Illicitly Manufactured Fentanyl-Involved Overdose Deaths with Detected Xylazine - United States, January 2019-June 2022

Abstract

In 2022, provisional data indicated that more than two thirds (68%) of the reported 107,081 drug overdose deaths in the United States involved synthetic opioids other than methadone, principally illicitly manufactured fentanyls (IMFs) (1). Xylazine, a nonopioid sedative not approved for human use and with no known antidote, has been increasingly detected in IMF products in the U.S. drug supply* and in IMF-involved overdose deaths (2). Limited studies suggest xylazine can cause central nervous system depression, respiratory depression, bradycardia, and hypotension in humans (3,4); chronic use might lead to severe withdrawal symptoms^† as well as skin ulcerations (4). This report uses data from CDC's State Unintentional Drug Overdose Reporting System (SUDORS) to describe IMF-involved^§ overdose deaths with and without xylazine detected that occurred during January 2019-June 2022. Among 21 jurisdictions, which included 20 states and the District of Columbia, the monthly percentage of IMF-involved deaths with xylazine detected increased 276%, from 2.9% to 10.9%. Among IMF-involved deaths during January 2021-June 2022 in 32 jurisdictions, xylazine was detected in a higher percentage of jurisdictions in the Northeast U.S. Census Bureau region; listing detected xylazine as a cause of death varied across jurisdictions. Expanded postmortem and illicit drug product testing for xylazine is needed to clarify prevalence in drug supplies; further investigation of xylazine's effects on humans is necessary to characterize morbidity and overdose risk. It is important for overdose prevention and response messages to highlight the potential presence of xylazine in IMF products and emphasize the need for respiratory and cardiovascular support to address the sedative effects of xylazine.

FIGURE 1

Number and percentage of drug overdose deaths involving illicitly manufactured fentanyls, by month and xylazine detection or co-involvement — State Unintentional Drug Overdose Reporting System, 21 jurisdictions, January 2019–June 2022 Abbreviations: IMF = illicitly manufactured fentanyl; SUDORS = State Unintentional Drug Overdose Reporting System. * A drug was considered involved or co-involved if it was listed as a cause of death on the death certificate or medical examiner or coroner report. ^† Fentanyl was classified as likely illicitly manufactured using toxicology, scene, and witness evidence. For the 8% of deaths involving fentanyl that had insufficient evidence for classification as illicit or prescription, fentanyl was classified as illicit because the vast majority of fentanyl overdose deaths involve illicit fentanyl. All fentanyl analogs except alfentanil, remifentanil, and sufentanil, which have legitimate human medical use, were included as IMFs. ^§ Connecticut, Delaware, District of Columbia, Georgia, Illinois, Maine, Massachusetts, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, Ohio, Oklahoma, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia. Illinois, Pennsylvania, and Washington reported deaths from counties that accounted for ≥75% of drug overdose deaths in the state in 2017 per SUDORS funding requirements; all other jurisdictions reported deaths from the full jurisdiction. Jurisdictions were included if data were available for each 6-month period (January–June 2019, July–December 2019, January–June 2020, July–December 2020, January–June 2021, July–December 2021, and January–June 2022), and toxicology reports were available for ≥75% of deaths in the included period or periods. Analysis was restricted to decedents with an available toxicology report or with xylazine listed as a cause of death on the death certificate.

FIGURE 2

Number and percentage of drug overdose deaths involving illicitly manufactured fentanyls, by xylazine detection or co-involvement — State Unintentional Drug Overdose Reporting System, 31 states and District of Columbia, January 2021–June 2022 Abbreviations: DC = District of Columbia; IMF = illicitly manufactured fentanyl; SUDORS = State Unintentional Drug Overdose Reporting System. * A drug was considered involved or co-involved if it was listed as a cause of death on the death certificate or in the medical examiner or coroner report. ^† Fentanyl was classified as likely illicitly manufactured using toxicology, scene, and witness evidence. For the 8% of deaths involving fentanyl that had insufficient evidence for classification as illicit or prescription, fentanyl was classified as illicit because the vast majority of fentanyl overdose deaths involve illicit fentanyl. All fentanyl analogs except alfentanil, remifentanil, and sufentanil, which have legitimate human medical use, were included as IMFs. ^§ Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Utah, Vermont, Virginia, Washington, and West Virginia. Illinois, Louisiana, Pennsylvania, and Washington reported deaths from counties that accounted for ≥75% of drug overdose deaths in the state in 2017, per SUDORS funding requirements; all other jurisdictions reported deaths from the full jurisdiction. Jurisdictions were included if data were available for the full period of January 2021–June 2022, including toxicology reports for ≥75% of deaths. Analysis was restricted to decedents with an available toxicology report; or, if no toxicology report was available, deaths were also included if xylazine was listed as part of the cause of death on the death certificate. Four funded states were excluded from analyses because they were known to have not tested for xylazine during the analysis period. Toxicology report data were not available for ≥75% of all deaths in eight states with complete death certificate data for January 2021–June 2022, and they were therefore excluded from analyses, but death certificate data identified IMF-involved deaths with xylazine co-involved: Alabama (46 deaths), Florida (261), Indiana (82), Mississippi (10), Missouri (93), New York (735), South Carolina (178), and Tennessee (167).