As more of the illicit fentanyl supply in the United States is cut with the veterinary tranquilizer xylazine, a public health crisis builds. Clinicians scramble to understand the lesions caused by the drug, its effects on pregnant women and the babies that they carry, and its withdrawal syndrome. Meanwhile, xylazine-dependent users from all over the country report being denied access to detox clinics, which don't have the capacity to care for their wounds and / or are unwilling to take on the liability of withdrawing patients from a substance about which so little is known.
The Kids Are Certainly, Most Definitely Not Alright
If you'd prefer to skip my summary of how the U.S. ended up where we are in 2024 with our illicit opioid supply hopelessly poisoned, please jump to "What Tranq Users Have to Say." There's also a bullet-point TL;DR summary at the end of the article. Lame.
It's a scenario out of a dystopian novel set in a country only vaguely recognizable as our own.
In the late '90s, a government beholden to Big Pharma interests that fund the campaigns of politicians from both sides of the aisle fails to regulate the sale of a high-potency, maximally addictive opioid substance called oxycodone, which is packaged into a high-dose formulation known as OxyContin, whose extended-release mechanism is defective.
Why doesn't the government take action as the dangers of this prescription heroin become obvious? Because the regulatory entity whose purview includes pharmaceuticals, known as the Food and Drug Administration, is headed by the same people who make up the upper management and Boards of Directors of the pharmaceutical companies, who walk through a revolving door between the FDA and industry. This is the same FDA that makes decisions on whether to approve new medications largely on the basis of research conducted by scientists bankrolled by these same companies, incidentally.
Back to OxyContin, which becomes a blockbuster on a megalithic scale: Between 1995 and 2001, Oxycontin generates 2.8 billion USD in revenue for Purdue. The company uses some of the money to fund its Political Action Committee (PAC), solidifying its status as a political powerhouse.
For 10 years, pill mills in Florida drown the entire U.S. in a quantity of OxyContin that is between 10 and 100 times the amount needed for legitimate pain management purposes. College students and drug dealers (and college student drug dealers) take interstate buses to reach these shady clinics, which are cash-only enterprises that are thinly veiled, semilegal drug-dealing operations. Despite the fact that oxycodone overdoses are increasing at an alarming rate and OxyContin pills from Florida are showing up in drug busts nationwide, for over a decade, politicians from both parties look the other way.
A whole generation of addicts is created, and tens of thousands die of prescription opioid overdoses. In 2010, as public awareness of the dangers of OxyContin increases,* Purdue is forced to reformulate it so that its extended-release mechanism works properly, and simultaneously the overprescription of the drug is drastically curbed.
*If you want to watch a beautiful, heartbreaking documentary about how a few good people finally cracked the Big Pharma facade and revealed the truth about OxyContin, check out Netflix's series The Pharmacist, which tells the story of Dan Schneider, an old-fashioned, Southern pharmacist who awakens to the reality of addiction in the U.S. when his son dies in a crack cocaine deal gone wrong. During the height of the prescription opioid epidemic, Schneider becomes wise to the fraudulent OxyContin prescribing practices of Dr. Jacqueline Cleggett and other "whale" physicians who flood the market with excess Oxy, and he gathers evidence that eventually brings Purdue's house of cards down.
Most of the patients who have become addicted to OxyContin cannot just stop taking the drug; this is chemical torture, and they cannot function without it. Unfortunately, due to draconian restrictions instituted during the 1970s, methadone maintenance clinics are few and far between and have extremely restrictive rules, meaning that they simply aren't an option for most of these addicts (read Metha-Don't for more info). Buprenorphine (Suboxone) is an emerging maintenance option that can be prescribed in less restrictive outpatient settings, but there are far too few doctors with the special certification necessary to prescribe it, and a low patient cap further limits enrollment.
What the legal market cannot deliver, the black market will. Consequently, between 2005 and 2015 or so, most of the patients who lose their pharmaceutical opioid supply end up on heroin. In answer to the drastically increased opioid demand from North America, the South American cartels ramp up production and trafficking of a high-purity, powdered form of heroin that can be snorted rather than just injected, resulting in a heroin epidemic unlike anything that the U.S. has seen since opioids were made illegal without a prescription through the 1914 Harrison Narcotics Tax Act.
As the cartels vie for control of the North American heroin trade, worth billions of dollars per year, firearms that originate in the U.S. are used in these organized crime groups' wars against each other, and innocent civilians are casualties. In many areas of Mexico and elsewhere in Latin America, corruption is so rife that the police and military are powerless against the cartels. It is a time of mass graves in the desert containing bodies half-dissolved by lye, promotional torture videos, and faces stitched onto soccer balls.
As the U.S. makes some headway in decreasing the amount of heroin that finds its way through the country's southern border, the traffickers search for an even higher-potency opioid - they need more bang for their buck per unit weight and volume.
Thus, they begin trafficking fentanyl, an opioid 50 times more potent than heroin and 100 times more potent than morphine; a dose the size of 5 to 7 grains of salt is enough to kill an opioid-naive adult.
In addition to offering greater potency per unit weight, fentanyl is fully synthetic, meaning that it doesn't require the cultivation of poppy plants in the Middle East and Southeast Asia. Rather, it can be synthesized on an industrial scale in labs in China, then moved through Latin America by the cartels (when China finally bans the production of fentanyl in 2019 due to pressure from the U.S., the cartels simply become their own chemists, importing the precursor chemicals from China rather than the finished product).
At this point, opioid maintenance programs offering methadone and buprenorphine have expanded significantly, and some addicts have stabilized on these drugs. Just as many, however, are either unable to access or pay for the programs or find these long-acting opioids unsatisfactory, so they continue using illicit dope, which by 2015-2016 is now predominantly fentanyl.
The high potency of fentanyl, as well as the sporadic presence of fentanyl analogues such as carfentanil - a compound 10,000 times more potent than morphine and 100 times more potent than fentanyl - trigger a wave of overdoses on an almost unimaginable scale. Fentanyl finds its way into the drug supply not just in the form of injectable or snortable powder, but also in pressed pills disguised as extended-release morphine, Xanax (alprazolam), and other popular pharmaceutical formulations. Rashes of ODs occur in Los Angeles and other cities due to fentanyl-tainted cocaine, as well.
Since 1999, more than one million Americans have died of drug overdoses. This is more than all of the American soldiers who have died in battle during all of the wars we've fought since the end of the Revolutionary War. For the first time since we have tracked such statistics, drug overdoses replace car accidents and similar misadventures as the number one cause of mortality in individuals aged 18-25.
In Oregon, a recently separated couple loses both their sons, Andrew and Stephen Riviere - aged 21 and 19, respectively - to OD on the same night; the boys die side-by-side in their apartment after consuming a pill that appeared to be OxyContin but was in fact fentanyl.
With fentanyl on the scene, there is a feeling that finally, at least, we must have reached rock bottom. The most extraordinary feature of the failed War on Drugs, however, is its endless ability to deliver new lows, and sure enough: In the wake of fentanyl arrives xylazine.
Beginning in 2018 and 2019, the veterinary anesthetic xylazine, which has long been used as a cut for heroin in Puerto Rico, begins to show up in the U.S. illicit fentanyl supply.*
*I put together a brief fact sheet on xylazine here; for more info on how the drug has infiltrated the illicit fentanyl supply in the U.S., check out this article.
Pharmacological note: Medetomidine is another veterinary tranquilizer that you might hear mentioned these days, which is very closely related to xylazine. Beginning in 2023, it started to appear in fentanyl samples from Massachusetts and other areas. I expect its prevalence to increase over the coming months.
The arrival of xylazine in any given area is indicated by two signature changes:
A spike in overdoses because xylazine potentiates the respiratory depression caused by fentanyl and cannot be reversed with the opioid antagonist Narcan (naloxone)
Extensive, necrotic lesions of unknown etiology that cover users' bodies and frequently become gangrenous, resulting in sepsis and amputation
The drug is an alpha-2 adrenergic receptor agonist, which means that it exerts its action through a subtype of adrenaline receptor. It is a phenothiazine compound related to the blood pressure medicine clonidine - which, in a strange synchronicity of pharmacology, is frequently used to decrease the anxiety and Restless Leg Syndrome caused by opioid withdrawal - as well as the antipsychotic Thorazine (chlorpromazine).
It is nicknamed tranq, and it initially appears in the Kensington neighborhood of Philadelphia, where it attracts a loyal following of "zombie" addicts who fall unconscious in strange, hunched-over positions that interrupt blood supply. It spreads outward from there, affecting the Northeast and Southern U.S. most intensely. By 2024, xylazine is found in 40 percent or more of the illicit fentanyl samples collected in some areas of the U.S.
As xylazine increases in prevalence, fentanyl is being used more sparingly (perhaps to avoid overdoses, especially since some jurisdictions have implemented or revived death by distribution statutes that penalize dealers for selling drugs that result in fatal ODs).
So, for those survivors from the initial OxyContin epidemic of the late 90s and 00s who cannot stop opioids entirely, the outcome tree looks like this:
OxyContin --> Heroin --> Fentanyl --> Xylazine or death
--> Methadone / Buprenorphine (Suboxone) or death
--> Methadone / Buprenorphine (Suboxone) or death
--> Methadone / Buprenorphine (Suboxone) or death
In general, I'm not a grand conspiracy theory kind of guy because I don't really believe in most people's ability to keep huge secrets, but oh, boy - it's almost as though the U.S. government, realizing how badly it had effed up in the above scenario, faced with hundreds of thousands of opioid addicts who are each going to cost millions upon millions of dollars in healthcare costs as they slowly die of viral hepatitis, various drug-related cancers, and a plethora of other addiction-related conditions - has allowed the introduction of fentanyl and xylazine into the illicit opioid supply to rapidly kill off the remaining users.
At this point, we're not dealing with an illicit opioid supply that is tainted or impure; we're dealing with an illicit drug supply that has been deliberately poisoned.
What Tranq Users Have to Say
The following comments are taken from a Reddit thread called "Detoxification Paradox: Tranq Dope (Xylazine / Fentanyl)," which appeared in r/opiatesrecovery (the original post, which I came across a couple of days ago, was deleted by the moderators of the subforum because it was judged to be soliciting medical advice, so I'm only able to view the responses, at this point).*
*This type of content loss is unfortunate, as I have increasingly seen Reddit threads cited in psychiatric, epidemiologic, and harm reduction research. Gathering, summarizing, and preserving what amounts to one of the best and most extensive sources of information about a novel, substantial public health threat - i.e., user accounts of the effects of xylazine - is one purpose of this blog.
Basically, the Original Poster (OP) had found himself or herself - as well as a number of his or her friends and acquaintances who were fellow tranq users with lesions on various areas of their bodies - unable to access medical detox services because of the Catch-22 discussed below. The tone was panicky, and the OP mentioned having had several friends die of xylazine / fentanyl ODs recently.
The thread broadened out to a more general discussion of tranq. The level of anxious, paranoid intensity that developed was something that I rarely find on Reddit, where even life-or-death stakes are approached with a nonchalant, often sardonic attitude.
The following are a few comments that stuck out to me, which, taken together, paint a stark picture of a fulminating public health crisis, which has thus far completely escaped mainstream media attention.
A quick scan of the thread reveals several descriptions of a protracted, severe withdrawal syndrome that - rather than the 5 to 7 days of acute fentanyl withdrawal - can last weeks:
"It's absolutely insane and horrifying, xylazine is literally the worst thing they could have ever introduced. It's becoming literally IMPOSSIBLE to detox off dope now. Gone are the days when you would only have to suffer 24 hrs because you could take a sub or methadone and you instantly felt much better. I had a friend who did it [tranq dope detox] cold turkey and it took him 3 weeks in bed before he was able to even move. Even after that, he had PAWS for months on end. This has become the worst drug combination ever. I feel bad for anyone stuck in this drug. You have my deepest sincere condolences and may God be with you."
This unique withdrawal syndrome combines features of opioid and benzo withdrawal, including, in at least one case, seizures (although these could have resulted from simultaneous benzo withdrawal; however, I believe that I have read accounts mentioning seizures from xylazine withdrawal in users who don't use benzos, as well).
Attempting detox is especially difficult because many medical detox units cannot or will not accept xylazine users due to their unfamiliarity with the drug and their inability or unwillingness to provide wound care to users covered in lesions from the drug (more on that below):
"I'm in the PNW and had to find a medical detox that would both take care of my wound on my leg and [handle] detox. I completely roughed it out 10 days at home and withdrawals didn't start until day 7. At day 10 I checked into medical detox after being sent away from 3 different hospitals. I withdrew from fent, tranq, benzos and nicotine all at once. It was complete hell. I didn't sleep for 11 days, I lost 35 lbs and had two seizures at the hospital. I medically was not allow to drive for 6 months due to those seizures. This was all last October which makes me 14 months off of that garbage."
As a result of their inability to find spots in medical detox programs, some xylazine users have been forced to detox at home. Even when they have been admitted to detox programs, however, many detox units either A) did not have protocols for xylazine withdrawal, and therefore couldn't manage it effectively, and / or B) could not keep patients for long enough to see them through acute withdrawal:
"I detoxed at home off what we believe was xylazine laced fentanyl (because suboxone only helped my withdrawals some, not nearly as much as they should at 32mg a day). Only a daily user for about three weeks. I did the Suboxone QuickStart induction method and literally thought I might actually die because the withdrawals were so severe for the first two hours. Was fine for a day and a half and then spent a week in bed too sick to even consider going to get well. I literally couldn’t get out of bed. Then spent four more days sweating through my clothes still. Finally, by day like 14 I was feeling okay. Had no comfort meds for the first four days after the QuickStart, then had clonidine, zofran, and gabapentin."
"The only other thing that helped was Suboxone but the medical detox was being a pain in my a** about giving me more. It wasn't until my 7th day at the hospital that they finally would give me a 4 mg evening dose which was finally my first night of rest, at least for a few hours. I eventually stabilized on 8 mg but it took me a month. I had a really large habit of doing rocked fent. I'm definitely not captain America, lol. What makes me proud of [myself] is I choose to quit. My last night of use, I woke up gasping for air, which scared the sh*t out of me. I had just re-upped a day before, and I had probably an ounce of fent at my house because I liked to have a variety. I had 4 fat lines broke down on a plate but did not give into temptation for the 10 days I was detoxing at my house."
"It’s scary out there - gone are the days where you can go to a 5-7 day detox center and get out done with your acute withdrawals. And it’s only getting worse. I was just talking about this. It’s almost impossible to detox at home (although I’m currently doing it after many failed detox attempts that actually worked as a taper bc the supply got sh*ttier and I was using less and less and relapsing for shorter amounts of times) but even so - on day 7 and still going through it. The anxiety is out of this world, too, which is something I didn’t have to this level while detoxing 3-5 years ago."
Tranq users who remember the halcyon days of heroin that was actually heroin reflect on how much worse this xylazine / fentanyl combo is even compared to fentanyl on its own; they marvel at users' ability to push through the pain from their extensive, necrotic ulcers to continue using:
"It's taken me months to wrap my head around why longtime active users were tolerating horrific skin lesions. Active addiction is so exhausting on so many different levels. Staying clean is just as exhausting without the momentary relief. You have to REALLY want it. And I'm still talking about my experience with just fentanyl and cocaine. Everyone that I know still using was unaware of tranq being introduced into the supply at the time. One person I know had to sneak tranq dope into the hospital for a surgical procedure on an infected abscess that would require multiple days of inpatient recovery. This included consistent administration of IV Dilaudid. They still needed the xylazine. That's how scary and different this withdrawal is. Post-op included minimal wound care (they have horrible wounds on both legs) without detox as an option. They just give you a pamphlet of local clinics."
One user mentions something that I've heard about from other users who I've spoken with, as well - that some "tranq" dope that tests negative for xylazine has another chemical in it, possibly medetomidine, that causes similar effects:
"This is the scariest sh*t and it recently just hit my city. I’ve known so many who got stuff from their normal plug who had no clue it was this sh*t, and ODd from it. It’s like there is barely even any fent in the sh*t anymore, it’s all tranq. The dealers have no clue what they are even getting. I’ve also noticed there is another type of tranq in the sh*t that will test negative for xylazine, but feels exactly like it. It’s really scary out there, guys. If you are somewhere tranq hasn’t hit, trust me, it will, and once it does, it will be impossible to find anything without it. If you want to get clean, get on methadone, subs, whatever, please do it before the xylazine gets there. Seriously. I wish you all the best in your recovery. Stay safe out there. Also, you can google “free xylazine tests” and you can get them mailed to you. Good luck everyone!"
There is a widespread recognition that xylazine is the "worst thing yet," and that there won't be many users who survive it even if something different does come down the pipeline afterward:
"It’s really horrible. I wrote about my experience accidentally detoxing from tranq dope while still using fetty and it was still utterly miserable. It’s horrifying how fast it impacts your body even just snorting it. I’m lucky that I can still get dope without tranq often and feel for those who have no other option. This is definitely making [addicts] quit. I can see the writing on the wall— things will only get worse."
One thing that tranq users have consistently commented upon is how quickly xylazine dependency sets in. Moreover, as my friend Mike's experience revealed, xylazine lesions can begin to develop all over the body after a single use of the drug:
"Yeah tranq wds are horrible too. I did it for maybe a week or two, couldn’t have been more than 2 buns. I got regular fent after that and it didn’t even make me feel not sick. Tranq wds make me puke less than 24hrs after doing the last bag. My whole body hurt and felt like when I got hit by a car. Even walking short distances around my house had me in excruciating pain. I was laying in bed trying not to move and would just start violently shaking uncontrollably like I was cold. Couldn’t sleep at all."
Users further noted the highly individualized nature of responses to xylazine's positive and negative effects:
"I've been reading a lot in the past month to try to understand the extent of the crisis. It seems that individual responses to tranq varies. Some people feel sick before withdrawal but come to like it like the strangely okay paranoia from smoking cocaine. But wds seem to be universally horrible: Pure anxiety and restlessness (RLS--the most unbearable wd imo), hellish irritation to physical stimuli, and elevated vitals across the board that when combined with comorbidities could certain give anyone over 30 a heart attack. A new, weird kind of barfing. Suprise, clonidine is not the saviour."
What We Know That We Don't Know
We have a decent level of knowledge about xylazine's mechanism of action (meaning how it exerts its effects on the Central Nervous System). Specifically, we know that it is an alpha-2 adrenergic receptor agonist, which decreases the release of the stimulatory neurotransmitters dopamine and norepinephrine in the CNS, resulting in sedation and analgesia.
However, due to the very limited trials of xylazine in human beings, we have essentially no information on xylazine dependence and withdrawal. As mentioned above, xylazine is closely related to the blood pressure and anti-anxiety / anti-RLS drug clonidine, which is used in treating opioid withdrawal. Because xylazine decreases blood pressure, we would expect rebound hypertension (high blood pressure) during withdrawal, which we do, in fact, observe.
Xylazine is also closely related to chlorpromazine (Thorazine), the "shot in the a**" that you get for having a diva moment in the psych ward. Some of the withdrawal symptoms reported above are in line with what would be expected for sudden antipsychotic cessation; specifically, the anxiety, Restless Leg Syndrome, and depersonalization / derealization (the "weird / surreal" feelings that users compare to benzo withdrawal) fit the picture of antipsychotic withdrawal.
However, the overall severity of the withdrawal syndrome, as well as the possible involvement of seizures, seems to eclipse what we would expect given the drug's pharmacologic cousins. Moreover, xylazine has an extremely short half-life, and it's therefore surprising that users report a withdrawal syndrome that lasts weeks.
Now, as someone who values science, I have to at least acknowledge the confounding possibility that some of what is being attributed to xylazine withdrawal is in fact severe fentanyl withdrawal. We know that because of the extraordinarily high doses that some users are taking for extended periods, as well as the high lipophilicity (fat solubility) of fentanyl, it is lingering in some users' bodies for weeks rather than days, which creates a protracted, severe withdrawal syndrome beyond anything that had been seen prior to high-dose, illicit fentanyl use.
It's also possible, of course, that there is a hype effect building from collective panic and over a decade of state-inflicted, War on Drugs trauma.
However, it would be arrogant to dismiss all of the above questions, to write off the severe withdrawal syndrome reported by tranq users as merely an effect of long-term, high-dose fentanyl use. Among other reasons, I believe users' accounts because most of these people were addicts who used fentanyl before xylazine came along, meaning that they know full well the difference between "pure" fentanyl withdrawal and the withdrawal syndrome caused by the fent / tranq hybrid substance that predominates today. Something else is going on in the withdrawal syndrome caused by tranq, and we need to figure out what.
Moreover, we are woefully ignorant about the mechanism behind xylazine-induced skin lesions. These extensive, necrotic ulcers form all over the body, and they frequently become infected, which has led to a statistically significant increase in amputations in some areas of the country where tranq use is prevalent.
We know that there is a component of decreased blood supply to the skin from peripheral vasoconstriction. We also know that some users who are initially immune to the allergy-like response that causes the ulcers to form can somehow have an immunological "switch flipped," after which they, too, begin to develop the ulcers with each episode of tranq use (it appears that once you have become sensitized to the substance, you will develop the lesions every single time that you use the drug). I'm continuing to gather detailed user accounts of xylazine lesions, including pictures of the ulcers at various stages of development and healing, in the hopes that this data will help shed light on the mechanism behind the ulcers' formation as well as how to best limit and treat the lesions.
Finally, we are almost completely in the dark about the effects of xylazine on human pregnancy, which is a problem given the many fentanyl-dependent mothers who are testing positive for xylazine. A friend of mine who is an epidemiologist at a clinic in Pittsburgh mentioned that her group is studying the effects of the drug on pregnant women; it is an early-stage, observational study that will track their pregnancies and attempt to discern any statistically significant changes in maternal or fetal health outcomes.
We know that xylazine is not toxic to mares (horses) during pregnancy, but that is no guarantee that the same holds true for humans, of course. We also know that the respiratory depression, bradycardia (low heart rate), hypoxia (decreased blood oxygen), and hypotension (low blood pressure) caused by xylazine can be dangerous in both horses and humans throughout the pregnancy into labor and delivery.*
*To inject some levity into what is turning out to be a fairly depressing post, here's a line that I came across when reading about the effects of xylazine on horses: "It is wise to remember that xylazine or detomidine alone may result in a deceptively sleepy patient that can still kick accurately." My guess is that it applies to human "mares," too. It's gems like this line that made my friends and me LOL over our textbooks during those 2-4 a.m. STEM cram sessions in undergrad.
We desperately need clinical trials that study withdrawal protocols for xylazine. Given its close relation to clonidine, I imagine that a clonidine taper - perhaps starting with a higher dosage than the standard 0.1 mg, which patients should be able to tolerate due to their xylazine tolerance - fused with a standard methadone / buprenorphine taper protocol might be a reasonable place to start. It would probably also make sense to include a typical or atypical antipsychotic in some of the experimental protocols, too.
The Detox Catch-22
The most urgent issue posed by xylazine, and the problem that made me decide to write this post this week, is the difficulty that xylazine users - especially those with unhealed lesions on their bodies - are having finding spots in medical detox units. This is a problem that has been reported by no fewer than a dozen Redditors from the Northeastern and Southern U.S., who describe very similar experiences despite differences in their demographics, insurance coverage, and the healthcare resources available in their areas.
(For those of you who aren't familiar with addiction treatment, medical detox is a process that typically precedes inpatient rehabilitation for addiction, which lasts between three days and a couple of weeks. During this phase of the treatment process, addicted patients who have stopped benzodiazepines, opioids, or alcohol are medically monitored in a hospital or hospital-like setting to ensure that they don't seize, dehydrate, develop electrolyte abnormalities, or suffer other, potentially fatal complications of stopping the substance that they were addicted to. Often, a benzo or opioid taper is used to wean a person off of their drug of choice, thereby minimizing the attendant physiologic shock).
From the detox unit's perspective, taking on xylazine-dependent patients is a losing proposition. Such patients suffer from sores that require intensive, regular wound care, which pose a high risk of complications - including going septic, leading to organ damage and potentially death, and requiring amputation.
Because there are no standard withdrawal protocols for xylazine, it's difficult to justify detox expenses to insurance companies (particularly given the protracted nature of the withdrawal syndrome; insurance companies rarely cover more than a few days in detox). The patients are likely to be highly uncomfortable because their doctors have little clue what they're dealing with, and the risk of litigation is higher than average for all of the above reasons.
I'm not at all surprised that patients are being given the run-around. The standard tactic seems to be to tell them that they cannot be admitted to a medical detox unit because the wound care that their sores require cannot be performed there.
Now, until the patients stop using xylazine, their sores will only continue to get worse, so this is where the Catch-22's start to kick in. If they present at the Emergency Room asking for treatment for the lesions, the hospitals will do everything in their power to treat them without admitting them; their wounds will be cleaned up / debrided, and they'll be given topical and oral antibiotics to use to minimize the risk of infection (and, of course, they'll be discharged with a set of instructions for at-home wound care that many of them cannot fulfill because they are homeless).
The hospitals will be very leery of admitting such patients because they know that they will require detoxification, and their excuse will often be that wound care units don't have the capacity to perform medical detox (which isn't exactly true, as I will explain below). So, unless the patients need surgery to amputate or are actively septic, it's unlikely that they will be admitted and detoxed while being treated for their lesions.
Moreover, the patients won't be given any opioids or other medications for the pain from the lesions (because "we can't give addicts what they want"), meaning that the users' only recourse to dull the extraordinary pain caused by the lesions, which are sometime bone-deep, is to take more xylazine and fentanyl, thereby worsening the lesions.
It's not subtle. You get the picture, I'm sure.
In this way, tranq addicts become stuck in a cycle that too many only find release from in death.
Forcing the Issue
Bear with me for a moment, please.
During the worst years of my opioid and benzo addictions in my early- to mid-twenties, I was six feet tall and weighed 155 pounds despite eating over 3000 calories a day. I was ghastly ill from Hepatitis C and untreated Graves' Disease, which led to a continuous manic state in which all of my systems were in overdrive. I was sleeping less than two hours a night despite taking family-sized quantities of benzos and opioids.
I suffered a seizure from benzo withdrawal, after which I was brought to the ER and admitted for monitoring in the telemetry (heart) ward because they were afraid that I would continue to seize.
Now, this was by no means a detox ward. In fact, I was the only patient in the unit with a drug problem - although there was a suspiciously relaxed looking granny with a patient-controlled morphine pump across the hall. Nevertheless, the general internists and neurologists and cardiologists, all of whom had weaned patients off of addictive medications in the past even though they had no special training in addiction medicine, came up with a plan to taper me off of benzos and opioids over a two-week period before I went off to inpatient treatment. To be honest, these doctors treated me better than I had ever been treated in a detox ward, and they tapered me off quite gently relative to previous treatment - likely partly because they were afraid of destabilizing me, leading to another seizure or heart trouble.
What I'm getting at here is that nearly all inpatient hospital units and the physicians and nurses who staff them have the knowledge and capability to detox patients off of addictive substances. They routinely do so pre- and post-operatively, following intubation or extended hospital stays for infection or other conditions, and for many other reasons.
Although they don't advertise it, they must have the ability to stabilize and wean off patients who are dependent on addictive drugs as they treat whatever primary medical issue led to their hospitalization (even in the old days of "never give an addict what they want," a patient disrupting an entire unit by howling in pain from drug withdrawal got old very, very quickly; plus, to the extent that untreated withdrawal can worsen outcomes for various procedures and conditions, the doctors and hospital would be taking on substantial liability by leaving withdrawal untreated).
If you're in a situation where you can't get into a detox unit and the hospital is refusing to admit you for wound care, there are some symptoms that you can, er, emphasize that will likely swing the scale toward admitting you rather than discharging you for outpatient wound care.
Specifically, if you mention having been feverish, you're much more likely to be admitted. It's okay if you're not running a temperature at the time that you present at the hospital; pre-septic fever is often intermittent because the bacteria sort of "leak" out of the sores and into the general circulation intermittently, after which the immune system fights them off - until enough bacteria enter systemic circulation and overwhelm the body's defenses.
So, symptom one is intermittent fever, which will raise your risk for sepsis and help you get admitted to the hospital.
Along with fever, altered mental state is considered a warning sign for sepsis. Perhaps mention some delirium-like symptoms that aren't explained by your drug use or any other factor. You don't have to get too descriptive with this - just mention feeling "weird" or "out of it," and perhaps a little tired, too.
Finally, you might want to throw in that you've felt a little lightheaded for the past 12 to 24 hours. Perhaps you've even slipped into unconsciousness for a few moments once or twice (again, in a way not explained by your use of fent / tranq).
If you mention these warning signs and the hospital doesn't admit you, they're taking on huge liability if you subsequently die of sepsis.
Now, once you're admitted, the worst-case scenario is that you get a resentful Internal Medicine doc who is the type of old-school sadist who enjoys seeing addicts suffer ("Now you'll learn what real pain is!" he says gleefully).
Realistically, if this happens, you can always leave Against Medical Advice and be no worse off than you were in the first place. However, the American medical system truly has shifted in its attitude toward addiction, so self-advocacy, decent manners, and not abusing whatever options you are presented with go a long way. It will also help you that you have an objective source of significant pain in the xylazine lesions, which will allow the physicians treating you to justify giving you opioids even if they wouldn't normally feel comfortable doing so for tapering purposes.
The Internal Medicine attendings in whatever unit you're admitted to should set up a consult with an Addiction Medicine attending shortly after you're admitted; if they haven't after 24 hours or so, use your first interaction with the social worker that they'll inevitably send around to facilitate this.
Start setting up inpatient treatment for yourself as soon as possible. You become a higher priority once you've been admitted to the hospital because programs know that A) you'll most likely arrive when you say you will, which helps them to plan, and B) your chances of recovery are much higher if you go directly into residential rehab from the hospital.
I don't feel great about recommending that people manipulate the way that they present to achieve their desired clinical outcome, but it's much better than them dying on the street after being denied any sort of inpatient treatment.
We need to create a medical system that incentivizes honesty from addicts rather than endless dissembling; the way that the entire medical system is currently engineered seems almost designed to produce sociopathic lying from active addicts (even those who want to recover are frequently penalized for telling the truth).
In the meantime, all we can do as the disadvantaged parties in the situation is share information and navigate a deeply flawed system as best as we can.
Our first priority has to be to stay alive; our second priority is to get better; and our final objective is to extend a helping hand to the fellow addicts who are where we came from.
TL; DR:
Tranq dope, a mixture of the opioid fentanyl and the veterinary anesthetic xylazine, continues to increase in prevalence in the U.S.
Tranq causes widespread skin lesions that tend to become necrotic, as well as a lengthy withdrawal syndrome that combines features of benzo and opioid withdrawal
Tranq users are being denied spots in medical detox units, which assert that they cannot handle wound care for the xylazine-induced lesions; patients often encounter equal difficulty in seeking hospital admission for wound care and other reasons
One possible solution is to emphasize symptoms of sepsis when presenting for wound care in the Emergency Department, which may force the hospitals to admit tranq-addicted patients, at which point the Internal Medicine doctors will handle detoxification from xylazine and fentanyl (in consultation with Addiction Med attendings)
As always, thank you all for reading! If you have individualized questions, feel free to message me using the Contact form here or on Instagram (@concreteconfessional).
If you're looking for a buprenorphine or methadone maintenance provider or 12-Step or SMART Recovery meetings, I've compiled a list of resources at the bottom of this article.
Be good.
If you can't be good, then at least be safe.
If you can't be safe, then at least be hygienic.
Love you all,
Brian
Great article! Really hope this problem will be solved!