The next frontier of the drug crisis — xylazine

Analysis by Caroline Anders May 9, 2023 at 11:56 a.m. EDT The Daily 202 A lunchtime newsletter featuring political analysis on the stories driving the day.

The big idea The next frontier of the drug crisis is here. Is the U.S. ready?

Xylazine, an animal sedative increasingly mixed into the illegal fentanyl supply, “is a dangerous drug,” said Rahul Gupta, director of the White House Office of National Drug Control Policy. (Derek Montgomery) First, there was the pain pill epidemic, fueled by Big Pharma.

Then came the next wave: heroin. As the government tried to crack down on opioid prescriptions, people turned to new ways to achieve the same high that had them hooked.

Next were synthetic opioids. Traffickers wanted to stretch their supply, and they did so with synthetic drugs like fentanyl, which is 50 times more potent than heroin. Just a few grains of the substance can kill you.

But the threat keeps changing.

Now there’s a new adulterant in the drug supply: xylazine. It’s extremely inexpensive, allowing sellers to extend their stores of heroin and fentanyl even further, and some users say it extends the sedative and euphoric effects of the opioids.

A new approach? After failing to grasp and react to the danger of fentanyl quickly enough to stop the wave of death it caused, federal officials want to avoid repeating their mistakes with this new drug.

Last month, the Biden administration designated xylazine mixed into fentanyl as an emerging threat, trying to get ahead of the drug as its illicit use continues to spread across the nation. This marks the first time that label has been used since Congress approved its creation in 2018, so what happens next could indicate whether the United States has made true strides in its drug policy since the fentanyl crisis began.

Xylazine 101 Known as “tranq,” xylazine is a central nervous system depressant that’s often mixed with fentanyl and can put people in a deep stupor. It’s known to cause rotting flesh wounds that, left untreated, can lead to amputations.

The drug is a potent animal sedative and muscle relaxant that’s only authorized for veterinary use in the United States. Its use in humans was first reported in Puerto Rico in the early 2000s, then became rampant in Philadelphia, and is now spreading across the United States.

The Drug Enforcement Administration said the sedative was present in 23 percent of fentanyl powder and 7 percent of pills it seized in 2022.

More than 3,000 people died of xylazine-related overdoses in 2021 — triple the fatalities recorded the year before. But, importantly, those overdoses were all from mixtures of xylazine and opioids like fentanyl or heroin. It’s not yet clear exactly how xylazine interacts with opioids, though researchers are looking into the question.

Sherri Kacinko, a forensic toxicologist at NMS Labs in Pennsylvania, told The Daily 202 that the xylazine-related overdoses we’re seeing are still opioid overdoses; people aren’t dying solely because of the xylazine in their systems.

That said, it’s possible that xylazine has an additive effect, making overdose more likely when it’s present.

The ‘emerging threat’ strategy By designating xylazine an emerging threat, the Biden administration is trying to prioritize federal resources to address the drug from the supply and demand side, both boosting testing and treatment and restricting the illegal supply of the tranquilizer.

The administration asked Congress for $11 million to combat emerging drug threats as part of its budget request.

In March, lawmakers also introduced bipartisan legislation that would classify the drug as a controlled substance. Some experts say it seems like the government is being more proactive in its approach to xylazine than it has been with new drugs in the past. “The federal government has been much quicker to start worrying about xylazine than they were about fentanyl,” Katharine Neill Harris, a fellow in Drug Policy at Rice University’s Baker Institute for Public Policy, said in an interview.

Rahul Gupta, director of the White House Office of National Drug Control Policy, told The Daily 202 that one of the key lessons the government learned from the fentanyl crisis is that this two-pronged approach is crucial. He said focusing only on how to cut off the drug supply is futile.

“If we do not address the unmet treatment needs for people with addiction, we will continue to suffer the same fate,” Gupta said.

The whack-a-mole challenge But many harm reduction advocates argue the government is heading down the wrong path by criminalizing xylazine, saying that approach will just lead manufacturers and dealers to come up with new, potentially more dangerous substances to cut into their supply.

“The crackdown on heroin eventually led drug manufacturers to come up with illicit fentanyl to make sure that they were getting around law enforcement, and that eventually led to fentanyl analogs,” Maritza Perez of the Drug Policy Alliance said in an interview. “So we are actually creating incentives for drug manufacturers to come up with stronger substances that carry a bigger punch that are cheaper to produce.”

In the coming months and years, the administration’s plan to tackle the crisis from multiple sides will be tested. But regardless of its effectiveness, experts say there will always be a new emerging threat.

“It’s literally like whack-a-mole, right?” said Mary Sylla, director of overdose prevention policy and strategy at the National Harm Reduction Coalition. “We try to stop this here and then something else pops up.”