The first responder community has seen the rapidly expanding US drug overdose crisis over the past few decades. Many responders have witnessed first-hand increases in overdoses driven by prescription opioids (2007-2013), heroin (2014-2015) and illicitly manufactured fentanyl (2016-present). In recent years, experts have suggested that there is a need to examine novel synthetic compounds and polysubstance use patterns.

In 2021, there were 106,699 drug overdoses in America, according to the Centers for Disease Control and Prevention (CDC). Synthetic opioids, other than methadone, (primarily fentanyl) were the main driver of drug overdose deaths with a nearly 7.5-fold increase from 2015 to 2021. The chemicals used to make fentanyl are sold by China to Mexican drug cartels, according to a 2020 report by the U.S Drug Enforcement Administration (DEA). The cartels package the fentanyl for distribution on the US black market. Often the fentanyl is disguised as drugs like Xanax or Adderall, even “look alike” children’s candy.

Most first responders are already aware of the fentanyl crisis, and some spend a significant amount of their time responding to victims of opioid overdose.

But, despite all this, it gets worse. In this blog I will discuss a substance being added to fentanyl, that can produce a “zombie-like” trance for up to 8 hours and horrendous soft tissue wounds often requiring amputations.

Xylazine and Fentanyl

Xylazine (Rompun®, Sedazine®, AnaSed®) is not a new drug. It was studied in the 1960s as a potential drug to manage hypertension but never approved in humans due to severe central nervous system sedation. It was approved by the FDA for veterinary use only as a sedative with analgesic and muscle relaxant properties.

Xylazine is used to calm and facilitate handling, performing diagnostic and surgical procedures, relieving pain, or acting as a local anesthetic in both large and small animals.

“Tranq,” as xylazine is called on the streets, is a non-opiate sedative which is not currently on the controlled substance list. Xylazine is sold directly to veterinarians in liquid solutions of 20, 100, and 300 mg/mL. It is also available on websites from Chinese suppliers in both powdered and liquid form at very low prices. These sites often do not verify the purchaser’s association to the veterinary profession or the intended use of the drug.

Initially noted in the street opioid supply of Puerto Rico over two decades ago, tranq has made its way into many American inner cities. According to the DEA, xylazine is mixed with a number of illicit drug mixtures (ie; fentanyl, heroin, cocaine). At its low price, tranq is used as an adulterant to increase the drug trafficker’s profits while reducing the amount of fentanyl or heroin in the mixture.

An adulterant is a substance added to a product but not listed as an ingredient, or a substance that ends up in a product by accident when the product is made. Of course, street dealers do not include ingredient labels nor precautions as would FDA approved products purchased in your local drug store. Some users (who inject drugs) look for the longer-lasting euphoria in the tranq mix rather than the short euphoria of fentanyl alone. Others may not be aware tranq was included as an adulterant.

According to DEA data, the number of xylazine-positive overdose deaths in the US increased by 282% from 2020 to 2021 (808 to 3098). They do recognize that the statistics are an underestimation since the CDC does not include xylazine in its national fatal overdose stats and not all jurisdictions routinely test for xylazine in their postmortem toxicology.

According to the Philadelphia Department of Public Health, in 2021, 90% of their “street” opioid samples contained xylazine. As fentanyl has overtaken heroin in Philadelphia, fentanyl is no longer the adulterant, but it is now the primary opioid and xylazine is the most common adulterant in the street drug supply. The update went on to provide guidance to the medical community on xylazine-related clinical management (eg; withdrawal management, increased overdose fatality risk, wound care and harm reduction).

Last year New Jersey was at 30% street opioid samples containing xylazine and recently nearly 20% of New York City opioid-involved overdose deaths involved xylazine.

What About Your Community?

What have the emergency departments been seeing, or worse, the medical examiners finding on autopsy?

Xylazine can be swallowed, inhaled, smoked, snorted, or injected into the muscle or vein. All injection drug users have a risk of cellulitis or abscess that can lead to lengthy healing time. However, tranq injection users often have severe necrotic wounds, dysfunctional limbs, and infections right down to the bone that require extensive treatment and frequent amputations. One user described observing another users arm turn completely black the day after he missed the vein.

Xylazine will have a rapid onset within minutes and can last 8 hours depending upon the dose, way it was taken, and whether it was mixed with an opioid or other drug. Initially users become sleepy with a dry mouth. Their heart rate and blood pressure will drop. With increasing dose, they may become comatose with constricted pupils, their muscles can become floppy and their body temperature can even drop. Eventually breathing will decrease and eventually stop. This can look very similar to an opioid overdose.

In the field it is difficult to clinically determine if someone has taken xylazine or an opioid or both. Xylazine should be suspected if the patient appears to have an opioid overdose with constricted pupils (miosis), depressed respirations, unresponsive mental status, no response to naloxone (Narcan®) and has bradycardia and hypotension.

As xylazine is not an opioid, it does not bind to opioid receptors, so naloxone does not reverse its effects. That is not to say that naloxone should not be used as it will assist in the respiratory depression effects of the opioid drug but the patient’s mental status can remain altered for a long time, requiring airway management, due to the ongoing effects of the tranq. 

Prehospital management is supportive. The airway should be secured, and ventilations provided. Monitor the vital signs and ECG. Atropine or low dose epinephrine should be considered to improve the heart rate and blood pressure (BP). The BP should respond to fluids or if a pressor is needed, norepinephrine (Levophed ®) is a preferred agent (follow local protocols).

How to Stay Vigilant

• Know your community and the substances “on the street.”
• Gauge suspected overdose patient response.  If they do not respond right away to ventilations and Narcan, there may be multiple drugs involved, so continue to support the airway, ventilations, vital signs, and transport per local protocols.
• Maintain situational awareness throughout the call and always be careful out there!

For more information refer to:

• The Growing Threat of Xylazine and its Mixture with Illicit Drugs, DEA Joint Intelligence Report, DEA-DCI-DIR-001-23, October 2022.
• DEA PRB# 2021-15, Drug Enforcement Administration, Diversion Control Division, Drug & Chemical Evaluation Section.
• Message #: PDPH-HAN-00417U-12-08-2022, Philadelphia Department of Public Health.
• Jalal H, Buchanich JM, et al. Changing dynamics of the drug overdose epidemic in the US from 1979 through 2016. Science. 2018;361(6408):eaau1184. Doi:10.1126/science.aau1184.
• https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates (accessed 2/11/23).

• What the Resuscitation of Damar Hamlin Teaches Us About CPR Training

About the author:

Bob Elling, MPA, EMT-P has been involved in EMS since 1975. He was a paramedic with the Town of Colonie EMS Department, Times Union Center, and Whiteface Mountain Medical Services. He is a retired clinical instructor from Albany Medical Center and worked in the Hudson Valley Community College Paramedic Program. He has served as National and Regional Faculty for the American Heart Association (AHA), and as Regional Faculty for the New York State Bureau of EMS. He was also a paramedic and lieutenant for New York City EMS, paramedic program director and associate director of the New York State EMS Bureau, and an education coordinator for PULSE: Emergency Medical Update. He is the ECSI Medical Editor for CPR and First Aid Series of products.