The following content is from the News Times on August 27, 2023 and was not written by HVHD.
A tranquilizer used on elephants, mixed with the deadly opioid fentanyl, has helped to fuel the surge in overdose deaths in Connecticut and across the country, health experts say.
Xylazine, a legal drug used by veterinarians, is often mixed with the powerful synthetic opioid fentanyl. This deadly cocktail can lead to kidney issues, heart problems, loss of the use of arms or legs, and death.
“It’s a large animal sedative,” said Jennifer Muggeo, deputy director at the Ledge Light Health District in New London County. “They use it when they’re operating on elephants.”
Xylazine, according to the U.S. Drug Enforcement Agency, is on the rise across the nation. In the northeast, the DEA’s forensic laboratory saw a 61 percent increase in identifications of xylazine between 2020 and 2021.
In Connecticut, xylazine-related overdoses first came to the attention of public health officials in 2019, according to state data. In 2020, there were 141 overdose deaths linked to a combination of fentanyl and xylazine. That number more than doubled to 298 in 2021, increasing to 354 in 2022.
By July 31 of this year, there were 150 deaths in Connecticut related to xylazine.
Xylazine, unlike heroin or fentanyl, is legal. “It is legitimately sold directly through pharmaceutical distributors and internet sites catering to veterinarians,” according to a 2022 DEA report, costing as little as $6 for a kilogram.
“At this low price, its use as an adulterant may increase the profit for illicit drug traffickers, as its psychoactive effects allows them to reduce the amount of fentanyl or heroin used in a mixture,” the DEA report says. “It may also attract customers looking for a longer high since xylazine is described as having many of the same effects for users as opioids, but with a longer-lasting effect than fentanyl alone.”
“Xylazine is making the deadliest drug threat our country has ever faced, fentanyl, even deadlier,” DEA Administrator Anne Melissa Milgram said in a public safety report. “DEA has seized xylazine and fentanyl mixtures in 48 of 50 States. The DEA Laboratory System is reporting that in 2022 approximately 23 percent of fentanyl powder and 7 percent of fentanyl pills seized by the DEA contained xylazine.”
Muggeo explained that not every person who uses substances knows their fentanyl is laced with xylazine, but some do, expecting the sedative to help with symptoms of withdrawal.
“The problem is, it’s very heavily sedating,” she said. “It is impacting their breathing. It is impacting their ability to move, and it is also causing these horrific wounds and kidney problems.”
Xylazine can, in fact, cause a host of medical problems.
“Some people are experiencing anemia because of repeated consumption,” Muggeo said. “Some people are experiencing changes in their blood sugar, either sharply dropping or sharply spiking so people who have not been previously diagnosed with diabetes, experiencing that fluctuation in their blood sugar.”
Perhaps most frightening, the health effects most commonly associated with xylazine are open sores and wounds.
“There’s something going on with the mechanism of how xylazine impacts our bodies that causes wounds, which are not necessarily related to injection,” Muggeo said.
People who use syringes sometimes present with infected wounds related directly to the injection, perhaps from an unsanitary needle. “The xylazine wounds are not those,” Muggeo said. They’re not infected, though they may become infected, she said.
“In the beginning, they’re like these ulcers from the xylazine itself, and they don’t necessarily occur at the site of injection,” she said. “People are getting them, maybe they inject in their arm and then they have a little cut on their finger that turns into this big ulcer, or their legs. People are getting them from smoking or snorting or consuming some other way where we wouldn’t typically be thinking about those ways of consumption causing wounds.”
Naloxone is not effective
Xylazine has, Muggeo said, added a “big layer of complexity” to the job of treating people who use substances, and it’s becoming more and more common.
“I am seeing more patients who are actually primarily here for infections related to their injection drug use,” said Amanda Therrien, a physician assistant who spearheads the inpatient addiction medicine consult service at Hartford Hospital. “That’s the majority of the population that I am seeing right now.”
Therrien could not say how many of those wounds are related to xylazine, because the tranquilizer is not part of standard toxicology screens.
“It’s hard to quantify because a lot of labs are not currently testing for it,” she said. “But we’re certainly seeing a lot of wounds related to injection drug use, and we’re doing our best to treat them.”
If a doctor has reason to believe that a patient has been using substances, they might test for heroin or fentanyl, but xylazine is not part of that standard test.
“We have partnered with a lab that we can send out to test for it, but we don’t have it available in-house yet,” Therrien said. “It’s new and we’ve had conversations with our pharmacy on how we can get it added and I hope one day it will be part of our general tox screen but currently it is not.”
Xylazine is not an opioid, which means naloxone, often called Narcan, has no effect.
If a person stops breathing in the midst of an overdose, naloxone binds to the opioid receptors “and your brain is going to get the signal to start breathing again,” Muggeo said. “The challenge is, that part of the overdose is going to be alleviated by that but xylazine is not an opioid. The person may still be experiencing the sedation from the xylazine and if it’s heavy enough, it may be impacting the rate of respiration.”
Knowing what comes next
Kevin Shuler, a recovery counselor in Hartford, who once briefly lost the use of his legs and kidneys after an overdose, said fentanyl starting appearing on the street in Connecticut in 2014 and has since completely overtaken the heroin market.
“I don’t know how it’s completely supplanted heroin, like, where’s the heroin supply? What happened here?” he said. “As time went on, like 2016, 17, we knew that was pretty much all fentanyl and dealers wouldn’t hide that fact, and then people sought fentanyl because it was longer acting and cheaper. So, some people won’t even want your traditional heroin. They’re looking for the fentanyl.”
Though xylazine is not part of common tests, it was toxicology screens that alerted advocates that it was being mixed with fentanyl. Xylazine is most often found in drug cocktails containing fentanyl.
“The emergence of xylazine across the United States appears to be following the same path as fentanyl, beginning with white powder heroin markets in the Northeast before spreading to the South, and then working its way into drug markets westward,” the DEA wrote. “This pattern indicates that use of xylazine as an adulterant will likely increase and be commonly encountered in the illicit fentanyl supply.”
The patterns of emergence are important to Muggeo, because she’d like to know about an emerging public health crisis before people die in large numbers.
“We didn’t really find out about xylazine until it was present in a significant number of the tox screens in people who had died from overdose and we want to know about the next thing before we get to that point,” she said. “It is important for us to know from a public health perspective so we can help our community members be more informed about what they’re consuming.”
Click here to download a Xylazine Basics: Overdose Prevention, Harm Reduction, and Wound Care from HHRCTraining and SAMSHA.