July 11, 2023
Three months after declaring xylazine an emerging health threat, the White House has unveiled a broad strategy to address the public health impact of the veterinary sedative's growing presence in the illicit drug supply.
Xylazine, which often is diverted from legitimate veterinary sources, is commonly combined with fentanyl to make the street drug "tranq dope." But it also gets mixed with cocaine, methamphetamine and fraudulent prescription medications. Tranq dope has become pervasive in Philadelphia's drug supply in recent years.
The White House response plan, released Tuesday, outlines measures to improve testing for xylazine, strengthen data collection on the drug's role in overdose deaths, and create a treatment framework with best practices for first responders and other care providers. The plan also calls for expanded research on xylazine and new approaches to limiting its use in illicit drugs.
The plan was required by the White House deeming xylazine an emerging health threat in April.
Xylazine is only approved by the U.S. Food and Drug Administration for use in large animals such as horses and cattle. When taken by people, the sedative slows breathing and heart rate. This causes complications that interfere with normal treatment protocols for opioid overdoses, since administering Narcan doesn't reverse the effects of xylazine. First responders may not be able to clearly distinguish between the effects of the opioid and the sedative, losing valuable time to address urgent breathing difficulties.
Many people who use xylazine also suffer from outbreaks of severe skin ulcers that require medical attention to prevent infections. The drug is addictive in its own right as well, often leading to dual dependency.
"As a doctor, I have seen the devastating consequences of xylazine combined with fentanyl firsthand," said Dr. Rahul Gupta, director of the Office of National Drug Control Policy. "And as President Biden's drug policy advisor, I am laser-focused on finding every tool we have and following the best evidence-based practices to take on this new challenge. This will be an all-hands-on-deck effort – but I am confident we can take action together and eradicate this emerging threat."
Improving treatment will involve searching for the best ways to stabilize people who have overdosed and determining how to best manage their withdrawal from xylazine. These symptoms can be overlooked in hospital settings that are accustomed to patient protocols for opioid dependency.
Currently, there is no drug that can be used to reverse the effects of xylazine. Broader availability of Narcan has long been touted as a crucial step for better overdose intervention, but the spread of tranq dope has hampered Narcan's lifesaving potential because it can be difficult to tell when a person has overdosed on both the opioid and the sedative.
Many people who use fentanyl and other substances may be unaware that they are taking drugs that contain xylazine, especially in areas where it has not yet become well-recognized an adulterant in street drugs. Delaware recently became the first state to roll out a combined fentanyl and xylazine test strip that allows people to test drugs for the substances before using them.
In addition to expanding the availability of such tests, the White House plan calls for rapid research into the development of drugs that specifically reduce or reverse the effects of xylazine. It also seeks expanded grant funding for training on how to treat xylazine-related flesh wounds, which can develop regardless of whether a person injects, snorts or smokes a drug that contains the sedative. When using tranq dope, flesh wounds often appear on parts of the body other than the injection spot.
Community-based groups are expected to be key to the implementation of the White House plan, which relies on local and state health authorities to take the lead on outreach, education and early intervention. In communities where tranq dope is prevalent, the plan urges wider adoption of mobile care units that offer treatment and proactively connect people with resources to get help with addiction.
The plan calls for research into how xylazine impacts the body, its behavioral effects based on how it's used, and how people have successfully recovered after periods of dependency.
Philadelphia has been called "ground zero" for xylazine's wider entry into U.S. drug markets. The sedative was found in 90% of the dope samples the city's health department tested in 2021, and nearly half of the fentanyl overdose deaths that year involved xylazine.
"We are grateful for the efforts of our federal partners to address fentanyl adulterated or associated with xylazine," a spokesperson for the Philadelphia Department of Public Health said. "Together with our health system and community partners, we have been working to develop and disseminate best practices for treatment of xylazine overdose and withdrawal symptoms as well as treatment of the severe and debilitating wounds that xylazine can cause.
"We agree that increased drug testing, including development and dissemination of rapid tests for xylazine, is important not only for addressing the spread of xylazine but for rapidly identifying and responding to future drugs that may pose additional hazards to people with substance use disorder."
As fentanyl has replaced heroin as the dominant opioid in the U.S., drug dealers have turned to xylazine as a way to prolong the high that users experience. Fentanyl, a synthetic opioid, isn't as long-lasting as heroin. Tranq dope compensates for this by extending the effects of intoxication.
Cutting fentanyl with xylazine also increases profit margins for dealers. Fentanyl can be produced synthetically in a lab and it is at least 50 times more powerful than heroin, by volume, making it cheaper and easier for drug dealers to acquire.
Forensic lab identifications of xylazine rose in all four U.S. Census regions between 2020 and 2021, according to the U.S. Drug Enforcement Administration. The sharpest increases were observed in the South and the West, where lab reports of xylazine rose 193% and 122%, respectively. Overdose deaths that involved xylazine increased by 1,127% in the South, 750% in the West, more than 500% in the Midwest and more than 100% in the Northeast.
In Pennsylvania, xylazine was linked as a contributor to 90 overdose deaths in 2017. By 2021, that number had jumped to 575 across 30 counties, an increase of more than 600%, according to the state Department of Health.
A handful of states, including Pennsylvania, have made the drug a schedule III controlled substance to address the worsening of the opioid epidemic. The White House plans to explore the ramifications of classifying xylazine as a federally controlled substance. A bipartisan bill currently in the Senate aims to make it a schedule III drug.
Some epidemiologists, including several in Philadelphia's health department, have cautioned against scheduling xylazine due to the risk of more dangerous substances emerging as mixing agents. The White House will evaluate this risk alongside the advantages that scheduling could provide law enforcement agencies in their efforts to take down illicit drug networks. The government will look into other avenues that can be used to prosecute people who manufacture and distribute xylazine to support fentanyl trafficking.
Earlier this year, the FDA restricted the importation of xylazine to limit its diversion from veterinary sources.
Fentanyl, originally developed as an intravenous anesthetic, was made a schedule II narcotic in 1970. The drug's emergence as a cheaper alternative to heroin led to the development of numerous, lab-made synthetic analogs that have since been classed as "fentanyl-related substances." Since 2018, these analogs have temporarily been made schedule I controlled drugs — the tier for the most dangerous substances.
Lawmakers and public health officials have debated whether making this designation permanent will do more harm than good, since federal and state governments have other tools available to target analogs for dangerous drugs. Scheduling entails stricter sentencing guidelines, which critics say are unwarranted given the lack of sustained national improvement in combating the opioid epidemic's deeper root causes.
"We are launching coordinated efforts across all of government to ensure we are using every lever we have to protect public health and public safety, and save lives," Gupta said.
