FEntanyl – the most important drug in the country – is getting even more dangerous. Across the United States, opioids are increasingly mixed with xylazine, a powerful tranquilizer that has been approved by the Food and Drug Administration for use in animals such as horses. But it’s known on the streets as “tranq” or “tranq dope,” and it’s a horrific side effect combined with an increasing number of fatal overdoses across the country.
The substance was first mixed with heroin in Puerto Rico two decades ago. Today, the epicenter of the national crisis is Philadelphia, where xylazine appeared in the supply of drugs as early as 2006, and was found in over 90% of the city’s sliding document testing in 2021.
Last week, the US Drug Enforcement Administration issued an erect of the “sharp increase in the trafficking of fentanyl mixed with xylazine,” saying that xylazine and the mixture of fentanyl have seized in 48 of the 50 states. The FDA has vowed bounce back on the importation of drugs, and again Bill Congress would add xylazine to the DEA’s list of controlled substances.
But doctors and advocates say there is still a severe lack of understanding about the problem and how to fight it.
James Latronica, an addiction medicine physician and public policy chair for the Pennsylvania Society of Addiction Medicine, has treated patients who had been taking xylazine for years. “Xylazine is not something we do on purpose,” he says. “You have an unfathomable and unfathomable supply that is available to be cut,” and from a supply perspective, “it’s likely to be simply cheaper than fentanyl.”
Xylazine adds multiple layers of complexity to an already insidious drug problem. Xylazine is a depressant. it slows the breathing and the heart of man, and lowers their blood. An overdose can put them in a coma, leaving them cold and vulnerable for hours on the street.
Typically, rescuers use a drug called naloxone (often sold as Narcan) to reverse fentanyl overdoses, but if someone takes too much fentanyl mixed with xylazine, even Narcan may not wake them up. Reservists could use too much of the drug, which could make the person vomit and possibly choke.
Xylazine has the most popular side effect: rough wounds that don’t heal. The exact reason for this is still not understood, but scientists suspect that xylazine may affect blood circulation in a way that affects skin repair. That is, using xylazine, something less blisters or needle punctures in large ulcers of dying flesh, sometimes eating by mouth.
The shame of the wounds deters some patients from seeking help, “and then they get worse,” says Latronica. About two years ago, he was admitted to an addiction patient who had recurring infections in his arms, but had no health insurance and was struggling to get help. “Eventually, he just stopped going until his arm was so bad that it was gangrenous. And to do nothing but to cut it off.
Despite the information, Latronica had no way of confirming if a patient was using xylazine because there were no available tests. “Unfortunately, doctors and public health are always behind. We’ve had conversations since we learned about xylazine, but it’s been around for several years now – and it’s probably the only part of this field that’s the most frustrating.
Local non-profits are desperately seeking help. In 2021, Shannon Ashe, a Philadelphia social worker, co-founded Everywhere Projecta group of volunteers who provide food, clothing, wound care, and supplies to the world using substances such as xylazine. What they are witnessing is undeniably horrific: “see the wounds as if people had been subjected to horrific chemical warfare,” he said. But there are no chemical burns – they come from within.
To reduce stigma, Ashe, xylazine weaponry requires an approach called harm reduction: “meeting people where they are, without judgment, in a way that keeps their boundaries to themselves.” His group does not require abstinence: “If people want to do it, that’s great. If you want to go to therapy, which is amazing, we’ll literally have you. But our end is not all end. Requiring someone to stop xylazine before it helps them is another “unrealistic expectation that leads us on the same track,” he says, “that people are more dead.”
As a model, Philly lawyers point to a New York City nonprofit called OnPoint NYC, which recently opened the country’s first two sanctioned overdose prevention centers – places approved by the authorities where people can use substances in the world, to monitor the setting without fear of being arrested. Since opening in 2021, OnPoint sites have been used nearly 70,000 times, during which staff have intervened in 850 overdoses, 65% of which were “severely adulterated fentanyl,” says Kailin Sedis, the nonprofit’s director of programming. Because of how closely people are monitored, OnPoint has only had to call an ambulance 14 times, and no one has died of an overdose there.
Because it is officially approved, OnPoint is able to work with city safety to track xylazine rates in the city. “Four or five months ago, we were seeing only a trace of weight,” says Ecce. But now, “we are starting to see batches that are higher – upwards of 25% concentration of xylazine in the bags.”
Great monitoring was gained over time to learn how to treat the symptoms of xylazine, from the coma-like dosage to the signature wounds. “We are preparing for the arrival,” See said. “We don’t take a fear-based approach.”
That’s against “war on drugs” policies that criminalize and punish people who use substances. Tools as simple as fentanyl tests are still banned in the states of Florida and Texas over fears they could encourage drug use. And even if the dose prevention centers remain deeply unpopular ideas in many countries, where residents and politicians say they will increase registrations and crime.
But “Latronica,” said “Latronica,” I cannot handle any act if they are already dead. He’s praising a recent bill passed in Pennsylvania that allowed bandages — which he hopes will clear the way for more xylazine tests to be done simultaneously. An effort to open a drug prevention center in Philadelphia has the support of city officials, but remains in limbo. legal battle and faces against the neighbors.
Just having the evidence won’t solve the problem, advocates say. “When you try your drugs, it’s not going to be judged by the use of those substances, because that’s not how addiction works, nor how poverty works,” says See. “People don’t choose to say, ‘Oh, it’s dangerous in my adulterous dose, I’m going to go to a cleaner dose.’ What ultimately matters is that the spaces are safe for people to use.’
And to advance further: to supply more safely. Some countries, including Canada, allow doctors to prescribe pharmaceutical-grade versions of the drug in severe addictions — which gives people a way to avoid fentanyl cut with xylazine, or hepatitis C from needlestick infections. In these cases, an injury reduction approach can be thought of as a form of preventive medicine, says Latronica.
Despite the horrors of xylazine, advocates hope they can raise another call for a breakthrough in national drug policy. Seat says there is “a mountain of peer-reviewed evidence” to suggest that preventive dose centers do not make a difference in the opioid crisis, “but what is important is American examples and American evidence.”
Over the past two years, OnPoint has held hundreds of tours for curious officials from other US states. ‘No one wanted to do it first,’ said See. “And soon we hope that everyone will want a second.”