As he approached a van that distributes safe supplies for drug use in Greenfield, Mass., a man named Kyle noticed a warning about xylazine.
“Xylazine?” he asked, pronouncing the unknown word. “Tell me more.”
A Tapestry Health street outreach team delivered what is becoming a routine alert. Xylazine is a sedative for animals. It’s not approved for humans, but it’s found in about half of the drug samples Tapestry is testing in the rolling hills of western Massachusetts. It is mainly found in the illegal fentanyl stock, but also in cocaine.
Kyle rocked back on his heels at the mention of cocaine. He and his friends regularly use cocaine, but lately they suspected that there was something else in the bag.
“For the past week, we’ve all been racking our brains like, ‘What’s going on?'” he said. “Because if we cook it and smoke it, then we fall asleep.”
(NPR and KHN use first names in this story for people who use illegal drugs.)
Kyle’s deep sleep could also have been caused by fentanyl, but Kyle said one of his friends used a test strip to check for the opioid and none was detected.
Xylazine rose first in some areas of Puerto Rico and then in Philadelphia, where it was found in 91% of opioid samples last year, the most recent reporting period. Data from January to mid-June shows that xylazine was present in 28% of drug samples tested by the Massachusetts Drug Supply Data Stream (MADDS), a state-funded network of community drug control and counseling groups that use mass spectrometers to monitor people. inquire about what is in sachets or pills that you have bought on the street.
Some parts of the state, including western Massachusetts, see xylazine in 50% to 75% of samples. In Greenfield this is a big change compared to last year, when xylazine was not a problem.
“We’ve seen an exponential increase during the pandemic,” said Traci Green, who oversees MADDS and leads the Opioid Policy Research Collaborative at Brandeis University. “The sad thing is we really see it all over the state. It’s absolutely dangerous.”
There is much speculation about how and why xylazine is on the rise. It can be added to fentanyl or heroin to prolong the effects of an opioid high. Dealers can also use this relatively inexpensive and easy-to-order tranquilizer because of supply chain gaps with other drugs.
Whatever the route to the drug supply, the presence of xylazine is triggering warnings in Massachusetts and beyond for many reasons.
As xylazine rises, so do overdoses
Perhaps the biggest concern is an association with more overdoses and deaths. In a study in 10 cities and states, xylazine was found in less than 1% of overdose deaths in 2015, but at 6.7% in 2020, a year in which the US set a new record for overdose deaths. That record was broken again in 2021 with more than 107,000 deaths.
The study doesn’t claim xylazine causes more fatalities, but study co-author Chelsea Shover said it could contribute. Xylazine, a sedative, slows breathing and heart rate, and also lowers blood pressure, potentiating some of the effects of an opioid such as fentanyl or heroin.
“If you have an opioid and a sedative, those two things together will have stronger effects,” said Shover, an epidemiologist at UCLA’s School of Medicine.
In Greenfield, Tapestry Health is responding to more overdoses as more tests show the presence of xylazine.
“It correlates with the turnout, and it correlates with Narcan being ineffective at reversing xylazine,” said Amy Davis, deputy director for rural damage control operations at Tapestry. Narcan is a brand name of naloxone, an opioid overdose medication.
“It’s scary to hear that something new is going around that might be stronger than what I’ve had,” said May, a woman who stopped by Tapestry’s van. May said she has a strong tolerance for fentanyl, but a few months ago she started getting something that didn’t feel like fentanyl, something that “knocked me out before I could even put my stuff away.”
A varying response to an overdose
Davis and her colleagues ramp up the safety messages: never use alone, always start with a small dose, and always carry Narcan.
Davis also changes the way they talk about drug overdose. They start by explaining that xylazine is not an opioid. Spraying naloxone in someone’s nose won’t undo a deep xylazine sedation — the rescuer won’t see the dramatic awakening that’s more common when giving Narcan after an opioid overdose.
With xylazine, the immediate goal is to ensure that the person gets oxygen to the brain. That’s why Davis and others recommend starting ventilators after giving the first dose of Narcan. It can help restart the lungs even if the person doesn’t wake up.
“We don’t want to be focused on consciousness — we want to be focused on breathing,” Davis said.
Giving narcan is still critical because xylazine is often mixed with fentanyl and fentanyl kills people.
“If you see someone you suspect has an overdose, please give Narcan,” said Bill Soares, an emergency room physician and the director of harm reduction services at Baystate Medical Center in Springfield, Massachusetts.
Soares said calling 911 is also critical, especially with xylazine, “because if the person doesn’t wake up as expected, they need more advanced care.”
‘Major sedation’ worries health care providers
Some drug users say xylazine knocks them out for six to eight hours, raising concerns about the possibility of serious injury during this “profound sedation,” said Dr. Laura Kehoe, medical director of Massachusetts General Hospital’s Substance Use Disorders Bridge Clinic.
Kehoe and other clinicians are concerned about patients numbed by xylazine lying in the sun or snow, perhaps in a remote area. They can be vulnerable to compression injuries from lying in one position, or they can be attacked.
“We see people who have been sexually abused,” Kehoe said. “They’ll wake up and find that their pants are down or their clothes are missing, and they’re totally oblivious to what happened.”
Kehoe argues that the increase in xylazine increases the need for supervised consumption clinics, where people can use drugs under the supervision of trained staff. Legislation that would have allowed for a pilot program in Massachusetts died in the State House committee this year.
Newton Police Chief John Carmichael, chairman of the Massachusetts Chiefs of Police Association’s Substance Abuse Commission, opposes supervised consumption. Carmichael says that in his experience, people who buy illegal drugs use them immediately and don’t take the time to travel to any of these sites.
“I just don’t see how these sites would really be effective,” said Carmichael, adding that he’d rather just focus on getting people into treatment. “I think we have an obligation to do that more.”
A study conducted in Vancouver, Canada showed an increase in treatment as the city added overdose prevention sites.
A recent study from France found that people who use clinics for supervised consumption have fewer boils and abscesses associated with injections. Clinicians say that’s especially appealing now, with xylazine.
In Greenfield, nurse Katy Robbins pulled out a photo of a patient seen in April when the xylazine contamination surged.
“We kind of went, ‘Wow, what’s that?'” Robbins recalled, examining her phone.
The image shows a wound such as a deep rash, with an exposed tendon and a spreading infection. Robbins and Tapestry Health have created networks so that customers can make same-day appointments with a local doctor or hospital to treat this type of injury. But it’s hard to get people to show their wounds.
“There is so much stigma and shame around the use of injection drugs,” Robbins said. “Often people wait until they have a life-threatening infection.”
That may be one of the reasons amputations are on the rise for people who use drugs in Philadelphia.
“We’re definitely seeing a lot more wounds and we’re seeing some serious wounds,” says Dr. Joe D’Orazio, the director of medical toxicology and addiction medicine at Temple University Hospital in Philadelphia.
D’Orazio and his colleagues are still trying to figure out why wounds get worse with xylazine. They may not heal as quickly because xylazine reduces blood flow. Some patients also report increased skin picking with xylazine.
“Almost everyone links this to xylazine,” D’Orazio said.
This story comes from a reporting partnership that includes: WBURNPR and KHN (Kaiser Health News).