There’s a new drug beginning to spread rapidly through the street drug supply of the United States: Xylazine, an animal tranquilizer, increasingly used as a synthetic cutting agent for opioids like heroin. Based on many years of U.S.-based research, we recently published a study that found that xylazine has been popping up in all major cities. The drug’s use is growing at an exponential rate wherever it land, leading to skin infections and overdoses.
National xylazine overdose is a serious public health risk. It also foreshadows the future of the overdose crisis—increasingly driven by powerful synthetic compounds mixed into potent combinations.
Xylazine can almost never be taken by itself. Instead, it is typically added to drug formulations containing fentanyl—a family of powerful opioids made in underground labs. The illicit opioid market has been dominated for the past 10 year by synthetically synthesized heroin. However, fentanyl may be hundreds of times more powerful than heroin and can even exceed heroin’s weight.
This has led to the worst overdose crisis recorded. Overdose deaths in the United States are now more than twice that of TK, and almost 20 times higher than the global average. Because of its strong, psychoactive effects, fentanyl has a lot to offer. However, fentanyl has a very short acting time and you may have to inject it up to 5-6 times per day if you are using heroin. This means that you will need to find a safe area, get a clean needle, and worry about possible overdose. This means that you have to wait longer between each injection in order to care for your basic needs. It also increases your risk for injection-related conditions like vein collapse and infections.
This is where xylazine comes in: it extends the effect of fentanyl––or, as this is often put on the street, “it gives it legs.” Adding xylazine to a hit can postpone cravings and withdrawal symptoms for twice as long as fentanyl alone.
There are some risks associated with this drug. It is an anti-depressant. Xylazine can cause complete unconsciousness in people who take higher amounts. Opioids can cause a semi-awake state, but people who take fentanyl with xylazine might experience sedation and then wake up hours later. Anyone who uses drugs this way in the interim is more at risk of harm, such as sexual assault or being struck by cars.
Sedative effects from xylazine can also raise overdose risk. Worse yet, naloxone (what first responders use for overdoses) does not reverse it, because it’s not an opioid.
Many people who use drugs as well as doctors and other advocates for harm reduction report that xylazine can cause blistering skin injuries at an entirely new level. Users who have had xylazine cause strange blood conditions and ended up in hospital with extremely low blood counts, are another example.
But xylazine isn’t the only dangerous synthetic spreading through the drug supply. Fentanyl’s displacement of heroin has ushered in a tidal wave of new synthetic additives. Novel benzodiazepines, opioids (such as “nitazenes,”) stimulants, cannabinoids, and sedatives are emerging at an alarming rate. The startup costs for synthesizing additional compounds are low because there is a large number of underground laboratories already producing fentanyl. The unregulated street market strongly encourages lab experiments and a never-ending race to find the best combinations of synthetic formulas.
New synthetic drugs pose many logistical problems for drug surveillance. Medical examiners with limited resources struggle to keep pace with changing profiles of overdose victims and synthetic drugs. It is not clear that the U.S. government and medical authorities have any idea of the actual range or volume of synthetic drugs today.
These substances are popular because they prolong the life of fentanyl, similar to xylazine. Drug use is made more fun by the addition of other drugs. Synthetic drugs are also attractive to sellers and drug makers. These drugs are cheaper than traditional methods to produce high-potency medicines and they allow you expand your market reach through innovative formulations.
These substances pose health risks, but there are distinct market forces that ensure their widespread availability. There will always be enough supply in the U.S. illegal drug market to satisfy any demand. We know from the legacy of Fentanyl that trying to reduce supply of dangerous synthetic drugs through police is expensive and almost always fails.
To make sure that drug users are safer, we need to develop new methods.
Comprehensive drug-checking service is a promising option. You can take your drug samples to harm reduction clinics and receive a complete ingredient list 10 minutes later. They can view the compositions and amounts of their drugs, just like grocery shoppers with labels.
It has been proven that the concentrations of fentanyl found in drugs can fluctuate even within the same supplier. This knowledge could help save lives. The most toxic chemicals, such as xylazine could be eliminated completely. You can make it easier for consumers to know how much xylazine they have and whereabouts.
There are already harm-reduction programs in the country. They help drug users stay safe by distributing sterile needles and naloxone. They need funding and federal training in order to provide free, comprehensive drug-checking services. Although there is a limited number of such programs currently in America, the technology required to run them has improved and become more affordable in recent years.
More limited methods of drug screening have been approved by the government. For example, fentanyl testing strips can identify the drug in powders, pills, and injectable formulations, but they only tell the user if fentanyl is present or absent—not concentration levels. This is a good choice for recreational non-opioid drug users.
One key strategy for harm reduction is to substitute deadly drugs with something more safe. Prescription heroin programs have been extensively used in Europe for years with considerable success. In these programs, nurses administer a safe injection of heroin—morning and night, free-of-charge. The risk of overdosing is practically zero under these circumstances. The user can choose to spend the remainder of their day looking for money to purchase expensive heroin street, and instead, they can be with their family or pursue other hobbies that will improve their quality life. Many people can achieve the stability and freedom they seek to overcome their problems. They have a better record than methadone programs in helping people to abstain from heroin use. Although it may sound counterintuitive at first, giving people access to the drug they want is the most effective way to assist them in overcoming their personal problems and achieving heroin abstinence.
Drug-checking and the prescription of heroin will come under heavy political scrutiny. We know from decades of experience that there is no way to arrest the growing overdose crisis.
Ten years ago there was an opportunity missed to respond effectively to market takeovers by fentanyl. We now have an opportunity to employ evidence-based strategies as we face the worst drug crisis recorded.
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