Xylazine, also known as tranq, seems to be wreaking havoc in the United States. Health departments have detected the substance in black market fentanyl in New Mexico, California, West Virginia and, well, almost every state. It has been associated with overdose deaths in Philadelphia and elsewhere in the country. It’s also crossed the ocean: A new study from Kings College London shows that xylazine appears in fake marijuana vapors, imitation codeine and Valium pills.
Veterinarians use xylazine on its own for sedation, muscle relaxation and analgesia. It is approved by the Food and Drug Administration, but only for these cases and explicitly only for use in animals. When mixed with fentanyl and used by humans, it can be a dangerous combination. In fact, many media outlets have started calling it a zombie drug because of the effects it can have: it can sedate its users and can cause large, rotting wounds if used frequently.
Here, we break down what’s happening, the main concerns experts have about its prevalence, and why they say this scary drug isn’t their main concern.
If it’s for animals, how does it get into the fentanyl?
Drug dealers have been mixing it with heroin since at least the early 2010s, says Jeanmarie Perrone, director of the Center for Addiction Medicine and Policy at the University of Pennsylvania, but clinically it was fairly silent, perhaps because it was in concentrations lower than what I saw now. Basically: It went under the radar for a while. And now it’s added to opioids.
Why would anyone add it?
Simple logistics play a role here: adding something to the fentanyl makes administration possible. A typical dose of fentanyl is in the sub-milligram range, essentially a pinhead amount. If I sold you this, you couldn’t see it, you couldn’t use it, explains Lewis Nelson, a medical toxicologist and chairman of the Department of Emergency Medicine at Rutgers New Jersey Medical School. Mixing these microscopic amounts with something allows users to maintain small doses.
Usually, that stuff is sugars and starches. Xylazine, as a mixture, has its own effects. Often called an adulterant because it is intentionally added, it not only carries fentanyl, but adds potentially attractive psychoactive properties. Xylazine may strengthen the effects of opioids. Basically, it’s meant to increase the general euphoria, or high, experienced with fentanyl, says Kim Janda, a professor of chemistry and immunology at the Scripps Research Institute in California.
Okay, but other things are going on. What happens when xylazine has negative effects?
The main adverse effect of xylazine can be traced back to its purpose: sedation. Xylazine has a faster onset of sedation than fentanyl, Nelson says. Such sedation is commonly compared to being very drunk, to the point where people are no longer comfortable or in control of their bodies, says Claire Zagorski, a graduate research assistant at the University of Texas who recently co-authored from an article on reducing xylazine harm.
And being sedated for a long time can cause some health problems.
We’re seeing people getting ulcers, for example, just because they don’t move for hours on end, Zagorski says. It is causing this damage and breakdown of the skin.
Users also report skin ulcers, and not just a small bruise: in extreme cases, people lose chunks of tissue on their arms and legs because of it. Those who use intravenous drugs can develop infections, so this is not necessarily a new thing, but the appearance and progression of these wounds is very different, Perrone says.
Researchers aren’t exactly sure what’s causing the injuries, but Perrone suggests it could have something to do with frequency of use. Many injections can cause itchy scabs, and the itching can cause the wound to progress. People with more occasional use tend not to have the injuries, he adds.
Another theory is that these sores are directly related to the ability of xylazines to constrict blood vessels, making it difficult for blood to pass through tissue. Zagorski thinks it seems unlikely that the injuries are behaviorally driven, as there are black areas of dead tissue in places like users’ fingers and toes, again suggesting it could be related to a flow poor blood But again, experts aren’t sure.
Is it as deadly as fentanyl?
Probably not. There is no really good data on death rates due to use in illegal drug supply. One of the things that muddies the picture is that xylazine is rarely found alone. Seattle police recently found it was being sold for the first time as a stand-alone pill, but in most cases it’s being used in conjunction with fentanyl or other opioids. And while there are many reports of xylazine-associated or xylazine-related deaths, that doesn’t necessarily mean xylazine was the direct killer, Nelson says.
But there are reasons to think that xylazine is not the direct culprit. Zagorski notes that there are examples of people working in the veterinary world who have only overdosed on xylazine. Even in these cases, it was generally not fatal. One very important difference between xylazine and fentanyl: It doesn’t shut down that drive to breathe like opioids do, he says.
If not fatal, what are some of the main concerns?
Many people who take fentanyl with xylazine are not housed. It’s so saturated in the opioid supply, Zagorski says. So we found this whole new set of problems with sedating people, especially if they’re not housed and can’t get to a safe place to sleep.
Not to mention, wounds present a major problem during treatment. Facilities are turning away patients because of their wounds, leading to a wider treatment gap and wound progression due to this barrier of waiting for a bed somewhere where someone can handle the problem of the wound, says Perrone. If the wounds are not treated, they can lead to infections and more problems in the future.
I heard Narcan doesn’t work on Tranq. This Looks Bad.
When people overdose on opioids, they take so much that it can stop their breathing. Naloxone, also known by its brand name, Narcan, essentially blocks the receptor that opioids act on, causing you to breathe again. However, xylazine is not an opioid. Naloxone specifically talks only to opioid receptors, Zagorski says, so it’s like the wrong key in a lock.
But since most products are a combination of xylazine and fentanyl, it’s still worth administering Narcan to try to reverse the opioid effects. If I give you naloxone, it will get you breathing again, Nelson explains. It’s just that if there’s xylazine in the mix, it won’t wake you up.
If Narcan has already been administered, Zagorski encourages people to shake the person, call their name, rub their chest and try to wake them from sedation.
Is there a way to test for xylazine? And is there a treatment?
Yes, there are test strips that use the exact same type of technology as pregnancy tests. But the problem is that given xylazine’s prevalence in the illicit drug supply, it can be hard to find a product that doesn’t have it, Nelson says.
As for treatment, Janda is currently working on a vaccine to block the sleep-inducing effects of xylazines. Janda and his team recently published a paper suggesting their vaccine could reverse xylazine-induced behavior in mice, and hope to replicate the findings in humans. But a real vaccine is years away.
Some patients have also described xylazine withdrawal syndrome, which researchers are still trying to analyze. They were still looking to characterize it and see how it might have to be treated differently than fentanyl, Perrone says.
How should I worry about this?
If you’re not a drug user, your risk is pretty low. It’s not the kind of thing that can affect you if you’re close. If you touch it and lick your hand, that’s a problem, Nelson says.
But the mere presence in the space you are in, the environmental exposure, is not a problem.
Interestingly, Nelson says some data suggests that xylazine has a protective factor. People presenting to hospitals with fentanyl and xylazine have a lower rate of requiring CPR and cardiac arrest. And, Nelson says, it probably doesn’t increase addiction.
As with any emerging health crisis, experts stressed that the picture is still forming and more research is needed. But as it stands now, they see fentanyl as the bigger problem.
You see headlines that xylazine is the world’s most dangerous drug, Nelson says. Actually, the 800-pound gorilla here is fentanyl. Xylazine is just one spectator
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