated with reduced all-cause and opioid-related mortality. MOUD use demonstrably cuts the risk of fatal overdoses by around 50% while also decreasing the prevalence of nonfatal overdoses, which are both traumatic and medically hazardous.

However, according to Dr. Carroll, suboxone may be a better alternative for medicated-assisted treatment.

Suboxone, a combination of buprenorphine and naloxone, is a long-lasting medication that acts on the same brain receptors as other opiates. It works by tightly binding to these receptors, preventing other opiates from attaching. This action reduces the effects of other opiates, eases cravings, and helps people with opioid use disorder return to a normal life.

While it’s difficult to know if suboxone can manage an overdose caused by a synthetic opioid such as xylazine, the presence of naloxone, may have a role in the future. However, more research is needed on suboxone and xylazine.

More Strategies to Consider

When encountering a patient who may be going through a xylazine overdose, it’s important to consider the following:

• Give naloxone immediately. This won't reverse Xylazine's effects directly, but it can help if opioids are also involved.
• Monitor the patient closely. Watch for signs like slow breathing, low heart rate, low blood pressure, low body temperature, unconsciousness, and skin lesions at injection sites.
• Consider using Xylazine test strips. These can help confirm the presence of Xylazine.

Medication such as tolazoline may be able to help reverse the effects of xylazine, but a reversal agent has been more approved. More research is needed on xylazine for that to happen. But for other opioids and patients with opioid use disorder, suboxone may provide an effective treatment option.