Overdoses Involving Xylazine Rose 34-fold Between 2018 and 2021

Xylazine was involved in nearly 3,500 deaths in 2021

A new report from the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) examined the literal texts of death certificates, searching for overdose deaths involving xylazine between 2018 and 2021.^[1]

The research uncovered an explosive rise in xylazine-related deaths, especially on the East Coast and among Black men.

Xylazine was involved in just 102 fatal overdoses in 2018. By 2021, that figure had risen to 3,468—a staggering 34-fold increase in just three years.

Over the same period, the death rate associated with the drug rose from 0.03 deaths per 100,000 people to 1.06 deaths per 100,000 population. 

However, xylazine isn’t hitting Americans evenly. The death rate among men was at least twice that among women in each year between 2018 and 2021. 

Additionally, in 2020 and 2021, the only years in which race and ethnicity were analyzed, rates were highest among Black people, increasing from 0.68 deaths per 100,000 people in 2020 to 1.82 in 2021, compared to 0.58 to 1.21 among white people.

The xylazine death rate was markedly higher in the Mid-Atlantic (Region 3, including Pennsylvania, Delaware, Maryland, the District of Columbia, Virginia, and West Virginia) at 4.05 per 100,000 standard population, reflecting the drug’s early emergence in Philadelphia. 

The surrounding regions have also seen xylazine deaths, which hit 2.62 per 100,000 population in New England and 2.44 in New York and New Jersey. However, west of the Mississippi, xylazine deaths were negligible and several regions didn’t meet the NCHS reliability criteria of 20 deaths or more. 

Xylazine: a deadly non-opioid sedative

Xylazine is a non-opioid tranquilizer, used in veterinary medicine as a sedative, anesthetic, and painkiller for large animals but with no approved use in humans.^[2] Known on the street as “tranq” or “tranq dope,” xylazine can cause euphoria and sedation and is said to prolong the high of opioids like fentanyl.

However, xylazine is perhaps even riskier than the potent opioid. It causes such profound depression of the central nervous system, cardiac and respiratory arrest are common. Users can also be left in such deep stupors they're vulnerable to crime, including theft and sexual assault. Xylazine can also reduce blood flow to the skin, causing ulceration and abscesses, both at injection sites and elsewhere on the limbs. 

And unlike opioids, xylazine’s effects can’t be reversed by Narcan (naloxone), making treatment difficult.

Xylazine and fentanyl are a common, fatal combo

The researchers found that overdose deaths involving xylazine nearly always (99.1% of the time) also involved the powerful opioid fentanyl. Cocaine was detected in around one-third (35.1%) of cases, while methamphetamine was found in around one-fifth (18.8%).

A separate study from the CDC, published last month, found that xylazine was detected in nearly 10% of deaths—4,900 of 54,000—involving illicit fentanyl in 32 U.S. jurisdictions between January 2021 and June 2022.^[3]

Additionally, data from 20 states and the District of Columbia found that the monthly percentage of fentanyl deaths involving xylazine increased by 276% between January 2019 and June 2022, from 2.9% to 10.9%.^[3]

“These data show that fentanyl combined with xylazine is increasingly dangerous and deadly – this is why the Biden-Harris administration recently designated it as an emerging threat,” said Dr. Rahul Gupta, director of the Office of National Drug Control Policy. 

“The administration is working tirelessly to launch a whole-of-government approach to tackle this emerging threat head-on, protect public health and public safety, and save lives,” he added.

Biden administration unveils a national strategy to tackle xylazine deaths

The Biden administration, which has made tackling the opioid crisis a key priority, has moved quickly to curb the spread of xylazine. In April the White House Office of National Drug Control Policy (ONDCP) designated the cocktail of fentanyl and xylazine as an “emerging threat” in the U.S., requiring the administration to launch a national strategy to counter the drug’s use and spread.

Now, the administration has published a National Response Plan, coordinating a whole-of-government response to xylazine. The federal government is targeting a 15% reduction in xylazine-involved overdoses by 2025 compared to 2022 levels.^[4]

White House Domestic Policy Advisor Neera Tanden said: “The proportion of xylazine-involved deaths in this country is continuously growing and is of great concern to this administration. Every one of these numbers is tragic. They represent individuals, families, friends, and communities torn apart by opioids. Addressing this crisis is a top priority for this administration.”^[5]

The plan has six “pillars of action”: testing, data collection, prevention, supply reduction, scheduling, and research. 

The federal government will move to standardize forensic testing, to better detect xylazine in overdose deaths, and develop new tests for clinical settings, in order to rapidly identify and treat patients exposed to xylazine. It will also develop tests to detect xylazine in drug supplies, which can be used by both law enforcement on seized supplies and by harm reduction services.^[6]

The administration will also work to stem the flow of xylazine into the U.S. Gupta said that the sedative is currently primarily entering the U.S. through online vendors based in China. Additionally, xylazine is also diverted from veterinary supplies in Puerto Rico, entering the mainland through the postal system and other means, and is mixed into fentanyl supplies by traffickers in Mexico. The government wants to know more about the xylazine supply chain, in order to develop strategies for disrupting it. 

The plan also calls for the development of a treatment framework for xylazine addiction and overdose prevention guidelines, which can be deployed in communities and healthcare settings. That includes the treatment of xylazine’s characteristic flesh wounds.

Guta said: “We’re going to educate and equip healthcare providers, harm reduction staff, health sector payers, as well as first responders on the best practices to treat these flesh wounds.”

The White House will also consider whether to schedule xylazine as a controlled substance. “This would enable both civil and criminal actions both in interdicting and reducing the illicit supply of xylazine,” Gupta said. “At the same same time, we will maintain the legitimate supply of xylazine for use in veterinary medicine.”

“As a doctor, I have seen the devastating consequences of xylazine combined with fentanyl firsthand,” he added. “And as President Biden’s drug policy advisor, I am laser-focused on finding every tool we have and following the best evidence-based practices to take on this new challenge. This will be an all-hands-on-deck effort – but I am confident we can take action together and eradicate this emerging threat.”^[4]