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

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

Joseph Friedman  1 , Fernando Montero  2 , Phillippe Bourgois  3 , Rafik Wahbi  4 , Daniel Dye  5 , David Goodman-Meza  6 , Chelsea Shover  7
Affiliations

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

Joseph Friedman et al. Drug Alcohol Depend. .

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.

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Conflict of interest statement

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1.
Fig. 1.
Xylazine-Present Overdose Deaths by Jurisdiction and Year. Xylazine-present deaths are show as counts and as a percent of all overdose deaths in text. Color indicates US census region. Values for 2021 represent estimates, should trends from the observed fraction of the year continue linearly.
Fig. 2.
Fig. 2.
Geographic Distribution of Xylazine Positivity in Overdose Deaths. This figure summarizes the geographic distribution of xylazine positivity in overdose deaths in the full database of 14 locations. Point shape corresponds to type of jurisdiction. Color corresponds to the magnitude of xylazine positivity in the most recent year of data available for each location. Values for 2021 represent estimates, should trends from the observed fraction of the year continue linearly. The time period shown in each point can be seen in Supplemental Table 1.
Fig. 3.
Fig. 3.
Drug Overlap in Xylazine-Present Overdose Deaths. Data are shown for the jurisdictions where drug overlaps with xylazine could be determined, for the six most commonly observed drug combinations in each jurisdiction. Each column corresponds to one cluster of drug classes. The drugs present in each cluster of deaths is indicated in the bottom panel, by the presence of a solid dot. The top panel shows the percent of all xylazine-present overdose deaths in that jurisdiction pertaining to each cluster. Color indicates the total number of drug classes implicated in each cluster. “Fentanyl” refers to any analog in the fentanyl family.
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