Inside the Emerging Xylazine Addiction Crisis in the U.S.

Devin Bair, a 42-year-old Pennsylvania resident, had used opioids on-and-off for years, but she never experienced anything like xylazine. She first took it without knowing two years ago when it infiltrated her dealer’s supply, and she unknowingly became addicted to it. Xylazine, a veterinary tranquilizer that isn’t meant for use in humans, is an increasingly common adulterant pervading the U.S. illicit drug supply, but little is known about its effects on the human body or how to treat the intense withdrawal symptoms it causes.

Xylazine has taken a stronghold in Philadelphia, a city at the forefront of addiction crisis and care. A 2021 study conducted by the city’s public health department found traces of it in more than 90% of samples of dope—a mix of different illicit drugs. It’s unclear exactly how many people in Philadelphia are using xylazine, but in 2021, at least 434 fatal overdoses there involved xylazine. How lethal and dangerous xylazine is remains a mystery, and as puzzled health care providers struggle, fear grows that the crisis will escalate in other parts of the U.S. The Biden Administration deemed xylazine-laced fentanyl an “emerging threat” in April and asked Congress for $11 million to combat it.

Infamous for causing severe flesh wounds that can require amputation, xylazine isn’t approved for human consumption but also isn’t a controlled substance, which means it isn’t regulated by the U.S. government. The Drug Enforcement Agency (DEA) has seized xylazine-fentanyl dope in at least 48 states and warned in November 2022 that many people don’t realize they’re taking it.

Bair said life on xylazine—also known as tranq—was pure “survival mode.” “When you start getting sick from the tranq, you start shaking violently, salivating, and vomiting. You’re pretty much just a mess on the ground,” she says.

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Bair was living in her hometown of Harrisburg in 2021 when she noticed concerning changes in the drugs she was buying that caused her to lose consciousness and go into withdrawal just a few hours later. After some research, she found out the supply was coming from Philadelphia, and the symptoms sounded like those caused by xylazine.

Within a few months, Bair decided she needed to get clean. None of the treatment facilities near her knew what xylazine was, prompting her to travel across the state to Philadelphia, where she waited four months to get admitted to an in-patient treatment facility. Although providers in Philadelphia are more experienced with xylazine than in many other places, most programs are designed for opioids, and Bair was left to fend off an excruciating three-month-long withdrawal mostly on her own.

Carla Sofronski, executive director of Pennsylvania Harm Reduction Network, which advocates for compassionate care for substance users, says that people she works with didn’t intend to get hooked on xylazine. They had no idea what they were buying. “There are people that still think they’re using heroin, and they haven’t used [pure] heroin in years,” she says.

Philadelphia was ground zero for xylazine in the U.S. when the drug permeated the street supply around 2019. During the pandemic, xylazine became even more popular as a cheap way to cut dope for a longer-lasting high. It also kept heroin and fentanyl users hooked because of the intense withdrawal symptoms it causes, which are painful and hard to treat.

For communities like Philadelphia that have fought drug epidemics—from crack to heroin, to opioids and fentanyl—for decades, xylazine is a familiar story but with raised stakes. As new drugs continue to pop up, “we can’t just keep playing whack-a-mole,” says Dr. Ashish Thakrar, who researches addiction at the University of Pennsylvania.

Advocates, substance users, and their loved ones have spent years pushing for a humanistic approach to treating addiction, with both short and long-term solutions. But if nothing changes, “we’re going to have a generation of children raised by grandparents or the child welfare system and a generation of people losing their limbs,” Sofronski says.

Treating xylazine addiction

Once Bair began treatment in 2021, the facility put her on a typical opioid withdrawal treatment course, but the regular medication dosages didn’t help. Bair still felt incredibly sick, couldn’t get out of bed to join group therapy, and lost 30 pounds that month from not being able to eat. “When I was in rehab, it was like they didn’t even want to hear the word tranq,” Bair says. “I guess because they knew they couldn’t treat it.”

The U.S. Food and Drug Administration hasn’t approved any specific medications for xylazine withdrawal, but some preliminary research suggests that certain drugs might be helpful for managing the pain and acute anxiety that xylazine withdrawal is known for.

Xylazine is almost always found with opioids, so in cases of suspected overdoses, experts say people need to work to address multiple drugs simultaneously. For example, naloxone (an opioid overdose reversal, available as a nasal spray) should be administered, and if that doesn’t revive someone, xylazine’s sedation effects can also warrant CPR.

“People withdrawing from tranq are not going the same course as folks who were using heroin. It’s very different, and the approach in treatment is going to need to change,” says Lydia Williams, a wound care nurse at Project HOME, an organization that provides accessible health care in Philadelphia. Medical guidance for how to treat xylazine withdrawal is limited and needs more research, she says.

Sofronski believes that one of the biggest challenges with xylazine is not treating it seriously enough. “This is an emergency, the epicenter of it is right here [in Philadelphia], and we haven’t even scratched the surface,” she says. Treatment options are even sparser outside of Philadelphia. In rural Pennsylvania and other states, “doctors and hospitals don’t know how to treat this and don’t have the education around it.”

Eventually, Bair left rehab and spent the next few months recovering at home, but the doctors labeled her non-compliant for leaving against medical advice, which later threatened custody of her children.

Bair went to family court and was able to convince the judge with her medical records that she left because she wasn’t being treated adequately at the facility. She got to stay with her kids, who she says are still recovering from a traumatizing several months in foster care.

The unique challenges of providing care for xylazine use

Williams, the wound care nurse, regularly treats people who are suffering from wounds caused by xylazine. The gaping wounds can be so large that the flesh starts to corrode and attract maggots. Reaching people early and often helps her save patients’ limbs, which would likely be amputated in the hospital.

The Project HOME team provides other services, including diabetes, HIV, and pregnancy care, but since xylazine’s emergence in 2019, their primary focus has been on caring for people who use the drug. Around that time, they noticed that a growing number of patients were dying, says Kara Cohen, the street medicine team’s assistant medical director and a nurse. “We have to go to people,” Cohen says. “Setting up and waiting for people to come to us wasn’t going to cut it.”

Meeting xylazine users where they are—which, in Philadelphia, often means Kensington, home to the east coast’s largest street drug market—gives health care workers like Williams the best chance at helping people who need her the most. “The health care that someone gets—for being poor, Black, white, living in a certain community, using drugs, or having mental illness—should not be different than the care any of us receives,” Williams says. Philadelphia’s numerous drug crises have been exacerbated by systemic issues, including poverty, gentrification, and racial segregation, and xylazine has proven no different.

Wounds are common among drug users because anytime you pierce the skin, you risk introducing bacteria. But those caused by xylazine are unusual. “For people who inject xylazine, wounds sometimes appear in places where they don’t inject,” Thakrar says. “It’s a new phenomenon.”

Seeing their wounds improve week-by-week with simple sterilization gives people hope for full recovery, says Cohen. “I hope that people going through this in other parts of the country realize it’s not like every single time someone gets one of these wounds, it’s going to lead to limb loss,” she says.

Monique Taylor, an outreach worker for the team who overcame a heroin addiction years ago, explains that building trust to retain patients is hard when so many people with addiction feel ignored by society. “If you’re not willing to take time and look at them like human beings,” she says, “you’ll never see them again.”

Samuel Santiago, outreach leader for the team, always carries a pack of cigarettes on his drives to break the ice with people, much to the disdain of the team’s nurses. The drug crisis has been personal for Santiago, a Philadelphia native, who lost his son to it.

The street medicine team currently cares for more than 500 people—many of whom use xylazine, and at least a dozen of whom died in April. “Part of it is all this junk that they’re putting in the drugs to keep people coming back, giving them free samples,” Santiago says. “Then tomorrow, you come and pay because you need it. How do you battle that?”

Xylazine remains virtually unregulated

This spring, Congress proposed several bills to regulate xylazine and to fund research on the drug, but no measures have passed yet. Experts note the government has been quicker to act on the xylazine threat than it was with fentanyl—but it’s not fast enough. “We need to prioritize those changes urgently rather than waiting the traditional months and years,” Thakrar says.

Throughout the opioid epidemic, stigma around addiction and substance use has persistently limited life-saving policies from passing, according to an editorial published in 2021 in the Lancet. Products and programs like syringe-exchange centers, naloxone, and xylazine test strips—which became available in March—are proven methods to reduce overdoses, but aren’t always widely available.

Many health care providers are frustrated that access to addiction services—both medical and psychosocial—can be costly and limited under insurance. “Addiction is a treatable condition,” Thakrar says. “We have incredible medications that should form the backbone of treatment.” Although they’re not yet specialized for xylazine, greater access to such medications could help prevent addiction issues that lead people to xylazine use.

A handful of states, including Ohio, Delaware, West Virginia and Pennsylvania, have moved to classify xylazine as a controlled substance in recent weeks. However, harm reduction advocates worry that scheduling measures could punish users through fines and prison time, rather than pave the way for better addiction treatment. “Don’t police us; we have a disease,” Taylor says. “It’s not a crime to be in active addiction.”

Another concern is that restricting xylazine could lead to the spread of newer, more potent drugs. Thakrar says that synthetic drugs like xylazine and fentanyl are cheap and easy to manufacture, so they’re likely to keep popping up, faster and faster.