Could the fentanyl crisis get any worse? Unfortunately, yes.
Just when fentanyl seems maximally destructive — addicting more youth, driving up overdoses and deaths — an even more dangerous drug, xylazine, has infiltrated the fentanyl supply, making the deadliest drug in the nation even deadlier.
Fentanyl powder and pills are now commonly laced with xylazine, a highly addictive animal tranquilizer known on the street as “tranq” and “the zombie drug.”
“Most people addicted to xylazine don’t even know they’re taking it,” says Brian Dawson, M.D., chief medical officer of Ideal Option. “It’s just like when the fentanyl era began, and people who bought oxy on the street didn’t know they were taking fentanyl.”
Ideal Option recently became one of the first networks of treatment centers to test for xylazine at its in-house laboratory, to ensure patients receive appropriate treatment.
As a sedative, rather than an opioid, xylazine has its own set of risks, including perilous sedation, high blood pressure, seizures, and respiratory depression. Users can persist in a blackout stupor for hours, only to emerge with a desperate urge for more.
Xylazine has gained notoriety for the gaping flesh wounds it can cause, sometimes necessitating limb amputation. The wounds can surface far from the injection sites, often on the forearms and shins, and can develop even in people who smoke or snort drugs xylazine-laced drugs.
What’s more, a xylazine overdose can’t be reversed with Narcan (naloxone), the life-saving nasal spray that counteracts the effects of opioids. When a patient overdoses on xylazine-laced fentanyl, the sedative effects of xylazine may require CPR as well as Narcan.
However, emergency responders who are unaware an overdose victim has taken xylazine may inadvertently administer too much Narcan, triggering particularly intense withdrawal symptoms.
There’s no shortage of horrors associated with xylazine.
“If you become dependent on fentanyl that is mixed with xylazine, it’s more addictive than fentanyl alone,” says Dr. Dawson. “And withdrawal is even worse, because you’re dealing with withdrawal from both drugs.”
Nausea, vomiting, anxiety, chills, sweats, and restless legs — fentanyl withdrawal symptoms are miserable enough. But xylazine withdrawal is even more excruciating, triggering migraines, double vision, numbness in fingers and toes, and sharp chest pains.
As one former user described it, “When you start getting sick from the tranq, you start shaking violently, salivating, and vomiting.”
What all this means for individuals who use xylazine-laced fentanyl: a greater risk of fatal overdose and a more complicated route to recovery.
Still, with medical guidance, recovery from addiction to xylazine is possible. The first step is to identify which substances are in your system.
“Most treatment centers are unable to test for xylazine, so they don’t know whether patients have it in their system,” notes Dawson.
In fact, xylazine is typically detected only after an overdose death, when a toxicology test is conducted, or when the U.S. Drug Enforcement Agency (DEA) analyzes confiscated samples.
Thanks to specialized protocols and in-house laboratory services, Ideal Option can now test patients for xylazine which is good news for individual patients but also for the 11 states where the company operates its clinics as Ideal Option makes all of its’ testing data freely available to the public.
Even with limited testing data, the DEA has found xylazine in nearly every state and in about 25% of fentanyl powder samples, though rates vary from state to state. On the East coast, roughly 25% to 50% of the fentanyl is likely cut with xylazine. On the west coast, the percentage is lower, says Dr. Dawson, “but that could explode and eventually it could be everywhere.”
One study, conducted by Philadelphia’s health department, detected xylazine in over 90% of confiscated drug samples.
“The dealers and cartels are always evolving their product, with stronger substances and more variety, to get people more dependent on multiple types of drugs,” says Dr. Dawson.
In response, medical providers like Ideal Option are constantly evolving their treatment protocols.
“For those with dependence, it is important to come to a place like Ideal Option, which has the ability to test for xylazine and uses the most up-to-date treatment options for all substances of addiction,” says Dr. Dawson.
The reason is that different substances must be tackled with different medications.
With fentanyl, the goal is to transition to Suboxone (buprenorphine), a medication proven to suppress opioid withdrawal symptoms and cravings and considered indispensable to recovery.
Xylazine is so new that guidelines for treating long-term dependence don’t exist. The current strategy is to treat xylazine withdrawal with safer sedatives known to reduce anxiety and restlessness and medication to lower the risk of seizure.
“Withdrawal from sedatives has to be treated with other sedatives,” says Dr. Dawson.
For addiction to both drugs, the biggest hurdle is the first 24 hours, when withdrawal can be excruciating.
“The best option is to undergo medically monitored detox,” says Dr. Dawson. “A provider can prescribe more intensive withdrawal medications to essentially knock you out for the first 24 hours, to get you through the worst of it.”
In most cases it is possible to detox at home, with the help of a responsible friend or family member, but for patients dependent on both xylazine and fentanyl, Dr. Dawson recommends inpatient detox so providers can adjust medications on the fly if symptoms become unbearable.
Once a xylazine-fentanyl patient has completed detox, ongoing treatment for fentanyl addiction — ideally with Suboxone, emotional support, and any needed mental health treatment — may offer the patient enough stability to sustain recovery from both addictions. Maintaining contact with an addiction-medicine provider is critical.
Though xylazine has seemingly come out of nowhere, the drug has been around since the 1960s. Developed for veterinary procedures, xylazine is used for anesthesia and pain relief in large animals, such as horses, cattle, and sheep.
The drug was never approved by the FDA for use in humans because early trials found it caused severe sedation and depression of the central nervous system.
Xylazine began creeping into the illegal drug supply in the early 2000s and swept Philadelphia between 2016 and 2019. During the pandemic, xylazine became more prevalent as a cheap way to extend the high from fentanyl.
For years, xylazine was not on the radar of law enforcement because it has not been classified as a controlled substance. However, the current crisis is sparking new state laws governing xylazine.
Today, xylazine is poised to become a nationwide emergency, compounding the one we already have.
“I’m definitely worried,” says Dr. Dawson. “Xylazine is going to make it more complicated for patients to get off of fentanyl.”