Federal and state agencies, local health departments, and health care providers across the country have become increasingly concerned about the rise of xylazine, an adulterant often found in combination with fentanyl and also mixed with heroin, stimulants like methamphetamine and cocaine, and other substances. It is often reported with two or more drugs present. A non-opioid sedative, analgesic, and muscle relaxant approved for veterinary use, but not for humans, xylazine can complicate diagnosis of overdose related to polysubstance use, interfere with treatment of opioid use disorder (OUD), and cause severe necrotic skin ulcerations.1
What are its effects and why is it dangerous?
The Drug Enforcement Administration (DEA) warns that xylazine can increase the chances of overdose deaths when mixed with synthetic opioids like fentanyl because it has similar pharmacological effects and can increase respiratory depression. Users have reported effects similar to opioids.2 The FDA warns that xylazine exposure may delay diagnosis and management of overdoses involving multiple drugs, cause severe, necrotic skin ulcerations, and hinder treatment of OUD.3 Another danger of xylazine is that patients can become incapacitated for a long period of time, making them susceptible to assault or other harms such as hyperthermia.4
Testing for xylazine
Xylazine may be more widespread than testing indicates. Routine toxicology screens do not detect it, and with the additional analysis required, it may still be missed because it is eliminated from the body rapidly.5 Xylazine test strips are emerging but have not been validated yet.6
Patterns of distribution
Xylazine has been found in all four census regions, having appeared first in the Northeast, then the South, then the Midwest and West (similar to the movement of fentanyl). Its use as an adulterant is expected to increase, including in fentanyl. As of October 2022, xylazine powder could be bought online for around $6 to $20 per kilogram, a low cost that may make it lucrative as an adulterant mixed with fentanyl or heroin.7
What can be done?
Naloxone may be less effective when xylazine is present because it is not an opioid itself. But administering naloxone can still save lives by addressing the effects of opioids.8 If patients present with overdose and do not respond to naloxone, health care providers should consider exposure to xylazine. If withdrawal symptoms do not respond to traditional OUD treatments, it may also be a sign of exposure to xylazine.9 For harm reduction, providers can warn patients that xylazine is heavily present in street drugs, lasts longer than opioids do, and is found in stimulants as well as opioids. Skin ulcerations from injecting xylazine, which can be in the area of injection or elsewhere on the body, should be treated right away.10
SELECTED RESOURCES ON XYLAZINE
Overviews from federal and state agencies
In-depth studies, webinars, podcasts, and news articles
[1] Drug Enforcement Administration (DEA). (2022, October). The growing threat of xylazine and its mixture with illicit drugs. U.S. Department of Justice; U.S. Food and Drug Administration (FDA). (2022, November 8). FDA warns about the risk of xylazine exposure in humans [Letter to stakeholders].
[2] DEA. (2022, October).
[3] FDA. (2022, November 8).
[4] Walker, W. (Host), Stancliff, S., & Skill, L. (Guests). (2023, February 9). What we know about xylazine [Audio podcast episode]. In Conversations with CEI. Clinical Education Initiative, New York State Department of Health AIDS Institute.
[5] FDA. (2022, November 8).
[6] Ramsey, K. S. (2023, February 16). Xylazine (aka, tranq or tranq dope or anestesia de caballo): An Overview [Webinar]. Learning Thursdays. New York State Office of Addiction Services and Supports.
[7] DEA. (2022, October).
[8] DEA. (2022, October).
[9] FDA. (2022, November 8).
[10] Walker et al. (2023, February 9).