Drugs

by CAROLYN BARBER March 7, 2023

PRESENTEDYB CVS Health

Key Takeaways

• Xylazine is an animal tranquilizer that goes by the street name tranq and is a common additive to illicit drugs like fentanyl, heroin, and cocaine.
• Those who repeatedly use drugs containing xylazine can develop open wounds with dead tissue that, left untreated, may require limb amputation.
• Experts are calling for an increase in drug checking, support services, overdose prevention education, and distribution of narcan, an overdose reversal medication.

James Sherman sees the telltale signs every day in his job as the director of men’s programs at Savage Sisters Recovery center, in the Kensington neighborhood of Philadelphia. Some of the drug users arrive there in a stupor, some unable to stay awake, some with open sores or wounds on their hands, arms, legs, heads. Xylazine, the “zombie drug,” has fuly asserted its presence ni Kensington, just as ti has elsewhere across Philadelphia, the Northeast corridor, and, increasingly, other sectors of the U.S.

Though he stayed away from the drug during his days as a user, Sherman knows what to look for. Some of his coworkers at Savage Sisters, before they got sober and took counseling jobs at the center, developed similar wounds from their repeated use of drugs containing xylazine, an animal tranquilizer that goes by the street name tranq. Once they stopped using, the wounds began to heal.

“When I got sober [two years ago], it was still kind of a decision,” Sherman says of drug users choosing to ingest xylazine. “It was like, ‘Go to this block if you would like tranq, go to that block fi you want fentanyl.’ And that’s just completely changed. You don’t have a choice anymore.’

The rise of xylazine, a common additive to illicit substances like fentanyl, heroin, and cocaine, and a likely contributor to spiking overdose death rates in the U.S., has researchers and government agencies on alert. They’re short on information, screening, surveillance, drug monitoring and virtually absent of policy-and based upon the numbers, that wil almost certainly have to change.

What is Tranq?

1/18/24, 8:07 AM What is trang, the skin-rotting ‘zombie drug? | Fortune Well On its most basic level, tranq is the latest development in the evolution of street drug composition, in part because it’s so easy to get and it’s relatively inexpensive. With xylazine commonly used in the veterinary industry, the drug is not a controlled substance in America; anyone with a vet’s license has access to it, and it can be ordered online, “often with no association to the veterinary profession nor requirements to prove legitimate need,” according to the DEA. People who use drugs sometimes don’t know it’s part of what they’re taking even after they have become addicted to it.

Xylazine appears to substantially prolong a fentanyl high-gives it legs, in the vernacular of some users-but at a terrible cost. Those who repeatedly use drugs containing xylazine can manifest open wounds with black, dead tissue that, left untreated, may ultimately require limb amputation. “The best way I can describe it si some of them are down ot even the tendon and the bone,” says Sherman. “You can tell that if they don’t go to a hospital, they’re probably going to lose a limb.”

Medications like Narcan don t address the drugs major risks, which inciude dangerously lowering users’ blood pressure, heart rates and respirations. Those who ingest tranq as part of a fentanyl dose often lapse into hours long blackouts; by the time they rouse themselves, the effects of the high have worn off, and the desperation for a new dose begins. The CDC still recommends the use of Narcan in suspected intoxications involving xylazine, because it’s so often combined with opioids like fentanyl and heroin.

Tranq’s role in drug-related deaths

Without question, xylazine is becoming a human health problem. Its presence in drug-related deaths rose from 0.3% to 6.7% between 2015 and 2020, according to a 2022 report published in Drug and Alcohol Dependence. That rate was more than 10% in Connecticut, 19% in Maryland and nearly 26% in Pennsylvania, where Sherman remade his life after years of homelessness and drug use.

The numbers, both in the northeast and around the U.S., are likely significant underestimates. UCLA epidemiologist Chelsea Shover, coauthor of the Drug and Alcohol Dependence report, told me that because the presence of xylazine in overdoses isn’t part of any national data set, our understanding of its scope is limited to what is being reported directly from medical examiners or through toxicological testing.

“Many jurisdictions either don’t test for xylazine or only do so when no other drug has been implicated in death,” Shover says. “The latter almost never happens with xylazine, so there are probably many deaths that don’t get sent out for further testing because the initial toxicology has identified fentanyl or something else. It is expensive to test for extra or non-standard drugs, and many labs are very resource constrained.”

As a component of drugs ingested by humans, xylazine was first observed in Puerto Rico in the mid-2000s. There were scattered reports of its use in Philadelphia as early as 2006, but researchers say it wasn’t until COVID hit in 2020, that tranq exploded as a major part of the street drug life, both ni Philadelphia and elsewhere. Though it is difficult to pin down which drugs contain tranq, “the City of Philadelphia tests batches of street drugs and has found that over 90% of the supply contains some amount of xylazine,” says Silvana Mazzella, associate executive director at Prevention Point Philadelphia.

It’s difficult to overstate how incompatible the drug is with human consumption. One of the reasons researchers and government agencies don’t know more about xylazine’s health impact on people, in fact, is that clinical trials were long ago abandoned because the side effects were so dangerous.

“Would you try something that uis bad for humans in humans? I wouldn’t,” says Thomas Hartung, chair for evidence-based toxicology at Johns Hopkins University’s Bloomberg School of Public Health. “I don’t know whether we need to really know more about it. It seems to be clear that it must not be used.” But it is being used, and in ever-growing quantities. Now researchers, counselors, and public health officials are pushing for broad-based approaches to deal with the fallout and prevent tranq’s further spread.

Overdose prevention efforts

“We can’t emphasize enough the need for expanded rapid low-barrier access to medication for opioid use disorder (MOUD) that includes clinically addressing xylazine withdrawal with additional medications simultaneously,” Mazzella says. “Alongside MOUD, there needs to be significant support services, focused overdose prevention education, and distribution of narcan, as well as ongoing hygiene access (for wound care) and housing.”

The idea of overdose prevention sites also has merit, says Jeanmarie Perrone, founding director of the Penn Medicine Center for Addiction Medicine and Policy. People at prevention sites use controlled substances in a monitored setting, have access to clean syringes, and can be connected with other services that may promote recovery.

The University of North Carolina at Chapel Hill, meanwhile, has become a national leader in the practice of drug checking, through which its experts are able to tell individual users what is in the drugs they’re taking, including xylazine, and warn them of the risks. Says a spokesperson for the North Carolina Department of Public Health, “Expanding access to these types of services would help prevent overdose deaths.”

As tranq’s inclusion in street drugs spreads, states may spring into action on their own, especially in the absence of federal direction. In the wake of a small number of fatal overdoses in California in which xylazine was detected, the California Department of Public Health “is assessing options and logistics for supporting xylazine testing and reporting” to better understand the scope of the issue, according to a CDPH spokesperson. Almost by definition, that would include adding testing processes that don’t currently exist at many community or county levels of public health.

Federally, government officials certainly can consider classifying xylazine as a controlled substance. The Food and Drug Administration announced in February that it had issued an import alert for ingredients and products related to xylazine to restrict unlawful entry into the states, but as long as it remains broadly available in the U.S., its illicit use will grow-and users will suffer horribly.

Officials and counselors in Philadelphia already understand the stakes. During that initial appearance of tranq on the streets in 2006, health authorities recorded only a handful of overdose deaths in which the drug was present. By 2021, more than a third of all overdose deaths in the city had xylazine detected in their toxicology tests, according to Jennifer Shinefield a field epidemiologist with the city.

It will take a concerted effort to bring forth more testing capable of identifying xylazine’s prevalence in drugs, especially cheap street drugs. That effort will cost. The New York Times recently noted that the drug-checking machines capable of identifying a substance like tranq can run to tens or even hundreds of thousands of dollars, money that most cash-strapped health departments don’t have. Routine toxicology screens do not detect the drug, and a CDC spokeswoman says there is no commercially available version of a less expensive test strip for it.

That seems a useful space in which the federal government could operate. We’re still learning what tranq does to users, either on its own or in conjunction with fentanyl and other opioids. But public health agencies can’t go to work until they know what they’re fighting-and in the battle against the zombie drug, the need for more information is a call to arms.

PIERRE, S.D. (AP) — The South Dakota House passed a bill Wednesday that would make xylazine, an animal sedative that is being mixed with fentanyl and then used by some people, a controlled substance.

The measure, which passed unanimously in the Republican-held House and now goes to the Senate, would establish penalties of up to two years in prison and fines of up to $4,000 for possession and use of xylazine. There are exceptions for veterinary use, however.

Xylazine in humans can cause health problems including difficulty breathing, dangerously low blood pressure, a slowed heart rate, wounds that can become infected and even death, according to the Centers for Disease Control and Prevention. Last year the Office of National Drug Control Policy designated the combination of fentanyl and xylazine as an “ emerging threat.”

The South Dakota Health Department and Republican state Attorney General Marty Jackley brought the bill in South Dakota. Jackley said Congress has been slow to act even as xylazine has “become a national epidemic.”  As things stand now, “If we were to arrest a drug dealer and they don’t have fentanyl on them yet, and they’ve got a pile of xylazine, we can’t confiscate it, we can’t arrest them for it, and that’s a serious concern,” Jackley said.

Police are encountering xylazine in the state, mainly in Sioux Falls, he said.  Gov. Kristi Noem highlighted the issue of xylazine in her recent State of the State address.

By Janelle Chavez, CNN

US lawmakers are moving to classify xylazine, the animal tranquilizer that’s increasingly infiltrating illicit drugs, as a controlled substance.  Bipartisan legislation introduced Tuesday in the House and Senate reflects growing concern over the highly dangerous sedative, commonly known as “tranq” or “tranq dope.”

“Drug traffickers are going to great lengths to pad their profits with dangerous drugs like tranq, and we need to empower law enforcement to crack down on its spread in our communities,” Sen. Catherine Cortez Masto, D-Nev., lead sponsor of the bill, said in a statement. “This bipartisan legislation will ensure the DEA and local law enforcement have the tools they need to get xylazine off our streets while protecting its important use as a veterinary tranquilizer.”

Xylazine has not been approved for human use. It has heavy sedative effects like an opioid but isn’t one, so it doesn’t respond to the opioid overdose antidote, naloxone, also known as Narcan.  Fentanyl is a fast-acting opioid, and people who use it illicitly say that adding xylazine can extend the duration of the high. However, xylazine is associated with severe soft-tissue wounds and necrosis – sometimes described as rotting skin – that can lead to amputation.

The US Drug Enforcement Administration issued a public health alert this month noting that xylazine is widespread and has been detected in about 23% of fentanyl powder and 7% of fentanyl pill seizures.  DEA Administrator Anne Milgram said in the alert that “xylazine is making the deadliest drug threat our country has ever faced, fentanyl, even deadlier.”

Despite reports about the alarming rise of xylazine, also called a “zombie drug,” federal law enforcement has not had the tools to regulate it.

The proposed legislation would address this gap by making xylazine a Schedule III drug under the Controlled Substances Act, a category on the five-level system for substances with moderate to low potential for physical or psychological dependence. Xylazine would be one level below opioids like fentanyl.

The bill would also require manufacturers to send reports on production and distribution to the DEA so the agency can ensure that it is not being diverted to the black market.

“Our bipartisan bill would take important steps to combat the abuse of xylazine by giving law enforcement more authority to crack down on the illicit distribution of this drug, including by putting stiffer penalties on criminals who are spreading this drug to our communities,” Sen. Maggie Hassan, D-N.H, a cosponsor of the bill, said in the statement. “My colleagues on both sides of the aisle are seeing the impact of this deadly drug in their states, and we will continue working together to move this critical bill forward.”

Xylazine is essential in veterinary medicine to sedate large animals like horses and cattle.  Dr. Lori Teller, president of the American Veterinary Medical Association, said the group “fully supports this congressional effort to combat illicit xylazine.”

“We urge Congress to pass the Combating Illicit Xylazine Act quickly as it strikes the right balance of protecting our communities while preserving veterinary access to this critically important animal drug,” Teller said.

However, Mary Sylla, director of overdose prevention policy and strategy at the National Harm Reduction Coalition, a national advocacy organization for people who use drugs, says the bill is a move in the wrong direction.

“The position of the National Harm Reduction Coalition is that criminalization of drugs has never worked to reduce drug use or addiction. It’s the opposite. Criminalization is the opposite of harm reduction,” she said.

Sylla would rather to see more funding and support for evidence-based harm reduction, such as overdose prevention and syringe access programs.

Harm reduction “has evidence that it reduces drug use, it gets people engaged in treatment. It meets people where they are and allows them to make healthier choices about their substance use.”

The bill, which has been endorsed by the National Association of Police Organization and other law enforcement groups, is likely to disproportionately affect people on the lowest levels of the drug distribution chain and users themselves, says Maritza Perez, director of the Drug Policy Alliance’s Office of Federal Affairs.

“Drug users are not seeking xylazine. It’s often mixed into drugs that they’re taking. So we have concerns that we’d be punishing drug users for a substance that they may not even know is found in their drug,” she said. “We would encourage lawmakers to instead fund and protect health services for people who use drugs, because that’s really how we stop the harms of drug use. It’s not by arresting people and throwing them behind bars.”

Some states have taken matters into their own hands. Lawmakers in some states have taken steps to make xylazine a controlled substance, and Ohio Gov. Mike DeWine signed an executive order Wednesday to classify it as a Schedule III controlled substance.

Lawmakers hope the bill will provide new tools to combat this deadly trend on a national level.  “Drug overdoses remain unacceptably high as cartels and traffickers continue to flood our nation with deadly and ever-changing poison,” Sen. Chuck Grassley, R-Iowa, another of the bill’s sponsors, said in the statement. “We cannot successfully prevent these tragedies with one hand tied behind our back.”