Tranq – the Next Drug Scourge

Fentanyl has a new rival

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by Dr. Derek Kerr

••••••• April 6, 2023 •••••••

Major East Coast cities are ravaged by “Tranq” or “Zombie Dope.” Tranq refers to a combo of fentanyl plus xylazine - an animal sedative and pain reliever commonly used to calm horses and cattle before veterinary procedures. Although not approved for humans, xylazine is being mixed into fentanyl, heroin and other street drugs, resulting in a zombie-like daze, intractable overdoses, and rotting ulcerations of the skin and soft tissues. Xylazine was detected in 34% of all overdose deaths in Philadelphia in 2021. And it’s spreading. According to the Drug Enforcement Administration (DEA), “Xylazine is making the deadliest drug threat our country has ever faced, fentanyl, even deadlier.".

Data compiled by the DEA shows a galloping step up in xylazine’s infiltration of street drugs;

Source: DEA

While Western states are relatively spared, identification of xylazine in confiscated drug samples doubled from 2020 to 2021. That’s an undercount because testing for xylazine is not a routine procedure in most jurisdictions. Just as fentanyl adulteration of the East Coast drug supply took a few years to migrate out West, it’s likely that xylazine will eventually assail San Francisco. Xylazine has recently been detected in overdose cases and drug seizures in Los Angeles, San Diego, and San Francisco.

Xylazine is just one of dozens of synthetic drugs infiltrating North American fentanyl and heroin supplies. For example, in British Columbia, Canada, 52% of overdose deaths showed traces of etizolam, a benzodiazepine similar to Valium. Like “Tranq," this “Benzo-dope” is causing more fatal overdoses, zombie-like intoxication, and complex addictions that are harder to treat than simple fentanyl dependency.

Government Warnings

Tranq contamination of the drug supply has surged so strikingly that the Food and Drug Administration issued a warning to Health Departments and physicians in November, 2022. Notably, Xylazine’s “toxidrome may appear similar to that of opioids, making it difficult to distinguish between toxicity from opioids versus xylazine. Of note, naloxone is not known to be effective in reversing overdoses involving xylazine, as xylazine is not an opioid.” In other words, Narcan - the agent that is used to treat heroin and fentanyl overdoses - doesn’t reverse the effects of xylazine.

Moreover, “Repeated exposure may also result in dependence and withdrawal. Withdrawal symptoms such as agitation or severe anxiety may occur when usual doses of the drug are decreased or discontinued.” Since xylazine is not an opioid, drugs like methadone and Suboxone aren’t helpful in treating withdrawal symptoms or managing detoxification.

Alarmingly, “Repeated exposure to xylazine, by injection, has been associated with severe, necrotic skin ulcerations that are distinctly different from other soft-tissue infections (e.g., cellulitis, abscesses) often associated with injection drug use. These ulcerations may develop in areas of the body away from the site of injection.” Some of these ulcers worsen quickly, become life-threatening and require amputations.

Xylazine in San Francisco

The City’s Department of Public Health (DPH) and the Office of the Chief Medical Examiner (OCME) launched an investigation, outlined in a 2/16/23 “Xylazine Media Statement.” Of note, “Testing overdose decedents who died between mid-December 2022 and mid-January 2023, the OCME found, so far, that four individuals who had died of drug overdoses had low levels of xylazine in their systems.”

Unfortunately, the DPH Media Statement failed to disclose the denominator, i.e., how many overdose cases were sampled before reaching four positive xylazine cases. The Westside Observer contacted David Serrano Sewell, Executive Director of the OCME. Turns out, 4 of 145 cases (2.8%) were initially positive for xylazine. The OCME obtained a State grant to retest overdose deaths from 2022 and implement a xylazine surveillance program for 2023 and beyond. So far, 410 fatal overdose cases have been tested, and 7 or 1.7% showed xylazine.

Meanwhile, overdoses appear to be rising. For January and February of this year, the City saw 131 fatal overdoses. At that rate, we’re heading for 700-plus drug-related deaths. For the record, there were 725 overdose deaths in 2020, declining to 640 in 2021, and 647 in 2022. Around 72% of these deaths were attributed to fentanyl. If xylazine gains a foothold in the City, fatalities and injuries will climb.

Interestingly, the Medical Examiner's reports on overdose deaths do not include testing for benzodiazepines like etizolam - the "Benzo-dope" that infests Vancouver's drug scene. The Westside Observer asked the OCME about this apparent omission but received no reply.

So, xylazine is here, albeit not widespread. This February, DPH officials told the SF Chronicle that SF is relatively xylazine-free. The characteristically grotesque soft-tissue ulcerations haven’t yet been reported here. However, the SF AIDS Foundation has proactively published an informative handout for those who may use xylazine, or encounter xylazine users.

Why Xylazine?

What makes a horse tranquilizer desirable as a cutting agent for fentanyl? Drug users say that xylazine extends the intoxicating effects of fentanyl. Some like the “knock-out” effect that induces amnesia and a nap. Eventually, they keep using just to avoid getting sick.

But drug dealers usually “cut” their products to increase profits. According to a 2022 DEA report, “A kilogram of xylazine powder can be purchased online from Chinese suppliers with common prices ranging from $6-$20 US dollars per kilogram.” Compare that to $36,000 for a kilo of fentanyl. Ergo, diluting fentanyl with xylazine saves big bucks. What’s more, xylazine is not a controlled substance, so there’s less risk of law enforcement entanglements.

Police interdictions can create difficulties in acquiring fentanyl supplies. Under US pressure, China banned the unauthorized manufacture of fentanyl products in 2019. Whatever shortages followed were transient. Resilient traffickers simply find alternate sources - or cheaper substitutes with similar effects. Unfortunately for drug users, Tranq is worse than fentanyl, just as fentanyl is worse than heroin, and heroin is worse than Oxycontin.

As the Westside Observer previously reported, drug prohibitions tend to generate more potent and toxic substitutes. This dynamic spawns demand for “safe consumption sites," aka "overdose prevention sites" and now, “Wellness Hubs.” Such harm-reduction measures trigger concerns that San Francisco is enabling drug use - unless tied to robust recovery services. The City’s 2022 Overdose Prevention Plan seeks to enhance drug treatment services.

Crack-Down

For now, the US Department of Justice is working to tightly regulate the importation and distribution of xylazine. The FDA recently issued an Import Alert authorizing the seizure of xylazine products until their legitimate purpose can be verified. Several states have declared xylazine a dangerous drug and have restricted its use. Congress is working on the Combating Illicit Xylazine Act to declare xylazine an emerging drug threat, restrict it at the federal level, and enable the DEA to track its manufacture and distribution.

Reflecting the ever-worsening scope of the drug crisis, xylazine test strips are now available for drug users, health departments and harm-reduction organizations.

Unfortunately, plenty of analogous adulterants are waiting in the wings. Also looming are thousands of distressed persons who will self-medicate with whatever the drug market provides.

Dr. Derek Kerr is a San Francisco investigative reporter for the Westside Observer and a member of SPJ-NorCal. Contact: watchdogs@westsideobserver.com

April 6, 2023