Xylazine in Fentanyl Complicates Efforts to Address Opioid Crisis

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A potent animal sedative found in the illicit drug supply is posing significant challenges to the United States’ response to the opioid crisis, disrupting established methods of overdose reversal and addiction treatment.

Xylazine, when combined with fentanyl, the synthetic opioid responsible for the majority of overdose deaths, is raising concerns among health professionals and law enforcement personnel in New Jersey, New York, and Pennsylvania. Although the drug has been linked to severe skin wounds, it remains unclear whether it directly contributes to increased fatalities. In fact, preliminary data suggests that xylazine might unintentionally weaken the effects of fentanyl.

However, there is a consensus that further information is needed to fully understand the impact of xylazine, combat the illegal drug supply, and develop medications to counter its effects.

Dr. Lewis Nelson, an advisor to federal regulators on drug safety from Rutgers New Jersey Medical School, emphasizes the lack of knowledge regarding xylazine’s role in overdose risk. He states, “We don’t know whether xylazine is increasing the risk of overdose or reducing the risk of overdose. All we know is that there are a lot of people taking xylazine, and a lot of them are dying, but it doesn’t mean that xylazine is doing it.”

Typically, xylazine, an animal sedative, is added to fentanyl to create a combination known as “tranq” or “tranq dope,” which offers users a longer-lasting high resembling heroin. Xylazine is favored by drug dealers due to its affordability and accessibility compared to fentanyl. It can be purchased from Chinese websites without a prescription for as little as $6 to $20 per kilogram, whereas fentanyl precursor chemicals can cost $75 or more per kilogram.

Sarah Laurel, the founder of Savage Sisters, an outreach group in Philadelphia, remarks, “Nobody asked for xylazine in the drug supply. Before anybody knew it, the community was chemically dependent on it. So now, yes, people do seek it out.”

The effects of xylazine are easily identifiable: users experience lethargy, a trance-like state, and may even black out, leaving themselves vulnerable to robbery or assault.

Approved as an animal sedative in 1971, xylazine can cause a decrease in breathing and heart rates when used by humans. It has also been linked to severe skin ulcers and abscesses, which can lead to infections, tissue decay, and amputations. The exact cause of these deep wounds, which differ from those caused by other injectable drugs, remains a subject of debate among experts.

Philadelphia, in particular, has encountered various challenges due to the introduction of xylazine into the local drug market. Naloxone, the medication used to revive individuals who have stopped breathing, does not counteract the effects of xylazine. Despite this, Philadelphia officials emphasize that naloxone should still be administered in all suspected overdose cases since xylazine is almost always found in conjunction with fentanyl.

Given the absence of an approved reversal drug for xylazine, the Savage Sisters group has resorted to carrying oxygen tanks to aid in revival efforts. Additionally, a mobile van staffed by local health workers and city employees now aims to treat skin wounds before hospitalization becomes necessary.

The presence of these wounds makes it more challenging to enroll individuals in addiction treatment programs, as most facilities lack the expertise to address severe lesions that expose tissue and bone. Jill Bowen, who oversees Philadelphia’s behavioral health department, explains, “If you have someone out there who’s ready to come in for treatment, you really want to act on that quickly.”

To mitigate this issue, the city has launched a pilot program where hospitals provide treatment for wounds and then facilitate direct transfers into addiction treatment.

Xylazine has addictive properties, and patients who discontinue its use report experiencing severe withdrawal symptoms such as anxiety and distress. While no approved treatment exists, physicians have been employing the blood pressure-lowering drug clonidine, sometimes prescribed for anxiety.

In April, federal officials classified xylazine-laced fentanyl as an “emerging threat,” citing the issues in Philadelphia and other northeastern cities. Although testing is not uniform, the drug has been detected in all 50 states and appears to be spreading westward, similar to previous waves of drug use.

Officials describe the toll of the drug using alarming statistics: Fatal overdoses involving xylazine increased by over 1,200% between 2018 and 2021. However, this surge primarily reflects increased testing, as most medical examiners had not been searching for the drug until recently.

Anne Milgram, the head of the Drug Enforcement Administration, acknowledges that xylazine is making fentanyl, the deadliest drug seen thus far, even more lethal.

Nevertheless, some experts who have closely examined the issue are uncertain about the true impact of xylazine.

One study that explored the subject reached a surprising conclusion: individuals who overdosed on a combination of fentanyl and xylazine had less severe outcomes compared to those who consumed fentanyl alone. This finding contradicted expectations, considering xylazine’s negative effects on breathing. The study, which analyzed over 320 overdose patients receiving emergency care, revealed lower rates of cardiac arrest and coma when xylazine was present.

Dr. Jennifer Love, an emergency medicine physician at Mount Sinai Hospital in New York, suggests that xylazine may be reducing the potency of each fentanyl dose. She emphasizes that this explanation is just one possibility and emphasizes the need for further research into the long-term effects of xylazine. Love also notes that the study did not examine potentially fatal downstream effects of xylazine, such as skin infections and amputations.

Additional indications that xylazine may be blunting fatal overdoses have emerged in New Jersey, where approximately one-third of the opioid supply contains the drug, according to drug paraphernalia testing. However, xylazine was implicated in less than 8% of fatal overdoses in 2021, the latest year with complete data. Police Capt. Jason Piotrowski, responsible for analyzing state drug data, proposes that xylazine’s ability to prolong users’ high may contribute to its lower-than-expected presence in fatal overdoses. He suggests, “If xylazine is lasting longer, and that’s why people are using it, then they’re not going to need as many doses. So now their exposure to the more deadly fentanyl decreases.”

Despite varying opinions, Philadelphia officials fail to identify any benefits associated with xylazine. Dr. Cheryl Bettigole, the city’s health commissioner, comments, “I don’t frankly see a plus side to xylazine. It seems to increase the risk of overdose and it causes these severe, debilitating wounds that interfere with peoples’ ability to get into treatment.”

Since xylazine became a significant component of the local drug market around 2018, Philadelphia has witnessed a 14% increase in annual fatal overdoses. In 2021, the city reported 1,276 overdose deaths, and Bettigole expects the final figures for 2022 to reveal yet another increase.

City data indicates that over 90% of lab-tested opioids in Philadelphia contain xylazine.

While organizations like Savage Sisters grapple with the consequences of xylazine, they are also witnessing the emergence of new drugs, including nitazenes, a synthetic opioid that can be even more potent than fentanyl.

The evolving mix of opioids, stimulants, and sedatives characterizes the ongoing U.S. drug epidemic, making it increasingly challenging to address a crisis that claims over 100,000 lives annually.

The Biden administration and Congress are contemplating changes to restrict the prescription and distribution of xylazine. However, previous restrictions failed to resolve the problem. When regulators cracked down on painkillers like OxyContin, people largely shifted to heroin and later to fentanyl.

Piotrowski summarizes the situation, stating, “First we had pills, then we had heroin, and then we had fentanyl. Now we have everything. And xylazine is just a part of that.”

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More about opioid crisis response

• The New York Times: Animal Sedative, Tied to Recent Overdoses, Has Long History of Abuse
• AP News: Animal sedative xylazine in fentanyl causing wounds, scrambling efforts to stop overdoses
• ABC News: Animal sedative xylazine in fentanyl is causing wounds, scrambling efforts to stop overdoses
• NBC News: Animal sedative in fentanyl causes concern amid opioid crisis
• The Washington Post: Xylazine, a drug used to sedate horses, is causing havoc in the U.S. opioid crisis