By Iris Smith, Ph.D.

On July 11, 2023, xylazine was classified as an emerging threat by the White House’s Office of National Drug Control Policy. Provisional data from the CDC indicated that 68% of the reported 107,081 drug overdose deaths in the United States involved synthetic opioids other than methadone.¹  Since 2019 xylazine has been increasingly identified in overdose deaths. A recent study of 21 jurisdictions found that the monthly percentage of deaths implicating xylazine increased 276% between January 2019 and June 2022, with the highest rates reported in the Northeast. All regions, unfortunately, saw an increase from 2020-2021 as reflected in the DEA Forensic Laboratory Identification of Xylazine by Region.²

There are several adverse effects associated with xylazine including hypertension, tachycardia, bradycardia, hyperglycemia, respiratory depression, and coma. Users who inject xylazine or drug mixtures containing xylazine often develop soft tissue injuries that may result in higher amputation rates compared to individuals who inject other drugs without it. Some users develop a dependency on xylazine that results in withdrawal symptoms as, or more severe as those associated with heroin or methadone.  There is no approved anecdote for xylazine, and its presence may make naloxone less effective.² 

Epidemiologic surveillance of xylazine is critical. The symptoms of xylazine are similar to that of other opioids and are difficult to detect in clinical settings. It is not currently being detected by most laboratories that conduct drug screens or postmortem toxicologies.  As a result, use and associated overdose rates are likely to be underestimated. Currently it is not included in the national data collected by Centers for Disease Control and Prevention (CDC). 

Available demographic data indicates that overall, the demographics of overdose victims who used xylazine do not differ from those who do not, except for intravenous drug use which is higher. This suggests that prevention messaging might be focused to this subpopulation of drug users. Harm reduction strategies such as the distribution of xylazine test strips and rapid point-of-care testing may also help to reduce overdoses.  Stigma may also be a barrier to seeking treatment. Ethnographic findings from Puerto Rico, which was among the first U.S. jurisdictions to identify xylazine use, found providers were often reluctant to treat users because of the appearance and odor of skin lesions resulting from the drug.

Resources

Kariisa M, O’Donnell J, Kumar S, Mattson CL, Goldberger BA. Illicitly Manufactured Fentanyl–Involved Overdose Deaths with Detected Xylazine — United States, January 2019–June 2022. MMWR Morb Mortal Wkly Rep 2023;72:721–727.

Department of Justice Drug Enforcement Administration (DEA) (October 2022).  The Growing Threat of Xylazine and its Mixture with Illicit Drugs.

Office of National Drug Control Policy (July 2023) Fentanyl Adulterated or Associated with Xylazine Response Plan.

Spencer MR, Cisewski JA, Warner M, Garnett MF (2023) Drug Overdose Deaths Involving: United States, 2019-2021. NVSS Vital Statistics Rapid Release; Report Number 30, June 2023.

Zhu DT (2023) Public Health Impact and Harm Reduction Implications of Xylazine-Involved Overdoses: A Narrative Review.  Harm Reduction Journal 20; pg. 131. PMID: 37700329  

“What You Should Know About Xylazine” Centers for Disease Control (CDC), Injury Center

CDC’s Drug Overdose Surveillance and Epidemiology (DOSE) System.  The DOSE program supports the collection of data on nonfatal overdoses through the Drug Overdose Surveillance and Epidemiology (DOSE) system. Data reported to DOSE are captured by health departments and are used to describe overdoses at the local, state, and national levels.