Gabapentin and xylazine provide a case study of why U.S.-style drug prohibition fails so miserably. I discuss how we can reform our system to prevent even more deaths from addiction.
“Those who can make you believe absurdities can make you commit atrocities.”
- Voltaire (18th-century French philosopher)
Lesions caused by xylazine. This was the mildest picture I could find; don't Google "xylazine lesions" unless you're ready for medical journal pics showing exposed bone and limbs rotten to the point of amputation. For those of you who are still using "fentanyl," especially in the Northeast, know that these lesions can occur anywhere on your body - not just at the site of injection.
The Nightmare Du Jour: Xylazine
I was recently catching up with a friend of mine named Katie, who is a phlebotomist at a methadone clinic. She mentioned that the clinic has recently had to stock large quantities of Emergency Department supplies that it has never needed before.
When I asked her why, she replied with a single word: Xylazine.
This horse tranquilizer, which has long contaminated the supply of heroin and other drugs in places like Puerto Rico, is now infiltrating the drug supply in cities throughout the United States (with the Northeast feeling it worst so far).
Katie recounted her interaction with a 26-year-old woman who came in for her intake appointment at the methadone clinic last week. This prospective patient showed up for the physical exam portion of the intake process and allowed Katie to draw blood, take her blood pressure, temperature, and heart rate, and so on.
The young woman insisted again and again, however, that Katie not touch her right arm, which she held gingerly away from the rest of her body. Eventually, Katie became concerned enough about the arm that she asked the young woman to pull up her sleeve and show her what was going on. The young woman shook her head no, so Katie returned with the doctor, who explained that a thorough physical exam was necessary for safety reasons before methadone treatment could be started.
Finally, the young woman pulled up her sleeve, revealing a four-by-two-inch hole in the flesh and muscle of her right forearm, which was eaten away to such an extent that both the radius and the ulna bones were visible. It was one of the worst lesions that Katie has seen in her two decades of medical experience and something that she never expected to see somewhere like the United States.
It turns out that xylazine has hit our home city in Upstate New York, where much of the fentanyl being sold as heroin is now contaminated with this unscheduled anesthetic that is not approved for use in humans. Most of the people using it have no idea that there is something other than fentanyl in what they are putting into their bodies, but this so-called "tranq" or "tranq dope” has attracted a loyal following in some cities, including Philadelphia.
It has been widely observed that users of xylazine develop necrotic ulcers - not just at injection sites, but all over their bodies, presumably because of changes in circulation caused by the drug. Because xylazine isn’t an opioid, overdose can’t be reversed with Narcan (naloxone), meaning that EMTs and other medical professionals now have an even more hellacious situation on their hands. More patients will need to be intubated and managed in the ICU, and undoubtedly, more sons and daughters and brothers and sisters will be lost. The public health authorities in my home city and across the United States are sounding the alarms.
For those of you who are familiar with Russia’s putrid hallucination of a Krokodil problem, the parallels will be obvious (if you're interested, Vice had some okay coverage).
If you're wondering what xylazine feels like, I've written a wild trip report about injecting pure, medical-grade xylazine.
Okay, this is all good to know, but what does it have to do with gabapentin? Bear with me, please; I’ll loop back around to xylazine, I promise.
What Is Gabapentin?
I have been prescribed gabapentin so often during the past 10+ years that I turned it into a verb.
“Are you gabapenting today?” I would ask my fellow detox patients over breakfast. I can close my eyes and picture the black imprints against the bright yellow capsules.
Gabapentin (trade name Neurontin), which in 1993 was FDA approved for use in treating certain types of seizures, has been prescribed off-label for everything from opioid and benzo withdrawal to insomnia to anxiety. It helps with nerve pain, particularly the kind caused by diabetes, fibromyalgia, and other disorders, which doesn't respond well to opioids or NSAIDs.
Gabapentin was the single safest and most effective anxiety medicine that I have ever taken. I found it much less addictive than the benzos (drugs like Valium, Klonopin, and Xanax). It was easy to regulate my intake of the medicine and much, much easier to come off of it.
Gabapentin also gave me more relief from opioid withdrawal than any other medicine aside from opioids themselves. It got me through my buprenorphine (Suboxone) and methadone tapers, which involve months of severe anxiety, insomnia, bone pain, muscle cramps, diarrhea, and more. During my relapse, there were many times when I relied on gabapentin to get me through periods of 24 to 48 hours without my drugs of choice; this is an addiction hack that opioid addicts in the U.S. commonly use it for.
To me, when taken sporadically, gabapentin feels similar to smoking a small amount of marijuana. It induces a light sedation with some relaxation, a mild body buzz, increased appetite, and a slight sensory shift toward more vibrant sounds, tastes, and colors. After three or four days of regular use, in my experience, gabapentin fades into the background; it becomes undetectable, though it still helps with pain, anxiety, and insomnia.
When I was first prescribed Gabapentin around 2011, it was the “great new thing” that psychiatrists and other doctors were turning to in the fight against benzos and opioids. Many, many a pill-seeker from the aughts and ‘10’s will tell you about interactions with physicians that ended with a statement to the effect of “We can’t give you X (controlled substance requested), but gabapentin is no problem.”
When I was first prescribed it, in fact, I was told that it was much safer than benzos but worked by a similar mechanism. No risk of dependence or addiction was mentioned, ever, period, by any of the several physicians who prescribed it to me through the years.
As I mentioned above, gabapentin was being prescribed so widely in part because benzo prescriptions were being cracked down on as the long-term effects of seizures, memory loss, and cognitive decline became apparent. Unlike gabapentin's sister drug Lyrica, which is a controlled substance, gabapentin wasn’t regulated federally or at the state level, meaning that the stringent requirements attached to controlled substances weren’t something that physicians had to consider when doling it out.
Now that we know more about gabapentin, we have realized that gabapentin has a more dangerous short- and long-term side effect profile than was initially appreciated. A benzo-like withdrawal syndrome sometimes involving seizures has been reported. Moreover, because gabapentin is often used to “boost” the action of prescription and black-market opioids alike, the respiratory depression that it causes has contributed to many polysubstance overdoses. Ostensibly for these reasons, some states began to classify gabapentin as a controlled substance even though it isn’t federally regulated in this way (yet).
As of July 2022, eight states had implemented legislation making gabapentin a controlled substance, and several others had instituted more rigorous monitoring and reporting requirements for gabapentin compared to other noncontrolled substances. During New York State’s 2017-2018 legislative session, NYS Senate Bill S8145A was passed, classifying gabapentin as a controlled substance.
Gabapentin Prescriptions Drying Up
I am in somewhat regular contact with dozens of opioid addicts, probably half of whom live in New York State, and several have recently mentioned their doctors discontinuing long-term gabapentin prescriptions. Others have switched providers and found themselves unable to restart or continue the medication, as well.
Although making a substance controlled technically shouldn’t stop doctors from prescribing it to patients who need it, practice is wildly different than theory in this regard, especially because of how litigious Americans are when it comes to malpractice cases and how vigorous the government has become in cracking down on doctors who overprescribe dangerous drugs (an otherwise positive development in response to the epidemic of Oxycontin overprescription that fueled the heroin epidemic).
The available evidence strongly indicates that gabapentin is being prescribed less often and in smaller quantities in the areas where it is controlled at the state level. It is almost guaranteed that physicians in areas where it has not yet been regulated are paying attention to these developments and shifting away from gabapentin in anticipation of their own states regulating it and / or gabapentin being added to the federal controlled substance schedules.
The bottom line: People who have used gabapentin for a long time, for whom it works well and hasn't caused deleterious side effects, can no longer obtain it.
The notorious 80-milligram OxyContin formulation: Addiction in a pill. I remember walking through parties during high school in the aughts and seeing yellow (40 mg) and grayish-blue (80 mg) streaks on many a partier's t-shirt from removing the extended-release coating to get even more of a kick from these pills. Taking them was essentially like ingesting a high quantity of pure heroin. Most opioid addicts my age or older entered opioid addiction through these pills - they were sort of the Lemmon 714's (quaaludes) of our time.
Back to Xylazine: The Big Picture
A pattern that we’ve seen again and again during the failed War on Drugs is reoccurring: We take a legal substance with known risks and restrict its availability by controlling or banning it, and we ultimately push the people who have come to depend on that substance toward illegal behavior, such as buying prescription pills illegally or substituting street drugs for prescription ones. We trade limited, known or at least knowable risks for unlimited, unknown, and unknowable ones. We push people over the precipice into criminal behavior and full-blown addiction.
Forced withdrawal from substances that cause physical and psychological dependence is a form of torture. Our government has made enemies of its own people and incarcerated millions of them for continuing to obtain something that their brains and bodies can no longer function without.
In the case of gabapentin, street benzos like bromazolam – which have become ever more popular as Xanax and the other prescription benzos have gotten much more difficult to acquire through the medical system – are taking over. Because most of these chemicals are not approved for use in humans, we don’t really know their full risk profiles, but many of them are ultra-potent and long-lasting. (Many of them are much more dangerous in nearly every way than the prescription benzos; this much is clear). Moreover, users of these black-market benzos have no way to know for sure whether they’re taking the substance that they believe they are, how much they’re taking, and if they’re taking only that substance. (We know that pressed pills meant to look like Xanax “bars” have been seized that contain both fentanyl and bromazolam, which is a recipe for fatal overdose if ever there was one).
So, just as we’re taking away gabapentin, an approved substance that opioid addicts use to manage their withdrawal symptoms and get off of these drugs, we’re seeing an increase in availability of xylazine, a cheap and highly dangerous drug that isn’t even approved for use in human beings.
This is exactly the mistake that we made when regulators suddenly took away OxyContin by ordering its reformulation and clamping down on prescriptions after it had been massively overprescribed for years and years. We pushed people away from prescription opioids, and those people eventually ended up on heroin, then fentanyl – and now xylazine.
One hundred and twenty years ago, an opioid addict could walk down to the corner pharmacy and buy tinctures containing opium, heroin, cocaine, and other drugs with medical and recreational functions. He or she could have visited the friendly neighborhood physician for a prescription for larger quantities of medical-grade drugs, who would have warned about the risk of addiction and helped manage tolerance and dependence in accordance with priorities set in collaboration with the patient. Addiction was still a serious issue, but it was no more onerous and awful than any other mental or physical illness. You could live a productive, prosocial life as an addict.
I have experienced both sides of this coin as a prescription drug addict in the U.S., then an illegal drug addict in the U.S., then a prescription drug addict abroad. Even after relapsing, when I was able to go into a clinic and buy a known quantity of a known substance in another country, I was able to hold down a fairly demanding job, enter into a long-term relationship, adopt and care for a pet, and travel and enjoy life. Sucked down an extinction vortex by the criminalization of substance use in the United States, by contrast, all of my time and energy were spent getting money to cover the drastic over-pricing caused by prohibition; I bounced between ineffective treatment and active addiction for years, and avoiding incarceration became the top priority. I'm an educated person with a strong work ethic, but I have wasted much of the past 15 years because of the criminalization of a mental illness that I suffer from.
My friend Kris K., a solid man who passed away in 2020 at the age of 43 from drug-related causes. He left behind two young, beautiful boys. Kris and I had a falling out shortly before he died, and I will carry the guilt of that until the day I join him.
More than one million Americans have died of drug overdoses since 1999. 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. When you stop and think about it, can you really imagine?
The Solution(s)
1. Right away, we can “grandfather” long-term users of gabapentin into lifetime prescriptions of the drug. We already have ways to flag patients for “bad” things - all of my medical readers will know about Epic and the PDMP. We can very easily make a note on any affected patient’s electronic medical records explaining that they need this substance for the conceivable future so that any prescriber who takes this patient under his or her care will be able to take this information into account. A grandfather clause for Oxycontin prescriptions could probably have prevented the heroin and fentanyl epidemics, saving millions upon millions of lives and billions upon billions of dollars.
2. We need to figure out the risks of drugs before we prescribe them, especially for off-label purposes, not after. The Food and Drug Administration (FDA), which approves substances for medical use in the United States, is a heinously corrupt organization whose leaders often walk back and forth through a revolving door with top positions in the big pharma sector. Let’s lose the advertisements for pharmaceuticals on TV, bring back protective, paternal medicine in the best sense, and hold our government properly responsible for keeping our children safe.
As an interesting side note, the former head of the Chinese equivalent of the Food and Drug Administration, a man named Zheng Xiaoyu who was reportedly once in the good graces of President Xi, was convicted of accepting relatively modest bribes (by Chinese bribery standards) in exchange for approving pharmaceutical products. He was executed. The “big, bad” Communist Party of China has seen what FDA corruption has done to the United States, and it will never allow its own children to be poisoned, tortured, and corrupted in the way that ours have been.
3. We need systemic reform. We need a cultural change toward limiting our use of dangerous substances, controlled or otherwise, legal or not. We also need to reform our way of regulating people’s intake of recreational and medical substances, including the system for scheduling controlled substances at the federal and state level as well as the outrageous criminal penalties for the decision to exercise bodily autonomy by taking drugs. The War on Drugs has failed. We need a new approach.
Portugal provides an instructive example, as I touch on in a previous post.
Thank you for taking the time to read! As always, I’ll respond to all comments below. Let me know if you’d like to read more on these topics. B.
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