The growing ubiquity of the veterinary tranquilizer Xylazine in Delaware's drug supply has left both drug users and healthcare providers grappling with a new challenge: identifying and treating Xylazine withdrawal. For now, healthcare providers say there is no consensus on how to manage Xylazine withdrawal, and that the transition from heroin to fentanyl and Xylazine may require the medical field to rethink previous rules.
Measuring the spread of Xylazine through Delaware’s drug supply is challenging, in large part because the state’s Division of Forensic Sciences does not provide up-to-date data on the number of drug samples seized by law enforcement that test positive for Xylazine. The agency’s most recent data – from the first half of 2022 – indicated that fewer than one in five drug samples tested in its lab contained Xylazine.
The Division is also still developing the capacity to test for Xylazine in post-mortem samples, so Delaware does not have any means to track the number of overdose deaths involving Xylazine.
But the half-dozen people in line outside of a mobile syringe exchange in downtown Dover in March paint a more dire picture. April, a woman in her late twenties who primarily uses methamphetamine, could recount her first encounter with what she believes was Xylazine six months ago.
"I remember waking up on the floor in a friend's living room, and I'm pretty sure I'd been laying there unconscious for hours," she said. "I was scared — that hadn't happened before.” Since then, April added that Xylazine has become a fact of life. “You can’t avoid it,” she said, “even though almost nobody wants to use it.”
The meteoric rise of Xylazine has captured the attention of public health departments and news outlets along the East Coast since last fall, with much of the attention centered on the most gruesome and recognizable symptom of chronic Xylazine use: the ulcer-like sores that appear on users’ bodies.
With little medical research on the impacts of Xylazine on humans – the drug is more commonly used to sedate horses for surgery – the exact mechanism by which Xylazine causes the ulcers is poorly understood. Unlike similar sores that develop when drug users accidentally inject fentanyl or methamphetamine into muscle tissue, the sores do not only appear at injection sites; instead, they can appear anywhere on the body. Notably, users who only smoke or inhale Xylazine also report the ulcers.
Far less attention has been devoted to Xylazine withdrawal, but for those gathered outside the mobile syringe exchange van in Dover, withdrawal challenges were a primary concern: after months of routine use, some fear that they have unintentionally become chemically dependent on Xylazine.
KC, a woman who says she has been using Xylazine for nearly a year, says that she initially struggled to distinguish between Xylazine withdrawal and opioid withdrawal; though Xylazine is often used as an additive in fentanyl – possibly to prolong the latter drug’s euphoric effects – it is not an opioid itself.
"It's hard to differentiate between the two," she said, because both "make you anxious and sweaty."
Dr. Jolomi Ikomi, Medical Director of Project Recovery at ChristianaCare, says there are key similarities between symptoms of withdrawal from Xylazine, opioids and alcohol.
“In all those cases, withdrawal symptoms include increased heart rates, anxiety, and restlessness,” he said, “but Xylazine withdrawal seems to be more intense, though doesn’t last as long.” Dr. Ikomi also noted that the characteristic sores are a sign that a patient may be suffering from Xylazine withdrawal, often in addition to withdrawal from other substances.
For people attempting to recover from substance use disorders, withdrawal is often a key barrier; Withdrawal symptoms can be overwhelming and, depending on the substance from which a person is recovering, potentially fatal.
“For people experiencing withdrawal from alcohol, we have well-established protocols,” said Dr. Ikomi. “The same is true for opioids – we can use opioid agonists like methadone and buprenorphine to manage symptoms. But there is no consensus on how to treat Xylazine withdrawal.”
Dr. Adriana Navas, the Medical Director for Brandywine Counseling and Community Services, oversees one of the largest medication-assisted treatment (MAT) programs in the state: an outpatient service that provides medications like methadone to those in recovery from opioid use disorder.
Navas says that when patients request higher doses of methadone despite already receiving high doses of the drug — a sign they are continuing to experience withdrawal symptoms — her team may suspect that some of the symptoms may be due to Xylazine withdrawal.
In those cases, her team will offer small doses of medications that may help with Xylazine withdrawal symptoms — with or without an additional methadone dose increase, depending on the patient.
Those can include a seven-day supply of medications like low-dose Clonidine, often used to treat high blood pressure and — in psychiatry — panic disorder and anxiety. Navas' clinic may also provide small doses of gabapentin, an anticonvulsant medication that is also used to treat pain.
“If these medications help it may be an indication that the symptoms experienced could be in part due to Xylazine withdrawal, rather than only opioid withdrawal," she said. "Urine can then be tested to confirm or rule out the presence of Xylazine in the system. We are just learning how to deal with this problem."
Dr. Varun Malayala, an addiction medicine specialist at an MAT clinic in Philadelphia and a part-time physician with ChristianaCare, takes a different approach: instead of providing gabapentin, his clinic provides patients small quantities of the anti-anxiety medication Ativan.
Meanwhile, Philadelphia’s Department of Public Health currently suggests treating Xylazine with medications that carry even greater risk of diversion into the illicit market, including ketamine and benzodiazepines – both of which also present addiction risks.
For now, emergency rooms are better-equipped to manage Xylazine withdrawal settings than outpatient MAT clinics.
But Ikomi says the two treatment settings both play a role in responding to Xylazine’s growing ubiquity. “We have found ways to manage Xylazine withdrawal symptoms, but what keeps people in the hospital are the ulcers,” he said. “If the ulcers are very severe – or if there are deep infections – we may need to keep a person in the hospital for a while, and we try to treat the pain to the best of our ability. But when they’re going to be discharged, we get them on medication-assisted treatment as quickly as possible. Methadone and buprenorphine are useful for treating opioid withdrawal, but they also help with pain management.”
However, Ikomi adds that healthcare providers offering medication-assisted treatment also need to consider increasing the doses of methadone and buprenorphine they provide patients – a response not only to Xylazine, but also to fentanyl. Much of the conventional wisdom surrounding opioid withdrawal treatment developed when heroin was the dominant opioid in Delaware’s drug supply. In the past half-decade, heroin has been overshadowed by fentanyl, which is significantly more potent and can therefore result in more intense withdrawals. “We can’t be as conservative with doses as we used to be,” said Dr. Ikomi.
For now, Delaware health care providers have assembled an initial strategy for responding to Xylazine — one that, in Ikomi's view, is a reason to be hopeful. That strategy isn’t exclusively focused on withdrawal management; Brandywine, for instance, recently launched a mobile wound care service for Xylazine users and purchased an order of Xylazine test strips to distribute in harm reduction kits alongside the opioid overdose reversal drug Naloxone.
But some Delaware drug users remain anxious that without a clear consensus on how to treat Xylazine withdrawal, their prospects for recovery will only become more difficult.
"We just keep getting sucked further into this," said KC as she packed a dozen fresh syringes into a hip bag. "It seems like the way out just gets further away."
