Drug users and harm reduction workers in Delaware report the veterinary tranquilizer Xylazine is increasingly seen in the state’s drug supply, especially in fentanyl sold in New Castle County.
Xylazine isn’t yet well-understood by drug and public health researchers, leaving users and outreach workers to begin searching for ways to adapt.
Xylazine is appearing more frequently in pills and powders tested by the Delaware State Police forensic chemistry unit: about 15% of evidence tested between October 2021 and July 2022 found some Xylazine - also called Tranq. However, because Xylazine is not a controlled substance, those tests were only conducted for research purposes and its presence was not officially confirmed.
But participants in a New Castle County needle exchange program say that the drug may be more widespread than the state's testing suggests. They describe an array new challenges presented by Xylazine.
Christina, who asked to be identified by her first name alone, says the initial high can be overwhelmingly intense, sometimes causing falls in which users can seriously injure themselves.
“It slows you down so much that even when you try to stand up slowly, you feel like you’re going to pass out – no matter what," she said. "Your head feels like a bowling ball and your ears ring. You’re going to pass out.”
Christina suggests that users lay down before injecting to avoid falls. Claire Zagorski, a research assistant at in the school of Pharmacology at the University of Texas in Austin, says there's another reason for Xylazine users to lay down.
"Tranq is so sedating that we're seeing people who don't respond to pain for 18 to 24 hours," she said. "In a couple of instances — at least that I know of — people have sat bent over on a doorstep for so long that they cut off blood flow to their legs. That should be horribly painful, but with Xylazine, people are waking up too late with hugely swollen, discolored limbs. They have to be rushed to the hospital to try and save them, but there's sometimes nothing to do but amputate."
Zagorski adds that Xylazine users try laying on their side with their knees tucked into their stomach to maintain circulation.
Christina and other participants in the needle exchange program also suggested that caffeine pills could help them recover from the most intense phase of the high.
Dr. Nabarun Dasgupta, who runs the street drug analysis lab at the University of North Carolina, says the pills could make sense in the absence of a clearer medical understanding of Xylazine’s impact.
"The next question I would be asking," he said, "is what is it like when they wake up."
Zagorski notes that some Xylazine users may also use stimulants to balance the effect of the tranquilizer.
"It's becoming more and more common to see folks that are injecting a little bit of cocaine or meth with their Tranq," she said, though she underscored that accidentally injecting stimulants into muscle can damage tissue and require medical attention.
Caffeine, she said, "may be the safest and most easily available option for people at the moment."
Dasgupta added that while the value of caffeine pills as a stimulant hasn't been proven medically, the pills' sugar content — or any other sugar-rich food — may be useful in and of itself.
"Xylazine causes a temporary and pretty massive drop in blood sugar," he said, "and it could be that sugar could help someone feel better as they're coming back."
More visibly, Christina and others point to ulcers in their skin – some so deep as to expose bone – left after injecting Xylazine.
C, who asked not to be identified by name, recommends outreach workers distribute wound care supplies like gauze, saline solution and antibiotics: a lesson she learned after an ulcer claimed a large portion of her forearm.
“Things like these, and bandages," she said. "I get a cream from the pharmacy, too. Wound cleaning is very helpful.”
Dasgupta says these wounds resemble burns and should be treated similarly.
“It’s going to heal like a burn – from the inside up – and not like an abscess that heals from the outside in," he explained, suggesting that outreach teams could consider distributing water-based antibiotics and burn kits.
While the ulcers can appear if a user accidentally injects Xylazine into their muscle or fat instead of into a vein, Dasgupta notes that the drug is unusual in that users report ulcers in places where they've never injected.
Jessica, another participant in the needle exchange program, offered her own experience as an example.
"It's not like the abscesses we used to get when you would miss a vein," she said. "It can happen in weird places, and you're just left with a hole." In her case, an ulcer on her wrist left her unable to use one of her hands.
Yonah Hicks, a member Brandywine Counseling and Community Service's mobile outreach team in Dover, pointed out that after wounds form scar tissue, users need longer and thicker needles to reach a vein. She says her team have seen a spike in demand for the longest needles they have in stock.
"There's been a really serious shift in what people are asking for," Hicks said, "and that's part of adapting so we can help people as Tranq shows up everywhere."
Meanwhile, the increasing presence of Xylazine could present some more fundamental messaging problems for harm reduction programs. Dasgupta pointed out that because Xylazine is not an opioid, people who regularly use it in combination with fentanyl might have trouble transitioning into a medication-assisted treatment program for opioid use disorder: programs that use weaker opioids like methadone to help people scale down their drug use while mitigating the potentially lethal effects of withdrawal.
Similarly, because Xylazine does not respond to the opioid overdose-reversal drug naloxone, some users expressed concerns that they may not know whether naloxone will help revive a person who has lost consciousness. Dasgupta says those sentiments could become a problem for harm reduction efforts, which often rely heavily on distributing naloxone.
"If the rumor that '[naloxone] isn’t working' gets purchase, then it will falsely weaken the resolve of having naloxone on hand," he said. "What we ask is that people count breaths when they encounter someone who has gone out after using drugs, not just gauge unresponsiveness." Even when unconscious from Xylazine, he said, a person will likely breathe normally; if they are overdosing from fentanyl, they will not.
Dasgupta and Zargoski emphasized that while Xylazine has existed as a veterinary drug for decades, substantial research into its impact on humans has only just begun. The suggestions and stories offered by users like those in New Castle County, Zargoski added, are vital to helping shape a public health response. "At this point, we have to crowdsource," she said.
