“Tranq-dope”: The first fatal intoxication due to xylazine-adulterated heroin in Italy

• Published in: Clinica chimica acta Vol. 561; p. 119826
• Main Authors: Di Trana, Annagiulia, Di Giorgi, Alessandro, Carlier, Jeremy, Serra, Francesco, Busardò, Francesco Paolo, Pichini, Simona
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 15.07.2024
• Subjects: Adult; Adulterant; Chromatography, Liquid; Drug Contamination; Fatal case; Fatal Outcome; Heroin - blood; Heroin - poisoning; Heroin - urine; Humans; Italy; Liquid chromatography-high-resolution mass spectrometry (LC-HRMS/MS); Male; Morphine Derivatives - blood; Morphine Derivatives - urine; Opioid; Tandem Mass Spectrometry; Tranq-dope; Xylazine; Italy; FDA; FullMS; Liquid chromatography-high-resolution mass spectrometry (LC-HRMS/MS); CNS; EDDP; EUDA; NPS; HRMS; EMA; EMCDDA; AGC; EWS; LOD; DEA; Adulterant; ddMS2; MP; OSAC; Xylazine; Opioid; Fatal case; Tranq-dope; IT; SNAP; LC-HRMS/LS; LOQ; NCE
• ISSN: 0009-8981; 1873-3492; 1873-3492
• DOI: 10.1016/j.cca.2024.119826

•“Tranq-dope”, xylazine-adulterated opioids, has caused many overdose deaths in the US.•Xylazine and opioids act in synergy, increasing the lethality of one another.•We report the first fatal case of xylazine-adulterated heroin in the EU.•Xylazine and its main metabolite were detected in blood and urine by LC-HRMS/MS.•Xylazine should be strictly controlled by public health authorities and toxicologists. The number of xylazine-involved overdose deaths tremendously increased from 2019 onwards in the US. This is due to the “tranq-dope” trend consisting in mixing opioids with the sedative to reduce drug manufacturing costs and enhance their effects. In this study, we report the first fatality involving xylazine-adulterated heroin in the EU. The subject was a 33-year-old Caucasian male with a documented history of drug abuse who was found dead in a public area with puncture marks at the elbow. Peripheral blood and urine were collected at the autopsy and analyzed by liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) after protein precipitation. 6-Monoacetylmorphine, total/free morphine, and codeine blood concentrations of 20.3, 236/105, and 38.3 ng/mL, respectively, indicated recent heroin consumption. Methadone blood concentration was below 10 ng/mL. Alprazolam, nordiazepam, and flurazepam blood concentrations were 23.9, 61.4, and 55.0 ng/mL, respectively. Benzoylecgonine blood concentration was below 5 ng/mL. Xylazine blood and urine concentrations were 105 and 72.6 ng/mL, respectively. The combination of central nervous system depressants, i.e., opioids, benzodiazepines, and xylazine, was the principal cause of death by cardiorespiratory failure. The case was promptly reported to the UE Early Warning System on drugs.