BILLIONHere’s a new drug that is beginning to spread rapidly through the US street drug supply: Xylazine, an animal tranquilizer, is increasingly being used as a synthetic cutting agent. for opiates such as heroin. We recently published a study, based on years of research across the United States, found that xylazine was popping up in cities around the country. The use of the drug is increasing at an exponential rate as it approaches, causing flare-ups of skin infections and overdoses.
The nationwide spread of xylazine is a public health threat. It also heralds the future of the overdose crisis – increasingly fueled by potent synthetic compounds being mixed into potent combinations.
Xylazine is almost never seen by itself. Instead, it is often added to drug formulations containing fentanyl—A family of powerful opioids created in underground laboratories. Over the past 10 years, synthetically produced fentanyl has dominated much of the illicit opioid market that was previously dominated by agricultural heroin; fentanyl can be several hundred times stronger than heroin by weight.
Combined with the inherent poor quality control over confidential supply chains, this has resulted in overdose crisis in recorded history. The United States now has a drug overdose death rate more than double that of the second (TK) country, and nearly 20 times Global average. Consumers are attracted to fentanyl because of its powerful psychostimulant effects. However, fentanyl is very short-acting, and appetite suppression may require injections up to five or six times per day, instead of perhaps just two or three if heroin is used. That means constantly finding a safe place, buying a clean syringe, and worrying about the risk of an overdose. It means less time between injections to take care of basic needs. And it increases the risk of injection-related health conditions, like infections and venous insufficiency.
This is where xylazine comes in: it extends the effects of fentanyl –– or, as this is often put on the street, “it gives it legs”. Adding xylazine to a hit can delay cravings and withdrawal symptoms for twice as long as taking fentanyl alone.
However, its risks are great. Xylazine is a sedative drug. At higher doses, it knocks people out completely. Instead of the semi-conscious euphoria of opioids, people taking xylazine-cut fentanyl may go black and wake up several hours later. In the short term, anyone who uses drugs in this way is more vulnerable to harm, such as being sexually assaulted or being hit by a vehicle.
The sedative effect of xylazine also increases the risk of overdose. Worse, naloxone (what first responders use for overdose) does not reverse it, because it is not an opioid.
Many drug users, as well as doctors and harm reduction advocates, report that xylazine causes blistering skin wounds to a whole new level of horror. There have also been reports of xylazine causing strange blood conditions, with users having to go to the hospital with dangerously low blood counts.
But xylazine isn’t the only dangerous synthetic that spreads through the drug supply. Fentanyl’s heroin replacement has ushered in a tidal wave of new synthetic additives. Novelty benzodiazepines, opioids (such as “nitazenes, ) Stimulants, cannabinoids, and tranquilizers are emerging at an alarming rate. With a host of underground labs already producing fentanyl, the startup costs to synthesize other compounds are low. And the unregulated street markets strongly encourage lab experiments in an unending competition to mix and match new synthetic formulations to see which combinations work best.
Novel synthetics pose many logistical challenges for drug surveillance. Underfunded medical examiners struggle to keep up with the ever-changing record of synthetic drugs leading to overdose deaths. The reality is that health authorities and governments in the US have little idea about the true scope and volume of synthetic drugs today.
Many of these are really appealing to consumers because, like xylazine, they make fentanyl last longer. Mixing drugs also enhances the effects on the nerves, making drug use more enjoyable. At the same time, synthetic drugs are also attractive to drug manufacturers and sellers. They offer lower cost avenues to create high potency products and allow for extended market reach and profitability through unique formulations.
Despite the health risks from these substances, distinct market pressures persist for them, practically guaranteeing their nationwide spread. In the lucrative illicit drug markets of the United States, there will always be a supply to satisfy any demand. The legacy of fentanyl has taught us that trying to limit the supply of dangerous synthetic substances through policy controls is costly and almost always fails.
Instead, new techniques must be implemented to empower drug consumers to make safer choices.
A very promising approach can be found in comprehensive drug testing services. Users can bring their drug samples to harm reduction clinics for quick testing, then 10 minutes later can walk away with the full ingredient list. Like consumers at the grocery store with food labels, they can see the compounds and amounts of what they’re consuming.
The concentration of fentanyl in drug samples has been shown to be widely fluctuating, even from the same seller. Knowing these changing concentrations on a daily basis can save lives. Some of the more toxic contaminants, like xylazine, can be avoided altogether. When consumers know enough xylazine is present and in what concentrations, they can create a market demand for safer, xylazine-free formulations.
Harm reduction programs already exist nationwide, and they help drug users stay safe by doing things like distributing sterile syringes and naloxone. But they need federal support, funding and training to open free, comprehensive drug testing services. Currently there are only a small number of these programme in the United States, although the technology needed to operate them has been readily available and has become increasingly cheaper in recent years.
National progress has been made towards more restrictive forms of drug testing. For example, fentanyl test strips can identify drugs in powder, pill, and injection form, but they only tell the user if fentanyl is present or absent — not the concentration. These strips are best suited for people who do not regularly use opiates.
Another important harm reduction strategy is simply replacing a deadly drug with something safer. This is seen in heroin prescribing schemes, which have been used for decades in Europe with remarkable success. In these programs, nurses administer heroin injections safely – free of charge in the morning and evening. Under these conditions, the risk of overdose is virtually zero. Instead of spending the rest of the day earning money to buy expensive street heroin, users can spend time working, spending time with family or pursuing other activities that improve their quality of life. In this way, many people gain the stability they need to confront their demons and overcome cycles of chronic use they no longer enjoy. These programs often have a better track record than even methadone programs for helping to achieve the ultimate goal of heroin withdrawal. It may sound counterintuitive, but giving people the medication they seek is often the best way to help them finally come to terms with their personal challenges and leave those drugs behind.
Of course, heroin prescribing and drug testing programs will face intense political scrutiny from supporters of the punitive and costly police/prison approach. But decades of evidence show us that we cannot find a way out of the unfolding overdose crisis.
Ten years ago, there was a missed opportunity to effectively respond to fentanyl’s takeover of the market. Now, as xylazine and other synthetics spread across the country in their shadow, we have another opportunity to use evidence-based strategies in the face of a lethal drug crisis. the most people in recorded history.
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