Fentanyl Combined With Xylazine Designated Emerging Threat

WASHINGTON — The White House’s drug policy czar on Wednesday designated fentanyl adulterated with the non-opioid tranquilizer xylazine as an emerging threat to the United States.

The decision by Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy, marks the first time the administration has used this designation authority since it passed Congress in 2018, and comes after a review of the impact of xylazine on the opioid crisis, including its growing role in overdose deaths.

Xylazine is a pharmaceutical drug approved by the U.S. Food and Drug Administration for use in the sedation, anesthesia, muscle relaxation and analgesia in animals such as horses, cattle and other non-human mammals.

However, the U.S. Drug Enforcement Administration says there’s been a sharp increase in the trafficking of fentanyl laced with xylazine over the past decade, and that the combined drugs have been seized in 48 of the 50 states.

According to the DEA Laboratory System, in 2022 approximately 23% of fentanyl powder and 7% of fentanyl pills seized by the DEA contained xylazine.

The prevalence of xylazine, also known as “Tranq,” is particularly troubling because the drug mixtures place users at a higher risk of suffering a fatal drug poisoning.

That is because xylazine is not an opioid, and naloxone (Narcan) does not reverse its effects.

As a result, DEA Administrator Anne Milgram has said, “Xylazine is making the deadliest drug threat our country has ever faced, fentanyl, even deadlier.”

People who inject drug mixtures containing xylazine also can develop severe wounds, including necrosis — the rotting of human tissue — that may lead to amputation.

“As a physician, I am deeply troubled about the devastating impact of the fentanyl-xylazine combination, and as President Biden’s drug policy advisor, I am immensely concerned about what this threat means for the nation,” Gupta said in a statement released by the White House. 

“By declaring xylazine combined with fentanyl as an emerging threat, we are being proactive in our approach to save lives and creating new tools for public health and public safety officials and communities across the nation,” he continued. “To parents, loved ones, community leaders and those affected by xylazine use: I want you to know that help is on the way.”

The Office of National Drug Control Policy is required to monitor novel and evolving patterns of substance use, establish criteria for determining when a substance or combination of substances should be designated an emerging threat, and declare emerging threats when the director deems appropriate based on the geographic spread of the threat, as well as impact on such metrics as overdoses in the course of a year.

The Drug Enforcement Administration reports that between 2020 and 2021, forensic laboratory identifications of xylazine rose in all four U.S. census regions, most notably in the South (193%) and the West (112%).

Xylazine-positive overdose deaths increased by 1,127% in the South, 750% in the West, more than 500% in the Midwest, and more than 100% in the Northeast.

While national overdose death numbers have flattened or decreased for seven straight months, xylazine is complicating efforts to reverse opioid overdoses and threatens progress being made to save lives and address the opioid crisis.

Now that the declaration has been made, Gupta said the administration will proceed with formulating a whole-of-government response that includes evidence-based prevention, treatment and supply reduction.

That will start with the Office of National Drug Control Policy convening an interagency working group to develop the national response plan. 

The response is expected to include work on xylazine testing, treatment and supportive care protocols, comprehensive data systems (including information on drug sourcing and supply), strategies to reduce the illicit supply of xylazine, and rapid research (such as work on the interactions between xylazine and fentanyl).

Senate Majority Leader Chuck Schumer, D-N.Y., applauded the administration’s decision to designate xylazine an emerging threat, calling it “a deadly, skin-rotting, zombie drug.”

The designation, he said, is “a vital step to save lives throughout the country. This is the first step in eradicating this awful drug once and for all.”

According to the Centers for Disease Control and Prevention, 107,735 Americans died between August 2021 and August 2022 from drug poisonings, with 66% of those deaths involving synthetic opioids like fentanyl. 

The DEA says a large percentage of these drugs are being imported into the U.S. by the Sinaloa Cartel and Jalisco Cartel in Mexico, using chemicals largely sourced from China.

Schumer is calling on the administration to pursue a two-pronged approach to combating xylazine: an approach he calls “fight and fund.” 

“First, the DEA’s specialized diversion control teams should increase their focus on xylazine to cut off the flow of drugs, much of which comes from China,” he said on Wednesday. “Second, we need more funding for prevention, recovery and treatment programs for those suffering with addiction, which I will continue to push in Congress to ensure law enforcement and public health agencies have the resources they need to fight this scourge on the front lines and help save lives.”

But Maritza Perez Medina, director of the Office of Federal Affairs at the Drug Policy Alliance, a New York-based nonprofit, warned that for the Biden administration to be successful in combating xylazine, it “must learn from the mistakes of the past and not push more supply-side interdiction policies.”

“They are incredibly counterproductive and lead to a more unknown and potentially more potent drug supply. Crackdowns on prescription opioids and heroin created the conditions for fentanyl analogues to flourish and overtake the drug supply,” Medina said.

As an alternative, Medina called for the proliferation of more “public health tools,” including  public education, evidence-based treatment and harm reduction, xylazine test strips and other life-saving overdose prevention services, such as overdose prevention centers. 

“And because xylazine is most often combined with opioids, we should continue to double down on increasing access to naloxone and medications to treat opioid use disorder, like methadone and buprenorphine,” she said, adding that Congress should fund further research into xylazine, its potential harms and possible antagonists that could reverse xylazine-involved overdoses, similar to the way naloxone can reverse opioid-involved overdoses.

Also weighing in on the issue was Third Way, the nonprofit, center-left think tank based in Washington, which issued a white paper appearing to try to head off further politicization of the issue.

According to Third Way, Republicans have been misleading voters into thinking that undocumented immigrants are the human supply chain for the fentanyl entering the country, when the reality is far different.

Of those convicted of fentanyl trafficking in 2021, 86% were U.S. citizens, while 1,322 of the 1,533 charged fentanyl trafficking offenders were also citizens, the group wrote.

“Even the CATO Institute, a libertarian think tank, acknowledges this point,” Third Way said. “In fact, just 0.02% of people arrested by Border Patrol for illegally crossing possessed fentanyl.”

The think tank’s analysis goes on to say that more than 96% of fentanyl seizures along the border since the start of fiscal year 2023 have been at legal U.S. ports of entry.

“Fentanyl is rarely carried over the border through the desert. It’s being smuggled across legal points of entry inside seat cushions, car batteries, even inside the metal frame of a walker,” Third Way said.

It went on to note that 90% of fentanyl seized by Border Patrol agents was at U.S. border crossings into Arizona and California.

“While Texas Republicans point to undocumented immigrants in their state as fentanyl drug smugglers and traffickers, almost all fentanyl seized by CBP was at legal points of entry in Arizona and California,” Third Way said.

The paper closes by outlining administration policies aimed at further securing the border and stopping the illegal flow of fentanyl and other drugs.

Last month, for instance, the Biden administration launched Operation Blue Lotus, a new coordinated operation among Customs and Border Protection, Immigration and Customs Enforcement, Homeland Security Investigations, and federal, state, tribal and local law enforcement to target the smuggling of fentanyl. 

In just its first week, Operation Blue Lotus seized over 900 pounds of fentanyl and made 18 arrests.

The administration is also installing new border technology called multi-energy portals at ports of entry to allow CBP to scan six times as much cargo per day. 

These scanners will ramp up U.S. inspection from 2% of passenger vehicles and 17% of cargo vehicles to 40% of passenger vehicles and 70% of cargo vehicles, greatly increasing their ability to detect fentanyl or other drugs.

Construction has already begun at some ports of entry, with the Biden administration planning to install 123 new large-scale scanners by 2026, Third Way said.

President Biden recently announced his fiscal year 2024 budget also increases investments in border security. 

This includes money to hire 350 more border patrol agents,150 more CBP officers, $535 million for border technology and $40 million for combatting fentanyl trafficking.

Dan can be reached at [email protected] and @DanMcCue