Xylazine in the drug supply: Emerging threats and lessons learned in areas with high levels of adulteration

Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore

“…Relatively few respondents mentioned xylazine by name, although there had been some news media in neighboring counties about xylazine as a new concern in the drug supply and some preliminary alerts to harm reduction providers about heightened overdose potential. A few providers reported hearing about ‘tranq’ and xylazine from PWID, as has been reported elsewhere [ 9 ], especially in areas more proximate to Philadelphia. Among PWID, there was some awareness of the emerging possible presence of an “animal tranquilizer” in packaged fentanyl associated with a specific set of experiential characteristics consistent with xylazine’s pharmacological effects [ 10 , 11 ]; specifically, a 20–30 min “very heavy” nod in which the person may not be able to be roused even though they are breathing and dry mouth, which was later clarified as extreme dry mouth.…”

“…Further information is needed to understand mechanisms underlying xylazine-related overdose mortality to inform prevention and response. Meanwhile, many are developing new protocols for overdose response, and there are increasing calls for emergency responder retraining to better respond to the respiratory depressant and sedative effects of xylazine [ 9 ]. A recent study showed that xylazine-involved overdose death circumstances are relatively similar to those without xylazine, although fewer have evidence of no pulse upon first responder arrival [ 18 ].…”

Xylazine in Overdose Deaths and Forensic Drug Reports in US States, 2019-2022

“…Recently developed xylazine test strips represent 1 such potential harm reduction strategy; research in this area is still nascent, especially relative to research on fentanyl test strips . In addition to test strips, integrating xylazine information in overdose prevention training may better prepare individuals who use drugs and other lay and professional overdose responders . The opioid reversal medication naloxone can counteract the respiratory depression caused by the opioids that commonly accompany xylazine but cannot address the effects of xylazine itself (because xylazine is not an opioid), so lay responders are often advised to not only administer naloxone but also call emergency medical services and provide rescue breathing, and medical professionals may need to provide additional interventions specific to xylazine-adulterated drugs .…”

“…The opioid reversal medication naloxone can counteract the respiratory depression caused by the opioids that commonly accompany xylazine but cannot address the effects of xylazine itself (because xylazine is not an opioid), so lay responders are often advised to not only administer naloxone but also call emergency medical services and provide rescue breathing, and medical professionals may need to provide additional interventions specific to xylazine-adulterated drugs . While arguably not directly related to overdose, wound care also represents a harm reduction priority particularly relevant for individuals who use drugs containing xylazine due to the severe skin ulcerations that may accompany use . These skin ulcerations, as well as xylazine withdrawal symptoms, also complicate the provision of effective substance use disorder treatment, necessitating additional research and evaluation to optimize treatment care protocols…”

“…Moreover, xylazine’s presence in illicit drug supplies has extended across the country, no longer limited to the Northeast . Timely identification of xylazine in local drug supplies and overdoses represents a first step in responding to this emerging threat, followed by the evaluation, optimization, dissemination, and implementation of xylazine-specific harm reduction strategies, including those pioneered by frontline workers in regions with a longer history and higher prevalence of xylazine in street drug supplies …”