Philadelphia hospitals test new ‘tranq dope’ withdrawal strategy

Unimaginable pain and restlessness. Vomiting so frequent and forceful that it can perforate the esophagus. Blood pressure and heart rate so high that they damage the heart. Sweat soaking clothes and sheets. Nervous sensitivity that makes even the gentlest touch distressing. A prolonged panic attack that is triggered and worsened by even mundane activities and conversations.

Withdrawal symptoms from “tranq dope” (the combination of the synthetic opioid fentanyl and the animal tranquilizer xylazine that dominates Philadelphia’s street opioid supply) are often far worse than those experienced even by users of heroin more serious than the past.

So it’s no wonder people do everything they can to prevent them. This includes leaving the hospital before your care is complete.

I am an Associate Professor of Emergency Medicine who has spent a decade as an Emergency Physician working in Center City and South Philadelphia. I have spent most of this time leading projects to improve care for people who use drugs.

Starting in 2022, our team, a group of emergency and addiction physicians, began experimenting with new approaches to treating tranq drug withdrawal.

We were able to more than halve the likelihood of these patients leaving the hospital before treatment was completed, from 10% to just under 4%.

We also reduced the severity of their suffering, reducing their withdrawal score, or how they rate pain and other symptoms, by more than half.

Traditional treatments don’t work

Before the tranq drug, treatment of opioid withdrawal in the emergency department was relatively straightforward, with well-studied conventional protocols.

For patients without chronic pain, health care providers started buprenorphine, known by its brand name Suboxone, when patients showed signs of withdrawal.

Buprenorphine works by partially, rather than fully, stimulating the body’s opioid receptors. This subtle difference eases withdrawal symptoms but reduces the risk of overdose if patients continue to use other opioids. Literally, it saves lives.

The tranq drug, however, creates a much larger set of challenges.

Fentanyl and other synthetic opioids are tens to hundreds of times more potent than heroin. Xylazine, on the other hand, adds sedative withdrawal symptoms to the mix: restlessness, adrenaline activation, and agitation.

As synthetic opioids became more prevalent in Philadelphia’s drug supply over the past decade, overdose deaths in the city tripled. These numbers are beginning to decline, for reasons that are not yet clear.

Meanwhile, tranq users began sharing buprenorphine horror stories. They refused the medication because of a phenomenon called “precipitated withdrawal.” Precipitated withdrawal is a condition in which taking buprenorphine paradoxically worsens withdrawal symptoms, rather than improving them. Because of the severity of their symptoms, some patients who precipitate severely even require treatment in the intensive care unit.

Furthermore, when patients accepted buprenorphine, their withdrawal symptoms were no longer effectively controlled, even at very high doses. We were adrift.

Patients request discharge

When people with severe substance use disorders are hospitalized, even compassionate staff members sometimes lose their patience.

Being confined to a stretcher in a noisy and chaotic environment, in withdrawal, with previous experiences of traumatic medical care, can lead patients to act out. They may ring the bell repeatedly, use inappropriate language, make impulsive decisions or sneak drugs into the hospital.

This creates a lot of stress for nurses and staff, and distracts from caring for others.

So when patients ask to leave before treatments are over, exhausted care teams are often quick to acquiesce. Traditionally, this was called discharge “against medical advice,” but is now called “patient-directed discharge.”

Patient-directed discharge is associated with higher rates of mortality, permanent disability, and rehospitalization.

Patient-directed discharge rates can be 10 to 50 times higher in people with an opioid use disorder compared to the general public.

A cycle of mistrust can also form, where the expectation that a patient may leave again leads to a less engaged care team, which in turn can increase the likelihood that patients will leave.

At staff meetings, some compared the challenges of caring for these people to those they experienced during the toughest parts of the COVID-19 pandemic.

A new approach is needed

Many doctors have been reluctant to consider other options for treating opioid withdrawal. I think there are two key reasons for this. One is the lack of Food and Drug Administration approval for alternative treatments. The other is that federal regulations consider addiction to be a behavioral rather than a medical condition, effectively separating most doctors from addiction care for these people.

As fentanyl and xylazine became ubiquitous as a street drug in Philadelphia, local hospitals reported astronomical rates of patient-directed discharge among these patients. This was despite the best efforts of hospital staff who are highly experienced in conventional opioid withdrawal treatment.

In 2021, an editorial al Annals of Internal Medicine The journal advocated the use of short-acting opioids for opioid withdrawal in some patients, which is already common practice in Canada. Short-acting opioids are medications that doctors traditionally use to treat acute pain.

Hospitals in Philadelphia began experimenting with the use of these previously detailed medications. This included our team at Jefferson Health.

Oxycodone, hydromorphone and ketamine

By using short-acting opioids such as oxycodone or hydromorphone, combined with a low-dose version of buprenorphine, we prevented precipitous withdrawal and treated opioid withdrawal and pain in our patients.

Low-dose bupenorphine can be increased over time to stable doses. This demonstrates to patients that the drug is safe and provides them with a bridge to long-term treatment.

Short-acting opioids replace the opioids your body is frantically seeking. They reduce pain and misery, and decrease when your symptoms are controlled.

Opioid use disorder patients will often do anything they can to stay out of the hospital for fear of withdrawal. Wondering how to manage withdrawal symptoms is therefore often their first priority when they are hospitalized. We see this even when they have conditions that require complicated and time-sensitive treatments.

Because of the large amounts of opioids that many of our patients use, we also give them additional strong medications, or “add-on therapies,” to complement the effects of short-acting opioids and low-dose buprenorphine. One is ketamine, an anesthetic that affects nerve impulses and is increasingly used to treat depression, post-traumatic stress disorder and substance use disorders.

Ketamine is also an effective pain medication that can extend the effects of opioids and reduce the number of doses needed.

In addition, we add muscle relaxants, which work similarly to xylazine, along with nausea medications and IV fluids, to help patients heal.

Side effects and future problems

In patients who received our drugs, the risks of serious side effects were minimal. The few patients who experienced serious adverse effects had other acute medical problems that may have contributed to the side effects. Almost all side effects we saw were mild and resolved on their own.

As powerful synthetic opioids and other pollutants spread to more U.S. cities, more emergency departments will have to figure out how to care for withdrawing patients so they don’t leave treatment.

We hope this work inspires others to do a better job of providing relief to patients suffering from this complicated and serious disease.

This article is republished from The Conversation under a Creative Commons license. Read the original article.