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How a Cattle Tranquilizer is Exacerbating |
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Author: Madeline Roberts, PhD, MPH and Katelyn Jetelina, PhD, MPH Mortality data for 2022 shows that the U.S. experienced an unprecedented number of overdose deaths: 106,699— a 747% increase since 2001. It’s not surprising that the National Institutes of Health ranks opioid addiction as a top public health concern for Americans. The Joint Economic Committee estimated the opioid epidemic cost the United States nearly $1.5 trillion in 2020, which included costs for health care, criminal justice, and lost productivity. Most recently, xylazine–an FDA-approved drug for veterinary medical use as a cattle tranquilizer–is complicating the picture. Perhaps in part because it is not a controlled substance and thus may be less subject to detection by law enforcement, xylazine has worked its way into the illicit drug supply. US Drug Enforcement Administration (DEA) lab results show xylazine is found most commonly in polydrug mixtures; the DEA describes it as an adulterant in the illicit fentanyl drug supply. Dealers are cutting illegal fentanyl/opioids with it, and the effects have been devastating. The American epicenter for a time was Philadelphia, but xylazine has now been detected in the illegal drug supply in 48 states. While the highest number of xylazine-positive lab identifications remain in the Northeast, the largest percent increase in has more recently been in the South where xylazine-positive overdose deaths have correspondingly increased 1,127% between 2020 to 2021. From a medical standpoint, xylazine depresses the Central Nervous System—respiratory function, heart rate, and blood pressure all decrease with its use. When used in combination with opioids, xylazine increases the risk of overdose. It also can leave necrotizing soft tissue wounds—truly horrific flesh wounds that are responsive to treatment, but if left untreated can require amputations or be life-threatening. Getting and maintaining proper wound care can be especially difficult for unhoused individuals. In March 2023, the FDA approved a drug, Naloxone, used to counter the effects of opioid overdose, particularly depressed respiratory function. Often referred to by one of its trade names, Narcan, Naloxone is a nasal spray that binds tightly to the same receptors as opioids and blocks actual opioids from taking effect. It is considered so important that it’s on the WHO model list of essential medicines. But it isn’t a magical antidote, per se. In 2020 and 2021 Naloxone was administered in around 20% of opioid overdose deaths. So, if Naloxone really is a life-saving drug, why did some people to whom it was administered still die? Three main reasons:
On March 29, 2023 the FDA approved Narcan for over-the-counter (OTC) or non-prescription use. This was a big deal as it made the drug easier to obtain in times of emergency. This approval resulted in the availability of Narcan in convenience stores, gas stations, even vending machines in New York City. One big concern, though, is that availability is different from administration. An education campaign is greatly needed to increase self-efficacy—the signs of an overdose, how to administer Naloxone, when, and what to do afterwards. For pricing, Emergent released a statement saying their goal is for the out-of-pocket retail price to be less than $50, which is their current charge to public interest groups like government agencies and nonprofit organizations. Importantly, because xylazine is not an opioid, Naloxone is of no use in reversing its effects or restoring respiratory function. Administering Naloxone is still advised in the event of overdose because xylazine is so often mixed with opioids—Naloxone can counter the effects of the opioid component, but xylazine may mitigate its effectiveness. On April 12, 2023, the Office of National Drug Control Policy (ONDCP) identified xylazine in combination with fentanyl as an emerging threat to the United States. On September 22, 2023, the DEA and the Department of Homeland Security issued a joint statement on pathways by which xylazine is entering the US, which concluded that import (from China and other countries), diversion (from veterinary drug supplies), and to a lesser degree, smuggling over the southwest border were the primary sources. China had previously placed production and sale restrictions on common ingredients for illicit drugs, however, deteriorating US-China relations are possibly implicated in a change of China’s position.
In July 2023, the ONDCP released the
Fentanyl Adulterated or Associated with Xylazine Response Plan,
with the stated goal of “a 15% reduction (compared to 2022 as the
baseline year) of xylazine-positive drug poisoning deaths in at least
three of four U.S. census regions by 2025.” The Plan outlined six
action areas:
♦ Standardization of testing and deployment in communities; ♦ Development of a comprehensive epidemiologic data system; ♦ Evidence-based prevention, harm reduction strategies, treatment development and deployment, and capacity building among service providers; ♦ Source and supply identification, and supply reduction actions; ♦ Regulatory pathways to disrupt production and distribution; ♦ Basic and Applied Research—ranging from treatment development to user motivation There is extraordinary, encouraging work already being done in community-based programs and nonprofit settings. ■ |
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