Rapid Action Drug Alerts and Response (RADAR) Alerts
Xylazine alert

The mechanism by which xylazine causes wound damage is not well understood. Xylazine can cause blood vessels to narrow and reduce the blood supply to the skin which can slow down healing of wounds and increase the chance of skin ulceration, infections and other complications.

People who inject drugs are at the highest risk of harm due to the direct toxic effect of xylazine on the skin, patterns of injection and toxicity of other substances which may be injected at the same time.

Wounds may appear as bruises, spots, blisters, ulcers and black lesions. They are most likely to occur at administration sites but can occur anywhere on the body, including the forearms and lower legs.

First aid should be carried out where necessary. Specific wound care interventions should be provided by trained staff.

The unregulated drug supply is increasingly toxic and unpredictable. Getting support and treatment reduces the risk of experiencing harm or dying from an overdose. Speak to your local drug service to get support. Click here to find a drug service in your area (external website).

High-risk settings are places where people may take more drugs than average, often at the same time and from shared batches. Places at higher risk include prisons, hostels, supported accommodation, nightlife venues, care homes and educational settings.

People living and working in these settings should:

• Ensure their setting is prepared and ready to respond to overdose situations.
• Be vigilant to opioid use and aware of the signs of an overdose. Encourage people to report overdose signs immediately. In an emergency, stay calm and call 999.
• If appropriate, ensure people have access to hand washing facilities and clean areas to take care of wounds to prevent infection. Offer convenient and discreet access to wound care supplies, such as simple, clean and adhesive dressings (like premierpore or mepore).
• Recognise that levels of consciousness may fluctuate for several hours while under the influence. Even if the person appears alert, this may be temporary. Stay with the person and monitor closely.
• Carry and promote naloxone. Ensure the setting has multiple naloxone kits available and trained people are able to respond. Check that kits have not expired and that they are easy to access.
• Provide regular refresher training on drug-related emergencies, including information on reducing the risk of injection-related injuries, wound care, overdose, basic life support and naloxone.

Where there are concerns about exposure to substances, staff should use appropriate personal protective equipment (PPE) and follow procedures.

• Services, and Alcohol and Drug Partnerships should share this alert with local partners who are likely to be in contact with people who take drugs.
• When asking patients about substance use, explain that the contents of drugs are changing and new substances like nitazenes (synthetic opioids) and xylazine are becoming more common.
• Be vigilant and proactive about asking people if they are injecting and recognise and respond proactively to high-risk injection patterns.
• Have staff members trained in assessing wounds and complications. ACT on wounds – ask, check and treat:
  • Ask: Start a conversation. Explain that xylazine can cause skin damage and infections and offer a safe space to discuss wounds and wound care.
  • Check: Look at sites or areas of concern. Be aware wounds can appear anywhere on the body, not just at injecting sites, and may present in people regardless of their route of administration.
  • Treat: Provide convenient and discreet access to wound care supplies, such as simple, clean and adhesive dressings (like premierpore or mepore). Wounds should be treated onsite wherever possible or referred to a specialist service for treatment.
• Discuss treatment options and harm reduction approaches, including the risk of mixing drugs and the importance of drug checking.
• Service staff can help people access the drug testing service WEDINOS. Staff should not handle substances but can facilitate service access by providing printed submission forms, stamped addressed envelopes and by sharing online results.
• Xylazine test strips can be used to show the presence of xylazine in a sample, but cannot provide information on safety, purity, quantity or other contaminants.
• Xylazine can cause memory impairment. Discuss ways to keep track of appointments such as sending reminders. Make a note of key points at appointments and recap these each time you meet.

Staff working in emergency services and healthcare should be vigilant for the presentation of xylazine toxicity, particularly when working with patients who have used opioids, are not responding to naloxone, have wounds, or have low heart rate and blood pressure.

Features may be indistinguishable from concomitant opioid toxicity. Look out for:

• decreased blood pressure
• decreased consciousness
• decreased mental activity
• decreased pulse
• decreased respiration
• decreased temperature
• increased blood glucose.

The most common clinical features of patients with multi-drug toxicity including xylazine, in the ASSIST emergency department project were reduced consciousness, low heart rate and small pupils.

Be aware that testing used by clinical services is varied and new substances may not be picked up by existing urine and saliva tests. Non-detection of a drug does not mean it is not present, and a person’s clinical history is also important to determine appropriate prescribing and psychosocial interventions.

Build links with your local drug services and liaison team and in all your contacts with patients, encourage them to access support and take-home naloxone.

1. The presence of xylazine as an adulterant in heroin, benzodiazepines, counterfeit pharmaceuticals and in THC vapes indicates widespread availability. Emergency care staff attending suspected incidents of drug intoxication and overdose should consider xylazine as part of their differential diagnosis.
2. Xylazine has largely been identified alongside other substances including heroin and new synthetic opioids, therefore carriage and administration of naloxone remain important harm reduction measures.
3. The potential for xylazine to be used as an adulterant increases the importance and need for drug checking and substance testing services, as well as routine testing within seizures.
4. The highest risk of harm is associated with injection. The risk of skin and wound infections is increased with poor hygiene. This emphasises the need for safe, clean injecting spaces, and a focus on reducing injecting-related injuries.
5. Scottish Government should consider how to support the scale up of wound care packages in primary care, secondary care, drug treatment and harm reduction or low threshold services as part of its urgent response to emergent substances.

• In the UK, the supply and importation of xylazine is controlled by the Psychoactive Substances Act 2016.
• In February 2024, the Advisory Council on the Misuse of Drugs (ACMD) recommended xylazine be added to class C of the Misuse of Drugs Act 1971.

• Xylazine information:
  • Use and harms of xylazine, medetomidine and detomidine – ACMD – gov.uk
  • Xylazine resources – Drug overdose – Centers for Disease Control, Injury Center
• For wound resources, visit SDF:
  • National wound care guide 
  • What workers need to know: wound advice – pocket guide 
  • E-learning – how are your sites?
• For help and support or information on drugs, visit NHS inform – drugs and drug use.
• To order naloxone, visit Scottish Families Affected by Alcohol & Drugs: Take-Home Naloxone.
• Drugs giving unexpected effects? Make a report to RADAR. Use our reporting form or email drugsradar@phs.scot