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Published in final edited form as: Ann Emerg Med. 2024 Mar 16;84(1):20–28. doi: 10.1016/j.annemergmed.2024.01.041

National Institute on Drug Abuse Clinical Trials Network Meeting Report: Managing Patients Exposed to Xylazine-Adulterated Opioids in Emergency, Hospital and Addiction Care Settings

Jeanmarie Perrone 1, Rachel Haroz 2, Joseph D’Orazio 3, Giacomo Gianotti 4, Jennifer Love 5, Matthew Salzman 6, Margaret Lowenstein 7, Ashish Thakrar 8, Stephanie Klipp 9, Lisa Rae 10, Megan K Reed 11, Edward Sisco 12, Rachel Wightman 13, Lewis S Nelson 14
PMCID: PMC11513573  NIHMSID: NIHMS1978298  PMID: 38493376

Abstract

Used as a veterinary sedative and not approved for human use, xylazine has been increasingly linked with opioid overdose deaths in the United States. A growing number of people have been exposed to xylazine in the illicit opioid supply (especially fentanyl) or in other drugs, particularly in some areas of the Northeast. Xylazine is an α–2 adrenergic agonist that decreases sympathetic nervous system activity. When combined with fentanyl or heroin, it is purported to extend the duration of the opioid’s sedative effect and to cause dependence and an associated withdrawal syndrome; however, data to support these concerns are limited. Despite the escalating frequency of detection of xylazine in people with nonfatal and fatal opioid overdose, direct links to these outcomes have not been identified. Because the strongest causal link is to fentanyl coexposure, ventilatory support and naloxone remain the cornerstones of overdose management. Xylazine is also associated with severe tissue injury, including skin ulcers and tissue loss, but little is known about the underlying mechanisms. Nonetheless, strategies for prevention and treatment are emerging. The significance and clinical effects of xylazine as an adulterant is focused on 4 domains that merit further evaluation: fentanyl-xylazine overdose, xylazine dependence and withdrawal, xylazine-associated dermal manifestations, and xylazine surveillance and detection in clinical and nonclinical settings. This report reflects the Proceedings of the National Institute on Drug Abuse Center for the Clinical Trials Network convening of clinical and scientific experts, federal staff, and other stakeholders to describe emerging best practices for treating people exposed to xylazine-adulterated opioids. Participants identified scientific gaps and opportunities for research to inform clinical practice in emergency departments, hospitals, and addiction medicine settings.

INTRODUCTION

Xylazine, a veterinary sedative not approved by the United States Food and Drug Administration (FDA) for human use, has been increasingly linked with adulteration of unregulated opioids in the United States. Anecdotally, people who use fentanyl combined with xylazine describe more rapid-onset and deeper sedation than is typical from the opioid alone. Increasingly, epidemiologic studies demonstrate the growing prevalence of xylazine detection in street drug samples, in patients who use opioids, and in decedents in whom testing is performed.1,2

In April 2023, the White House designated fentanyl adulterated with xylazine an “emerging threat” in response to its increased detection in the illicit drug supply. This designation was quickly followed by a national response plan with detailed areas of focus.3,4 To plan the next steps to address xylazine adulteration, the National Institute on Drug Abuse (NIDA) Center for Clinical Trials Network (CCTN) convened a meeting, which included participants from other federal agencies, noting that collaboration will be crucial to advancing research. The significance and clinical effects of xylazine as an adulterant is evolving and focused on 4 domains that merit further evaluation: fentanyl-xylazine overdose, xylazine dependence and withdrawal, xylazine-associated dermal manifestations, and xylazine detection in clinical and nonclinical settings.

It is important to determine where sufficient information is available to develop best practices or guidelines and what areas are the highest priority for investigation and innovation. For example, what is the most effective approach to address the sedation that accompanies xylazine exposure and which may persist after naloxone administration? Despite concerns that xylazine is an empirical threat, there are indications that people who have been coexposed to fentanyl and xylazine have less serious morbidity (eg, reduced risk of cardiac arrest and coma within 4 hours) than those exposed to fentanyl alone. Additional knowledge is needed on the effects of repeated xylazine exposure on the development of physiological dependence and the existence of an objectively defined withdrawal syndrome. Furthermore, the clinical experience of those who care for xylazine-associated wounds are rapidly evolving to innovate more effective management strategies. Detailed approaches to research questions are outlined in the Appendix E1 (available at http://www.annemergmed.com).

Meeting Purpose

On June 14, 2023, the NIDA CCTN convened clinical and scientific experts, federal staff, and other stakeholders to discuss the emerging threat of xylazine and to describe emerging best practices for treating people exposed to xylazine-adulterated opioids. Participants also identified scientific gaps and opportunities for research to inform clinical practice in emergency departments (EDs), hospitals, and addiction medicine settings. The meeting focused on pressing clinical questions related to managing outcomes associated with the use of xylazine-adulterated opioids along with related evidence. Presenters were selected by a planning committee consisting of National Institutes of Health personnel (KH) and 2 emergency medicine and addiction medicine physicians (JP and RH) to represent clinicians with experience in caring for patients with xylazine exposures from within and external to the NIDA Clinical Trials Network. The draft agenda was revised using a consensus process to create the final agenda. Meeting attendees drew on their clinical experiences and emerging evidence to identify best practices and prioritize needs for clinical research and resource development.

FENTANYL-XYLAZINE OVERDOSE

Clinical Pharmacology

Xylazine stimulates presynaptic α–2 adrenergic receptors in the brain, triggering a negative feedback signal that reduces central catecholamine release. Clinically, this decreases sympathetic nervous system outflow and causes sedation as well as relative, and generally limited, hypotension and bradycardia.5,6 In large doses, xylazine initially causes peripheral vasoconstriction and occasionally transient hypertension given its effects on vascular α-adrenergic receptors.7

Although xylazine has no direct effect on respiratory drive, in certain animals, it may blunt the counterregulatory response to hypercarbia. Xylazine has pharmacological effects similar to imidazolines, such as clonidine, but its activity at α–2 receptors exceeds that at imidazoline receptors, resulting in clinical effects more similar to dexmedetomidine.8 In veterinary practice, intravenous xylazine produces rapid-onset sedation that lasts up to 2 hours.9 However, the human pharmacology of xylazine is poorly studied.

The clinical manifestations of isolated xylazine exposures are largely derived from case reports of intentional administration in self-harm attempts.5 Emerging data from preliminary studies of people coexposed to xylazine and opioids suggest that they do not differ significantly from those of individuals exposed to opioids alone.10,11 The contribution of the opioid to respiratory depression and death appears to be more consequential than that from xylazine.

A recent multicenter cohort study hypothesized that patients would have greater morbidity following combined opioid-xylazine overdose than opioids alone.6 However, after adjusting for relevant characteristics, patients with confirmed opioid-xylazine exposures had lower odds of cardiac arrest and coma within 4 hours than those with only opioids. The total dose of naloxone received did not differ between the 2 groups and the mortality was also low for both. The reason for the apparent lesser severe clinical outcomes is unclear but may be related to a reduction in the relative amount of fentanyl in the product when xylazine is present. An analysis of fentanyl samples in Toronto did not find lower amounts of fentanyl, whereas another drug checking service in Rhode Island/Massachusetts has reported increasing quantities of xylazine relative to fentanyl over time.12,13 Additional possibilities are safer use practices by people who are aware of the likelihood of adulteration with xylazine in specific drug products.

Naloxone

The management of patients who overdose remains empiric and based on clinical findings, not simply on presumed exposure. Because hypoxia due to respiratory depression is the primary determinant of adverse outcomes, symptomatic and supportive care, with attention to ventilation and oxygenation, are generally sufficient. Naloxone should be administered using conventional criteria.

Because xylazine is not active at the mu-opioid receptor and naloxone has no direct effect at the α–2 receptor, naloxone will not reverse the effect of xylazine. Currently, however, xylazine is almost always combined with an opioid, and naloxone remains highly effective at restoring ventilatory effort in patients with this cointoxication. Situations in which patients appear to have “naloxone-resistant overdose” frequently represent a polysubstance exposure (eg, benzodiazepines or xylazine) or metabolic insults, such as hypoxia or hypercarbia. Furthermore, the goal of naloxone administration should not be awakening but rather improved ventilatory effort, which can be a comparatively difficult outcome to assess. Failure to recognize that the endpoint is improved breathing, not awakening, may lead to the administration of multiple doses of naloxone, increasing the risk of precipitated opioid withdrawal. In summary, patients with respiratory compromise from presumed opioid-xylazine overdose should be treated with supportive care and naloxone, as clinically appropriate.

Xylazine Reversal Agents

There are currently no FDA-approved xylazine antidotal therapies for use in humans. In veterinary anesthesia, tolazoline (nonselective α-receptor antagonist) is approved for xylazine and atipamezole (a selective α–2 antagonist) for dexmedetomidine reversal.14,15 Given the limited contribution of xylazine to overdose mortality, the pursuit of xylazine-specific reversal agents does not currently appear necessary or worthwhile. Treatment should be focused on the opioid component of the overdose.

Xylazine Dependence and Withdrawal

As fentanyl replaced heroin as the predominant opioid in the illicit drug supply, the severity and timeline of opioid withdrawal changed. This is likely related to the unique clinical pharmacology of fentanyl that manifests with chronic exposure. Due to the high lipophilicity of fentanyl, it bioaccumulates in adipose tissue and subsequently slowly redistributes systemically.16 This leads to the sustained presence of fentanyl blood concentrations, adaptive changes in the mu receptor, and increased depth of opioid dependence.17 Buprenorphine is a partial agonist of the mu receptor and can displace fentanyl from the receptor, thereby precipitating withdrawal, which is commonly termed precipitated opioid withdrawal. Whether xylazine has independent effects from fentanyl on the difficulty with initiating buprenorphine is unclear. The current regionalization of xylazine exposure and widespread availability of fentanyl offers an opportunity for a natural experiment—ie, comparing objective signs of withdrawal between regions of high and low fentanyl-xylazine prevalence.

Despite the increasing prevalence of xylazine, it is not yet clear whether xylazine withdrawal is a unique entity, whether xylazine changes the clinical syndrome of fentanyl withdrawal, or whether known xylazine exposure imparts a perception and anticipation that opioid withdrawal in the presence of xylazine will be different. Extrapolation from clonidine and dexmedetomidine suggests that a xylazine withdrawal syndrome is possible. Approximately one third of patients who experience an abrupt discontinuation of clonidine manifest hypertension and protean symptoms, such as insomnia, headache, and anxiety.18 However, the limited pharmacological similarity between clonidine and xylazine makes it difficult to assess whether xylazine discontinuation would produce similar findings. One patient, a veterinarian with chronic daily use of xylazine, was hospitalized following discontinuation but did not experience any serious withdrawal manifestations.19 Similarly, patients who receive a prolonged infusion of dexmedetomidine may have a withdrawal syndrome, but these cases are confounded by other medication infusions and critical illness recovery.20

In a cohort of 73 hospitalized patients with laboratory-confirmed xylazine-fentanyl exposure, chart review did not identify signs and symptoms of a specific withdrawal syndrome, although 26% of patients had a unique presentation.11 In these cases, the authors could not rule out the possible effect of xylazine withdrawal on the clinical presentation, but there were other clinical conditions that could have explained the findings. For example, patients in this category presented with agitated delirium or intoxication related to other substance use, precipitated opioid withdrawal, or untreated opioid withdrawal. Very few (<3%) had hypertension or tachycardia following xylazine abstinence, and nearly all patients had good outcomes with non-ICU care.11 In patients experiencing severe opioid withdrawal during hospitalization, co-occurring conditions, such as sepsis or mental health disorders, can impede the measurement of opioid withdrawal and complicate the recognition of a unique xylazine withdrawal syndrome.

Some patients who are aware of xylazine in their drug supply report that their withdrawal is not adequately treated with standard opioid withdrawal strategies, implicating xylazine withdrawal. However, due to the universality of opioid coexposure and escalating fentanyl dependence, the development of xylazine dependence and a specific withdrawal syndrome remain unclear. One published case report described a 29-year-old woman hospitalized for wound care after chronic exposure to combined fentanyl-xylazine. She ultimately received intensive care for administration of multiple medications including hydromorphone, phenobarbital, dexmedetomidine, tizanidine, clonidine, and buprenorphine to provide analgesia and sedation for bedside wound procedures.21 Whether this is a consequence of unrecognized tolerance to barbiturates, opioid tolerance or withdrawal, hyperalgesia, or another clinical entity, this pharmacological requirement would be unexpected for patients with xylazine withdrawal. Although there are currently no criteria to diagnose xylazine withdrawal, best practices for assessing and addressing xylazine withdrawal are being investigated.22,23

Xylazine Dermal Manifestations

Although typical dermal manifestations of injection drug use include cellulitis and abscesses, xylazine-associated wounds are distinct and more commonly start as small round ulcerations. These ulcers then coalesce and deepen and are associated with progressive tissue loss.24 Wounds have been reported following smoking, intravenous, or intranasal use, and occur at both sites of injection and sites not associated with injection. Wounds remote from injection sites are most common on the extensor surfaces of the extremities. Research characterizing the risk, pathophysiology, or clinical progression of xylazine-associated wounds is needed.

Theories were proposed and discussed about the pathophysiology of wound development. Xylazine is itself cytotoxic, and other adulterants may contribute to tissue damage.25 Xylazine has peripheral vasoconstrictive effects that may contribute to tissue hypoxia.26 The short-lived clinical effects of fentanyl prompts more frequent episodes of daily injection use, raising the risk of injection site toxic or infectious complications. However, this hypothesis poorly accounts for the variable distribution and progression of xylazine-associated wounds and their frequent development distal to injection sites or in patients who report only inhalational or intranasal use.24 The sedating effect of xylazine may lead to extended periods of unconsciousness, resulting in extremity compression effects at sites distant from injection. Although this may account for a minority of wounds, most do not have a history or anatomical location consistent with this mechanism.

Interestingly, when xylazine is used as a single dose for procedural sedation in veterinary practice, no adverse effects or wounds have been observed. Data on repeated exposure to xylazine in animals do not exist, nor do data on the adverse effects of chronic use or subcutaneous injection of dexmedetomidine.

Wound management: care provided in the community.

Xylazine-associated wounds generally start as small ulcers or blisters and progress to deeper and larger necrotic wounds. Deep space and necrotizing soft tissue infections are seen and feature a unique “Swiss cheese” pattern with surrounding viable tissue. This latter finding is distinct from typical injection drug use-related wounds and implicate xylazine.24

Care for xylazine-associated wounds includes surgical or enzymatic debridement, antimicrobial ointment, and nonadherent and absorptive dressings.24 These treatments are often provided in low-barrier clinics because these wounds heal slowly over weeks to months and patients are frequently reluctant to seek or continue inhospital settings due to challenging opioid withdrawal and pain. For unhoused people, wound care is complicated by difficulty accessing scheduled medical care and wound care supplies. Chronic open wounds are an added barrier to entry into inpatient drug treatment centers due to lack of colocated medical wound care in these treatment settings. Other barriers leading to poor wound healing include inadequate nutritional status, lack of access to personal hygiene, and ongoing drug injection into the wound site, which accelerates the risk of deep space and other infections.

Hospital care: managing complex wounds.

Wounds do not always warrant antibiotics, and wound care can be effectively performed outside of hospital settings. However, hospitalization is frequently necessary for wounds known or suspected to harbor superficial or deep infections. Although surgical debridement of wounds has been common, this may impair healing of the wound and lead to exposure of tendon and bone, the development of chronic osteomyelitis, and the need for amputation. Topical wound care should proceed while avoiding aggressive debridement that will excise healthy tissue and increase bone and tendon exposure.

Wound closure with split thickness skin grafts should be delayed until patients are stabilized in substance use treatment. Dermal substitutes, such as biodegradable temporizing matrix, a synthetic polyurethane dermal matrix, integrate rapidly into the wound and carry other benefits over natural skin. More information is needed about outcomes with xylazine-associated wounds and when drugs are injected into biodegradable temporizing matrix.

XYLAZINE SURVEILLANCE AND DETECTION

Despite reports of xylazine in the drug supply first documented over a decade ago, xylazine testing and surveillance in the United States was uncommon until very recently. Xylazine is not included in standard hospital or office-based testing, but xylazine clinical testing is emerging using advanced chromatographic technology and is increasingly available in some academic centers and reference labs.6,27,28

Information on the content of fentanyl and xylazine quantities in drug samples is needed to inform people at risk because there is variability in users’ awareness and perception of xylazine in their drug supply. In areas of low prevalence, people are less aware of the potential for xylazine exposure; however, xylazine knowledge, experience, and concern among people who use drugs is common in Philadelphia.29 Qualitative research, such as focus groups or surveys, is also needed to understand how patient experiences have changed over time. Furthermore, studying quantitative drug concentrations in biological samples of patients with acute intoxication will help better understand the development of tolerance, dependence, withdrawal, and naloxone dosing strategies. Expanded testing will inevitably lead to questions of the appropriate testing context, cost effectiveness, optimal matrix and timing, and proper interpretation.

Some preliminary clinical laboratory xylazine test characteristics can be gleaned from a cohort of 128 patients hospitalized from March 2022 to February 2023 with opioid use disorder who had urine samples analyzed for xylazine using gas chromatography/mass spectrometry.11 Among the 128 patients who were screened for xylazine, no tests were positive after 43 hours had elapsed from last reported use. Using 43 hours as the cutoff, 73 of 120 tests performed earlier were xylazine positive, whereas 0 of 6 later tests were positive. Interestingly, 2 of 3 tests were positive after 30 hours. However, on further exploration, these cases involved inhospital substance use. Therefore, the first approximation for the duration of xylazine detection in urine is likely less than 30 hours. In this small cohort, factors associated with xylazine-positive tests include younger age, white race, and fentanyl exposure, which are consistent with the demographics of patients using xylazine-fentanyl. Methadone detection was also associated with xylazine-positive tests, but this more likely represents early treatment with methadone during the hospitalization prior to xylazine testing. There was less frequent ICU admission associated with xylazine-positive tests with a trend toward shorter hospital stays.

In another hospital-based laboratory detection study, testing of urine and blood samples of 76 patients at the time of an ED visit for suspected opioid overdose in Rhode Island detected xylazine in urine in 33% of samples and in blood in 14% of samples.30 Similar to other reports, each sample that was positive for xylazine also tested positive for fentanyl. Unfortunately, the ability to interpret clinical testing results is limited by the lack of pharmacokinetic data on xylazine in humans. Data from animal models, and as noted above in humans, suggest the window of detection for xylazine in biological matrices is short and that urine will have a longer window of detection than blood. Potential false positives and negatives in urine immunoassays, detection time parameters for acute versus chronic exposure, and determination of clinically meaningful detection thresholds and toxicity concentrations need to be evaluated.

Harm Reduction, Drug Checking, and Xylazine Test Strips

Increased xylazine appearance in local drug supplies reveals many of the shortcomings of current surveillance testing and creates an opportunity to build comprehensive testing systems to be prepared for detection of xylazine and other adulterants and emerging drugs in the unregulated drug supply (eg, nitazenes). Xylazine testing, previously omitted by many states in postmortem and drug seizure testing and/or reporting, is being expanded.

Xylazine has also been detected across the country through mobile point-of-care drug checking and confirmatory drug sample testing.31 One such effort, the National Institute of Standards and Technology Rapid Drug Analysis and Research (RaDAR) program, analyzes submitted drug or paraphernalia samples with rapid reporting within 24 to 48 hours.31 RaDAR has analyzed more than 2,900 samples from 35 unique sites across 5 states. Currently, this system detects xylazine in about 40% of fentanyl samples. In addition, RaDAR has identified 77 novel substances in Maryland, including related α–2 adrenergic agonists, such as medetomidine, a veterinary sedative that is used in a manner similar to xylazine, and nitazene opioids, such as metonitazene and protonitazene.32,33

Additional findings from “testRI,” a 2-year community-based drug surveillance study in Rhode Island, integrated ethnographic and advanced toxicologic methods to understand the local drug supply.34 The drug samples were donated by study participants or anonymously along with the location and substance the individual reported buying. Samples included drug use equipment (eg, syringes) and were tested using liquid chromatography–quadrupole time-of-flight–mass spectrometry. In 2022, xylazine was present in 63% of samples bought as fentanyl and 45% of overall samples. Xylazine was only detected in the presence of fentanyl. The researchers also conducted interviews with people who use drugs and rapidly disseminated toxicology results to inform harm reduction efforts. Participants reported changes in their drug use experiences and observed drug effects in others, such as incontinence, compression wounds, and deep sedation. Most participants reported that they tried to avoid xylazine, but some sought the drug for a variety of reasons (eg, trying to decrease fentanyl use).

Currently, xylazine test strips are available for both forensic testing and drug checking indications. Xylazine test strips provide rapid point of care testing for xylazine using lateral flow immunoassay with minimal sample prep or training required. Xylazine test strips are sensitive to xylazine concentrations as low as 2 μg/mL. False-positive results occurred secondary to adulterants, such as lidocaine, diphenhydramine, and levamisole.35,36 However, the strips did not react to nonxylazine α–2 adrenergic agonists. Test strips correctly identified the presence of xylazine in 98% of drug samples examined when compared with a gas chromatography tandem mass spectrometry standard.36

Research findings from qualitative interviews of people who use fentanyl in Philadelphia indicate that many do not like the sedating effects of xylazine and negative consequences (eg, being robbed while unconscious).37 People who use drugs are interested in using xylazine test strips. However, test strips may be less helpful to avert use in xylazine-saturated markets given the difficulty in finding opioid product without xylazine.

DISCUSSION

This NIDA CCTN Meeting outlined 4 areas for research pertaining to the emerging threat of xylazine for people who use drugs. First, we noted a need for research on the effects of xylazine exposure on physiologic parameters, the experience of drug use, medications for opioid use disorder initiation, overdose, and overdose reversal with naloxone. Second, we described a need to investigate whether a unique xylazine withdrawal syndrome exists and, if identified, its incidence, characteristics, complications, and treatments. Third, we suggested further research pertaining to the characteristics, incidence, risk factors, mechanisms, and treatments for wounds related to xylazine use. Finally, we described a need for research to inform xylazine testing both in product (eg, with test strips) and human biological samples (eg, with blood and urine toxicology).

Although these proceedings aimed to delineate and organize these research priorities into distinct topics, these topics are interrelated and should be considered in the context of each other (Figure). For example, understanding the clinical effects of xylazine directly informs research on xylazine overdose and withdrawal. In addition, the pharmacokinetics of xylazine directly pertain to clinical testing for xylazine in biologic samples, and knowledge about the experience of opioid and xylazine co-use will deepen our understanding of xylazine wounds and potential harm reduction responses.

Figure.

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Key research questions

We also highlighted shared challenges across these topic areas. Although xylazine is not a federally scheduled substance, it is also not FDA-approved for use in humans. This introduces regulatory challenges and potential delays in conducting clinical research with human participants and is further detailed in Appendix E1. Additionally, among people who use drugs, xylazine is currently detected almost exclusively as a coexposure with an unregulated and rapidly changing supply of opioids. This adds challenges to isolate the effects of xylazine for people who use drugs. Ultimately, it is the rapidity of xylazine’s spread across unregulated drug supplies that makes these questions and their clinical implications truly urgent.

In conclusion, xylazine, a veterinary sedative not approved for human use, has been increasing identified in the unregulated opioid supply, due to both expanded testing and an increased prevalence. The outcome of overdose following coexposure to fentanyl-xylazine compared with fentanyl alone preliminarily appears less severe. Naloxone is highly effective in fentanyl-xylazine overdose and reverses opioid-induced respiratory depression. Because nearly all xylazine is detected with fentanyl or other opioids, naloxone and ventilatory support are the best strategies to prevent fentanyl-related fatal overdose. The characteristics of xylazine dependence require larger studies to assess the prevalence, prophylaxis, and treatment if a distinct xylazine withdrawal syndrome can be differentiated from fentanyl dependence and withdrawal. Although clinical observations suggest xylazine is associated with serious dermal manifestations, especially ulcers and tissue loss complicating the treatment of opioid use disorder, the toxic dermatologic effect has been elusive and requires exploration. Although treatment strategies are emerging, further research is needed in multiple domains to mitigate xylazine-fentanyl exposure.

A recording and summary of the meeting are available.38 NIDA has published a Notice of Special Interest to encourage research on the prevalence and consequences of xylazine co-use with opioids or opioid/stimulant combinations. This Notice of Special Interest also encourages research into how xylazine affects treatment of opioid use disorders and overdose.39

Supplementary Material

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Acknowledgments

The authors acknowledge the National Institute on Drug Abuse Center for the Clinical Trials Network (CCTN) organizers, moderators and speakers in the NIDA CCTN Meeting “Managing Patients Taking Xylazine-Adulterated Opioids in Emergency, Hospital, & Addiction Care Settings”: Lewis S. Nelson, MD; Joseph D’Orazio, MD; Giacomo Gianotti, DVM, DVSc, Jennifer Love, MD; Matthew Salzman, MD; Margaret Lowenstein, MD, MSHP; Ashish Thakrar, MD; Megan Reed, PhD, MPH, Stephanie Klipp, RN, CARN, CAAP, CRS; Lisa Rae, MD; Rachel Wightman, MD; Edward Sisco, PHD, Kristen Huntley, PhD, Aidan Hampson, PhD and NIDA science writer Lori Whitten. This is the Proceedings of a (virtual) convening led by the National Drug Abuse Treatment Center for Clinical Trials Network on June 14, 2023 from 9:00 AM to 12:30 PM.

Funding and support:

By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The NIDA meeting was supported by the Department of Health and Human Services, NIH, NIDA, under contract No. 75N95019C00054. The authors have stated that no such relationships exist.

Footnotes

Supervising editor: Richard C. Dart, MD, PhD. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclaimer: This manuscript reflects the views of the authors and may not reflect the opinions, views, and official policy or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies.

Contributor Information

Jeanmarie Perrone, Department of Emergency Medicine, Penn Center for Addiction Medicine and Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Rachel Haroz, Center for Healing, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ.

Joseph D’Orazio, Center for Healing, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ.

Giacomo Gianotti, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA.

Jennifer Love, Icahn School of Medicine at Mount Sinai, New York, NY.

Matthew Salzman, Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ.

Margaret Lowenstein, Division of General Internal Medicine, Penn Center for Addiction Medicine and Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Ashish Thakrar, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Stephanie Klipp, Courage Medicine, Unity Recovery, Philadelphia, PA.

Lisa Rae, Lewis Katz School of Medicine, Temple University, Philadelphia, PA.

Megan K. Reed, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.

Edward Sisco, National Institute of Standards and Technology, Gaithersburg, MD.

Rachel Wightman, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI.

Lewis S. Nelson, Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ.

REFERENCES

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