Pain Management In Patients

Undergoing Tranq Dope Withdrawal:

Strategies And Challenges

INTRODUCTION

DISCUSSION

RESULTS

The fentanyl epidemic has coincided with the first documented cases

of recreational human xylazine, originally a veterinary anesthetic.

Xylazine is an alpha-two agonist sedative thought to have been used to

extend the duration of the effects. The addition of synthetic opioids

and xylazine to the non-medical opioid (“Tranq dope”) supply has been

spreading nationwide. There is a paucity of literature on the treatment

and outcomes of individuals treated for pain control while experiencing

fentanyl and/or xylazine withdrawal. This study aimed to describe a

cohort of individuals who received medications for pain control while

experiencing Tranq dope withdrawal in the ED.

Davis Cho DO, Yutong Li, Sebastian Roque MD, Jamus Mulholland MD, Kory London MD

Thomas Jefferson University Hospital

§ 270 patients received care between September 14, 2022 and

May 9, 2023 were included. 179 were male (66.30%), 91 were

female (33.70%), average age of 39.81.

§ 100% of patients who had urine toxicology screening were

positive for fentanyl.

§ Inclusion criteria: individuals who were treated for medical or

surgical disease, while experiencing Tranq dope withdrawal

§ Exclusion criteria: patients on outpatient MOUD or pregnant

§ Triplet Strategy Treatment Protocol:

1. Micro-induction buprenorphine

2. Full mu-opioid agonists (oxycodone, hydromorphone) and

adjunctive treatments.

3. Adjunctive medications include ketamine, neuroleptics

(droperidol, olanzapine), alpha agonists (tizanidine, guanfacine),

anticholinergics (diphenhydramine) and lactated ringer IVF

METHODS

• Patients receiving mild medication order set had their pain score

decrease, by an average of 18.47%.

• Patients receiving severe medication order set had their pain score

decrease, by an average of 16.41%.

• Patients receiving ketamine had their pain score decrease, by an

average of 17.97%.

• Recorded adverse effects were few and all resolved without

complication.

• Pain control in patients experience Tranq dope withdrawal is

complicated both by tolerance from large doses of synthetic opioids

consumed by patients as well as, potentially, the effects of the

alpha-agonist, xylazine.

• Potential treatment strategies include micro-induction

buprenorphine, full mu-agonist opioids, non-opioid analgesics,

ketamine, and other adjunctive medications.

• These strategies, alone or in combination, should be further

evaluated for managing concurrent pain and withdrawal symptoms.

References

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of Medicine. 2023.

2. Montero F, Bourgois P, Friedman J. Potency-Enhancing Synthetics in the Drug Overdose Epidemic: Xylazine

(“Tranq”), Fentanyl, Methamphetamine, and the Displacement of Heroin in Philadelphia and Tijuana. Journal of

Illicit Economies and Development. 2022;4(2).

3. Boyce T, Whitehill G, Anderson B. Management of Xylazine Withdrawal in a Patient Admitted to the Intensive

Care Unit With Carbon Monoxide Poisoning. In: C48. CASE REPORTS: TOXICOLOGY AND OTHER INVOLVING

MEDICATIONS. American Thoracic Society; 2023:A5204-A5204.

4. Lee EN, Lee JH. The effects of low-dose ketamine on acute pain in an emergency setting: a systematic review

and meta-analysis. PloS one. 2016;11(10):e0165461.

5. Jones JL, Mateus CF, Malcolm RJ, Brady KT, Back SE. Efficacy of ketamine in the treatment of substance use

disorders: a systematic review. Frontiers in psychiatry. 2018;9:277.

Table 1: Pain Score Table

Figure 1: Pain Score Graph