Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis

Joseph Friedman; Fernando Montero; Phillippe Bourgois; Rafik Wahbi; Daniel Dye; David Goodman-Meza; Chelsea Shover

doi:10.1016/j.drugalcdep.2022.109380

Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis

Drug Alcohol Depend. 2022 Apr 1:233:109380. doi: 10.1016/j.drugalcdep.2022.109380. Epub 2022 Feb 26.

Authors

Joseph Friedman¹, Fernando Montero², Phillippe Bourgois³, Rafik Wahbi⁴, Daniel Dye⁵, David Goodman-Meza⁶, Chelsea Shover⁷

Affiliations

¹ Center for Social Medicine and Humanities, University of California, Los Angeles, CA, USA; Medical Informatics Home Area, University of California, Los Angeles, CA, USA. Electronic address: joseph.robert.friedman@gmail.com.
² Department of Anthropology, Columbia University, New York, NY, USA.
³ Center for Social Medicine and Humanities, University of California, Los Angeles, CA, USA. Electronic address: pbourgois@gmail.com.
⁴ Fielding School of Public Health, University of California, Los Angeles, CA, USA.
⁵ Department of Pathology, University of Alabama, Birmingham, AL, USA.
⁶ Division of Infectious Diseases, University of California, Los Angeles, CA, USA.
⁷ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA. Electronic address: CLShover@mednet.ucla.edu.

Abstract

Background: Sharp exacerbations of the US overdose crisis are linked to polysubstance use of synthetic compounds. Xylazine is a veterinary tranquilizer, long noted in the street opioid supply of Puerto Rico, and more recently Philadelphia. Yet its national trends, geographic distribution, and health risks are poorly characterized.

Methods: In this sequential mixed-methods study, xylazine was increasingly observed by ethnographers in Philadelphia among drug-sellers and people who inject drugs (PWID). Subsequently, we systematically searched for records describing xylazine-present overdose mortality across the US and assessed time trends and overlap with other drugs.

Results: In 10 jurisdictions - representing all four US Census Regions - xylazine was increasingly present in overdose deaths, rising from 0.36% of deaths in 015m 6.7% in 2020. The highest xylazine prevalence data was observed in Philadelphia, (25.8% of deaths), followed by Maryland (19.3%) and Connecticut (10.2%). Illicitly-manufactured-fentanyls were present in 98.4% of xylazine-present-overdose-deaths - suggesting a strong ecological link - as well as cocaine (45.4%), benzodiazepines (28.4%), heroin (23.3%), and alcohol (19.7%). PWID in Philadelphia described xylazine as a sought-after adulterant that lengthens the short duration of fentanyl injections. They also linked it to increased risk of soft tissue infection and naloxone-resistant overdose.

Conclusions: Xylazine is increasingly present in overdose deaths, linked to the proliferation of illicitly-manufactured-fentanyls. Ethnographic accounts associate it with profound risks for PWID. Nevertheless, many jurisdictions do not routinely test for xylazine, and it is not comprehensively tracked nationally. Further efforts are needed to provide PWID with services that can help minimize additional risks associated with a shifting drug supply.

Keywords: Drug Surveillance; Ethnography; Mixed methods; Overdose; Xylazine.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Analgesics, Opioid / adverse effects
Drug Overdose* / epidemiology
Fentanyl
Heroin
Humans
Substance Abuse, Intravenous*
Xylazine

Substances

Analgesics, Opioid
Xylazine
Heroin
Fentanyl

Abstract

Publication types

MeSH terms

Substances

Grants and funding