Attempts to ban an emerging drug threat are repeating the mistakes of the drug war, experts caution

Illicit fentanyl, the powerful opioid that is involved in more than 100,000 fatal drug overdoses every year, has completely shifted underground drug markets. In some places, it has completely replaced other opioids like heroin. The unpredictable nature of "dope" is part of what makes it so deadly.

But now a new drug is complicating the drug supply with even more grisly results. It's called xylazine, a commonly-used animal tranquilizer veterinarians routinely employ in their practice. For many years, in places like Puerto Rico and Philadelphia, xylazine has been mixed with heroin (and now, fentanyl) in what is known on the streets as "tranq dope." However, the drug mixture is increasingly spreading to new markets.

When injected, xylazine can cause devastating wounds, such as skin lesions that can become infected and in severe cases lead to amputation or even death. It also dangerously sedates people for up to eight hours, sometimes in vulnerable positions, while also complicating emergency responses in the case of an overdose.

Following the Biden Administration’s plan to address the growing prevalence of xylazine and the Drug Enforcement Agency’s warning against the drug issued in March, this month, Congress passed legislation restricting xylazine as a schedule III controlled substance, the same tier drugs like ketamine and buprenorphine (Suboxone) are placed in. It's a rank less regulated than marijuana and LSD, which are in schedule I. Fentanyl, cocaine and methamphetamine are in schedule II.

If the bill is passed by the Senate and signed by the president, those caught possessing, selling, manufacturing or transporting xylazine can face criminal penalties of up to 15 years in prison plus fines under the bill.

The legislation, officially named the Support for Patients and Communities Reauthorization (SUPPORT) Act of 2023, also increases access to opioid reversal medications like naloxone and medication-assisted treatment like buprenorphine or methadone for Medicaid beneficiaries, among other initiatives.

“Specifically, this bill increases treatment options for intensive inpatient care, allows law enforcement to crack down on illicit xylazine distribution [and] continues support for at-risk youth, among many other important provisions,” said Eastern Washington Congresswoman Cathy McMorris Rodgers, who helped pass the legislation.

However, many oppose making xylazine a controlled substance because they say it could inadvertently make people turn to even more dangerous drugs instead. Various states have already restricted xylazine without any evidence that these measures reduce overdoses, said Dr. Ryan Marino, an emergency medicine physician at Case Western Reserve University School of Medicine.

“It is unclear what these knee-jerk reactions are intending to accomplish besides imposing additional criminal charges on already vulnerable people who use drugs,” Marino told Salon in an email. “What we do know is that they will impede research on xylazine – like to find antidotes for humans and how to best treat wounds and withdrawal – and will create a significant burden on xylazine’s very important use in veterinary medicine.”

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Xylazine first entered Puerto Rico's drug supply in the early 2000s. By 2015, it had made its way to the U.S., with one study of drug overdoses in 10 cities reporting xylazine was detected in 1% of deaths. That number jumped to 7% by 2020. At this point, xylazine has spread to nearly every corner of the country, with one study of a group of syringe exchange programs in Maryland detecting xylazine mixed in with 80% of opioid samples.

More than one million Americans have died in the opioid overdose crisis since 1999. Last year alone, 111,000 people died from a fatal overdose and Americans are now dying from overdoses at a higher rate than they are from diabetes.

In the first “wave” of the overdose crisis in which people were dying primarily from overdosing on prescription painkillers, the federal government restricted access to these medications, which failed to address the underlying issue of hundreds of thousands of Americans who had already become addicted to them. The restriction of the drug supply pushed users to instead use unregulated drugs like heroin, which led to the second “wave” of the overdose crisis. 

A similar pattern happened when the federal government criminalized heroin, which also disproportionately impacted Black and brown communities and caused mass incarcerations of people of color. This led to the third “wave” of the overdose crisis, which involved deaths primarily caused by fentanyl, a synthetic opioid 50 times stronger than heroin detected in 88% of overdose deaths in 2021. Today, some are defining the current fourth "wave" as concurrent use of fentanyl and other drugs like xylazine, cocaine or methamphetamine.

One 2018 report published in The Journal of Law, Medicine & Ethics compared the criminalization of drugs to alcohol Prohibition in the 1920s, which caused consumers to drink spirits adulterated with toxins. 

“Production volumes of illicit drugs are so high, and drug trafficking is so profitable, that interdiction cannot raise prices enough to induce lower consumption,” according to the report. “Instead, supply-side suppression has encouraged traffickers to smuggle cheaper and more potent opioids.”

Louise Vincent, the executive director of the North Carolina Urban Survivors Union, said people are now becoming addicted to xylazine, which has its own withdrawal symptoms. The problem is, medications that are the golden standard for treating substance use disorders like buprenorphine do not work against xylazine.

“It's just like fentanyl,” Vincent told Salon in a phone interview in September. “Nobody wanted fentanyl, but people started to use it because it was what was around and they needed it to satisfy withdrawal.”

Marino said new substances are already turning up on the street and being used instead of xylazine, including benzodiazepines and synthetic opioids called nitazenes that can be even stronger than fentanyl.

“Instead of acknowledging that these policies are not working, and changing our approach to follow science and public health, we are still doubling down; in fact, the White House is even pushing for additional permanent scheduling for fentanyl right now,” Marino said. “Besides just not being helpful, these measures distract from other things that we could be doing to actually make a difference.”

While it’s unclear why xylazine is being mixed in the drug supply, some have also reported using xylazine to lengthen the euphoric effects of opioids. Although xylazine is not an opioid, it is still recommended to use opioid-reversal medications like Narcan or naloxone for a person who is suspected to have overdosed. One not yet peer reviewed study in mice did show promising signs that naloxone could reverse xylazine overdose, because although xylazine primarily acts on adrenergic receptors, there seems to be some activity at certain opioid receptors as well.

Some are urging the federal government to put the energy it would take to police xylazine into harm reduction efforts instead. For example, there are test strips available to ensure a drug supply has not been contaminated with xylazine, but in some states, xylazine test strips are still considered drug paraphernalia and are therefore illegal. Reversing legislation like this could improve access to a safe drug supply. Others have emphasized the importance of safe injection sites because of xylazine’s long sedation hours, which could make users vulnerable to assault or injury.

“In short, we need a lot of services that are not part of the criminal justice system, and we need to start funding public health approaches to this public health crisis,” Marino said.