Xylazine: Advocates, Service Providers on High Alert

As friends to organizations whose missions are primarily centered on harm reduction and as an organization that recognizes and often seeks to break down the silos associated with HIV, Hepatitis C, and Substance Use Disorder as distinctive but intersecting health states, Community Access National Network (CANN) is sometimes skeptical as to “alerts” the United States law enforcement community might offer through various news media. The “rainbow fentanyl” hype from the fall of 2022 speaks to why advocates may find themselves questioning the veracity of these kinds of warnings. However, the issue of xylazine is unfortunately based in very tangible realities for the United States, which have been documented as far back as the 2000’s in Puerto Rico. The prevalence of xylazine is increasing across the country’s street-based drug supply, often times in combination with fentanyl – most significantly complicating efforts to reverse overdoses and causing wounds which are atypical to more common fentanyl or heroin use.

Last week I spent time discussing a friend’s personal (and social) sexual health and as conversation developed they expressed concern over the development of xylazine, sometimes known as “tranq dope” or “down”, becoming more prevalent in the illicit drug trade of their community. Planning for events and even social outtings are requiring them to consider carrying more doses of Narcan on them and they’re noticing a higher demand for fentanyl testing strips. They conveyed a familiarity with the strips being used to ensure the illicit substances being used were indeed fentanyl and not the animal tranquilizer that seems to be driving up fatal overdoses in the surrounding community. Our conversation wrapped up with my friend sharing with me a sentiment another friend had shared, “Crack sucked, opioids suck…but they were a progression. People knew what they were doing. This is innocent. People aren’t making these choices.”

And while some might moralize what making “those” choices might mean, ultimately the best approach to helping folks navigate substance use doesn’t come with judgment but an acceptance that we all cope with the world around us differently. History tells us readily that prohibition movements seldomly achieve their goals and, economically, criminalization is less beneficial than harm reduction measures in curbing illicit substance use. Harm reduction measures, when adequately situated and supported, link people who use drugs to care where wounds may be treated, safe supplies might be obtained, chains of transmission of infectious diseases are identified and interrupted, and, when someone is ready, linkage to substance use counseling is available. It is this intersection of interest where harm reduction and patient advocacy intersect.

Hard-won victories which have helped advocates create safer environments for people who use drugs may not be sufficient for handling this corruption of street supply, as the wounds being associated with xylazine are resulting in amputations, in part because of providers being less familiar with how these wounds are presenting, which may still be present even when someone is not injecting their substance of choice, but swallowing, smoking, or snorting it. Trust in hospital providers is slim because emergency rooms are received as hostile environments which do not typically offer substance use treatment referrals and where people who use drugs often experience provider biases, sometimes resulting in substandard care. Fear of withdrawal is also a compelling factor for avoiding necessary care, as community-based programs are trying to meet the needs of their clients, their communities, mostly on their own.

While Philadelphia’s struggle with xylazine infiltrating the street supply is well documented, other jurisdictions are seeing signs of the tranquilizer. Delaware firmly expects to see 2022’s fatal overdose tally surpass 2021’s, even as provisional data is still being cleaned. Similarly, Connecticut, New Hampshire, and Rhode Island among several other east coast states have identified xylazine in the local supply as well as fatal overdoses increasing.

In the face of these challenges, House Republicans have asked the Drug Enforcement Agency and (DEA) to “schedule” xylazine and if the agency doesn’t, they might seek legislation to schedule it anyways – a move advocates warn might only make the problem worse. “Scheduling” refers to introducing a specific substance to the “schedule” of illegal and illicit substances maintained under the Controlled Substances Act – thereby adding certain criminal enhancements to the possession, use, and distribution of the tranquilizer. The concern from advocates in such a move is it would encourage further addition of other synthetic adulterators into street supplies, just as we’re learning (and researching) how to handle xylazine. Dr. Ryan Marino, medical director of toxicology and addiction medicine at University Hospitals in Cleveland scolded, “This is more of the same short-sighted and reactionary political grandstanding that may help politicians but won’t help any American citizens and doesn’t solve any of our drug problems.”

The U.S. Food and Drug Administration (FDA) issued an alert to health care professionals in November 2022, and the Biden Administration’s other agencies are already beginning to tackle the subject. But, what will it amount to?

Federal and state funding is already largely prohibited from backing safe consumption sites and Canada’s advocate proposal of a “safe supply” would be an ever further stretch for politicians wishing to appear “tough on drugs” (but apparently lacking the empathy and expertise to be helpful to communities struggling with deaths). A congressional Research Service report, also shared in November 2022, offered some answers, ranging from treating safe consumption sites similarly to medical marijuana dispensaries, wherein the U.S. Department of Justice (DOJ) is prohibited from using resources to seek prosecution of those businesses so long as they comply with state law, lawmakers could opt to fund these sites, giving explicit endorsement of a well-proven intervention that has already saved hundreds of lives in New York, or Congressional leaders or the President might choose to actively pursue criminal litigation and legislation which explicitly outlaw safe consumption sites. The Biden Administration appears to be leaning toward non-enforcement, if the recent updates about the DOJ and Safehouse, an organization in Philadelphia, meeting an “amicable settlement” prove to be fruitful.

Because overdoses of the tranquilizer are also presenting atypically from more traditional fentanyl overdoses, community health workers are noticing Narcan is less effective in reversing these overdoses and even when they are effective, the person experiencing the overdose may not rouse as easily because of the contamination with xylazine. Some have reported oxygen supplements might help in stabilizing someone in need of emergency care in response to an overdose. This would prove an exceptional challenge for street-based workers but certainly something a safe consumption site would be able to have on hand. As states continue to develop their harm reduction policies and empower community-based organizations to respond to these crises, policymakers should evaluate things like ensuring adequate oxygen supplies for these entities and even their community partners (which might include businesses like bars) and increasing allowable and covered purchases of Narcan, as administering the overdose reversal medication is still highly recommended when encountering an overdose.

We urge our partners to keep a close eye on this issue at it continues to develop.