In early March 2023, Montreal Public Health issued a warning about what some are referring to as a dangerous drug appearing in the city’s opioid supply: xylazine. Xylazine is a nervous system depressant that slows the user’s heart rate and breathing. Xylazine mixed with fentanyl, also known as “tranq dope,” is emerging as a major concern in the ongoing toxic drug supply crisis in North America. Montreal’s Department of Public Health (DRSP) reached this conclusion through urinalysis results collected through a citywide study conducted in the Fall of 2022, where xylazine appeared in five per cent of all samples collected. Roughly two weeks later, the United States Drug Enforcement Agency issued a warning based on reports from across the country about xylazine in the opioid supply.
Xylazine is proof of the danger of supply side intervention or drug prohibition. As a result of prohibition, Canada’s opioid supply is becoming increasingly unpredictable and therefore risky. Since the mid-2010s, when heroin and other opioids began to be diluted with fentanyl, there has been a dramatic increase in the number of opioid-related overdoses in North America. This has led many to refer to the spike in overdoses as the “fentanyl crisis.” Fentanyl is a widely prescribed and highly effective painkiller, often given to people recovering from surgery. Since the beginning of the crisis, fentanyl has been the subject of much misinformation and law enforcement efforts, with some going so far as to (inappropriately) call it a weapon of mass destruction. One of the most important protective factors for people who use opioids in recent years has been the increased availability of take-home naloxone kits. Naloxone is an opioid antagonist that blocks the effects of opioids on the brain for a limited period of time, which can temporarily reverse an overdose.
Xylazine, like fentanyl, is a central nervous system depressant, meaning that too large of a dose will result in the same symptoms fentanyl can produce: lowered heart rate and decreased respiration. Unlike fentanyl, xylazine is not an opioid, meaning that naloxone will not have any effect on a xylazine overdose. It is not, as some have said, “resistant” to naloxone – it is simply a different substance altogether. That said, in the case of tranq dope, the combination of fentanyl and xylazine, naloxone may mitigate an overdose by blocking the effects of fentanyl. People responding are advised to check whether the person is breathing, protect the head and airways, apply naloxone, and call for backup.
In addition to the risk of overdose, xylazine poses a challenge because it causes painful and dangerous wounds, which can appear regardless of the method of consumption. Even in cases where the substance was injected, the wounds are not necessarily found at the site of injection, often appearing on the shins and forearms. The wounds lead to an eruption of eschar, a type of dead skin. If left untreated, eschars can be quite severe, with some cases leading to amputation. Research into xylazine’s effects on humans was discontinued early in its development, with the effect that very little is known about how it functions in the human body. The drug began to grow in popularity as a recreational substance in Puerto Rico in the mid-2000s, with researchers observing the risk of infection as early as 2011. Doctors remain unsure of what exactly causes the wounds, which resemble chemical burns or skin ulcers and which appear in nearly 40 per cent of people who use xylazine.
Xylazine was synthesized in the 1960s as a treatment for hypertension and is used extensively by veterinarians as a sedative or anaesthetic, often in conjunction with ketamine. It’s been used recreationally by humans since the early 2000s, making it a relatively new addition to the recreational drug scene, with little research done to investigate its effects on the body. Xylazine was rejected by the FDA for use in humans because of the risk of hypotension, which has led to a dearth of information about its mechanism of action in the human body.
In the case of tranq dope, xylazine appears to be being used as a cutting agent. A cutting agent is a product used to dilute recreational drugs with something less expensive than the drug itself in order for the manufacturer to increase their profit margin. When a bar sells a mimosa instead of a glass of champagne, for instance, the orange juice is the cutting agent. If the government decided to crack down on mimosa consumption by banning the sale of orange juice, bartenders would be forced to innovate. Some speculate that this is what has led to tranq dope – as political leadership and law enforcement focus on fentanyl, manufacturers may be innovating by adding xylazine to their products in order to stretch their supply.
Illegal substances are impossible to regulate. While legal medications have to meet stringent requirements regarding ingredients, unregulated substances are held to no such standard. This is not unique to the illicit substance market. The nature of the unregulated global drug market often means that a product will pass through many hands before reaching the consumer. At each step of the supply chain, the person supplying has a financial incentive to cut the substance in order to increase their profit. The more links in the chain, and the more often the product has been cut or diluted, the more opportunities for a toxic interaction or undesired effect.
Suppliers often improvise using products that are affordable, easily accessible, and that mimic the effects and physical properties of the substance being cut. When choosing a cutting agent, the manufacturer usually tries to find a substance that is inexpensive, easy to get, relatively non-toxic, and copies the physical attributes of the drug to be adulterated, such as cutting cocaine with caffeine.
Supply side intervention is the practice of banning a psychoactive substance in order to discourage its use. In theory, banning the use of drugs will reduce the supply of a particular substance and force people to stop using it. However, the reality is more complex. A myriad of examples demonstrate what decriminalization advocates refer to as the “Iron Law of Prohibition,” which states simply that: “the harder the enforcement, the harder the drugs.” As pressure from law enforcement increases, demand does not decrease. Instead, suppliers turn to more potent alternatives. This is one of the ways that drug prohibition, despite its good intentions, actually increases the risk to public health associated with psychoactive substances.
At the beginning of the twentieth century, when opium was first banned, some suppliers began selling heroin, which was both far more potent than opium and odorless, making it harder to detect. As law enforcement tightened border regulations and increased penalties associated with the sale and possession of heroin, suppliers turned to selling fentanyl, which is more potent and synthetic, meaning it can be conveniently produced in a lab. A potent cutting agent is especially attractive under prohibition because the more potent a substance is, the less volume is required to achieve the same effects. Less volume means it’s easier to transport undetected. Evidence suggests that xylazine potentiates the effects of opioids, meaning that less opioid is needed to achieve the desired effect.
The pandemic and the ensuing lockdowns have also contributed significantly to disruptions in the supply chain for psychoactive substances as much as for anything else. Border closures considerably affected the stability of Montreal’s opioid market, contributing to a significant increase in fatal overdoses beginning in 2020.
Some might suggest that the answer is to make xylazine less readily available, but experts disagree. Dr. Kim Sue, Assistant Professor at the Yale School of Medicine, advocates supervised consumption sites as a response to the current crisis as well as an end to the stigma surrounding illicit substance use. Sue says, “What kills [her patients] is our society’s cruelly stigmatizing approach to substance use disorders and the lack of safe places they can use and receive immediate overdose supports.” Maia Szalavitz, author of Undoing Drugs, has also spoken out against the use of law enforcement to respond to a public health crisis, as have many others. Locally, Francois Mary, director of Cactus Montreal, called on public health to share data promptly and invest further in drug screening to protect the public.
Doubling down on supply side interventions is likely to keep producing the same results – more unpredictable and potentially risky innovations by suppliers leading to uncertainty and danger for consumers – and yet Western governments persist in their effort to scare users straight by allowing some of them to die unnecessarily. People who use opioids deserve access to a safe supply. People who use xylazine deserve knowledge and research to make using it safer. Prohibition is not keeping citizens safer. It makes using drugs more dangerous by preventing research and regulation and by making it more difficult for people who use drugs to seek information and support. If the goal of prohibition is public health and safety, then it has been a failure and we need to end it. If the goal of prohibition is to violently coerce the public into “good behaviour” and sobriety, then it has been a failure and we need to end it. If the goal of prohibition is to make the lives of vulnerable Canadians even more dangerous and precarious, then the proliferation of xylazine in the opioid supply is the latest example of its success.
Urgent action is necessary to protect the lives of people who use drugs in Montreal and elsewhere. It is clear that supply side interventions are endangering our communities. It is inaccurate to refer to this ongoing crisis as a fentanyl crisis – it is a toxic drug supply crisis, and its origin is not opioids but dangerously misguided drug policy. If anyone wishes to learn more or to get involved, AQPSUD – the Association Québécoise pour la promotion de la santé des personnes utilisatrices de drogues – will host an overdose awareness event in Montreal on April 6 at Place Émilie-Gamelin.