Drug meant for large animals is being mixed into street drugs

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Xylazine is a drug that can cause serious life threatening effects in people, and recently this substance has been found in street drugs in Central New York. So I'm talking with Dr. Ross Sullivan to learn more about xylazine. He's an assistant professor of emergency medicine at Upstate and director of medical toxicology. Welcome back to "The Informed Patient," Dr. Sullivan.

[00:00:36] Ross Sullivan, MD: Hi, good morning. Nice to be here.

[00:00:39] Host Amber Smith: Xylazine was in the news recently, and it may have been the first time many people heard of it. Is xylazine a new medication, or is it just new to the Central New York area?

[00:00:50] Ross Sullivan, MD: Well, it's probably just newer to our area. In fact, those of us who kind of work in this field, we've really noticed it actually here probably over a year ago now, kind of creeping in, geographically, from other areas in the Northeast. However, the last few months to six months, particularly more recently though, we've noticed it to really start becoming a larger problem. So it is newer. We have kind of been monitoring it already, over maybe the past year, but it's certainly exploded recently.

[00:01:20] Host Amber Smith: Xylazine - does it have other names?

[00:01:23] Ross Sullivan, MD: You know, on the street they might call it something like "tranq," I guess short for like tranquil or something like this. We hear that name quite a bit, or "sleep dope," or something like this. But we mostly call it Xylazine, but there's a lot of words for it on the street. We probably don't even really know all of them. Tranq probably is the most popular one.

[00:01:44] Host Amber Smith: So, is there a therapeutic use for xylazine in humans?

[00:01:49] Ross Sullivan, MD: No, not in humans. You know, it's used as a veterinary medicine, in these large animals, and it causes sedation, right? So as a sedative in the veterinary medicine. So unfortunately it has similar effects in people too.

[00:02:04] Host Amber Smith: And so the drug suppliers are somehow getting their hands on the veterinary medicine and mixing it with other drugs? I mean, nobody's out on the street looking for this to buy just this, right?

[00:02:18] Ross Sullivan, MD: Right. To the best of our knowledge, we don't think people are purchasing drugs that have xylazine in it. And in fact, most people, they tell us they have no idea. So why it's in there, we really don't know. You know, sometimes it's a bulking agent. But we do know that it will make someone be sedate for a long period of time.

And we are not sure if that would be desirable. It probably really isn't. So it is put in there probably unknowingly to the people who use drugs, and which makes our drug supply, which is already unsafe, even more unsafe.

[00:02:54] Host Amber Smith: Well, I wanted to ask you what it does in the body, and I imagine it depends on how it's ingested, right? So, so it can be inhaled or injected?

[00:03:03] Ross Sullivan, MD: Yeah. I mean, these things probably can be inhaled or injected, like any drug. A lot of the effects we're seeing locally are from people injecting it. But the effects would probably be similar in the human body. And what it does is it causes a profound sleepiness. We say almost coma-like. It's an anesthetic, right? So you'd be sleeping. It lowers your heart rate quite a bit, too. It'd be very difficult to arouse.

So why it's dangerous is, if you have a very low heart rate, you are in a coma, maybe even slows your breathing. And when you add that to something with fentanyl, which is what this is almost always mixed with. Fentanyl, of course, also causes maybe coma, so to speak, and decreased to no breathing. So when you mix these two things together, what we're having is a real deadly combination.

[00:03:53] Host Amber Smith: And fentanyl's been a problem. We've talked with you about that in the past, as well. That's another illegal drug that's showing up in drugs. People don't expect it to be there, but it is.

[00:04:04] Ross Sullivan, MD: Yeah. Exactly. We're to a point now where our heroin supply is probably 80% or greater fentanyl, right? So it's almost expected. It is expected. We know it's here. And it's also in a great degree in a lot of other drugs that people are using. We know that it's been found in a cocaine supply, maybe in some methamphetamine supply. So, it's to the point now where it should be expected in our community, and if someone's using an illicit drug that it has a potential or a probability of having fentanyl in it.

[00:04:36] Host Amber Smith: So how fast does xylazine take action once it's ingested?

[00:04:41] Ross Sullivan, MD: Well, we think the xylazine works pretty quickly. It's pretty potent, or powerful. And when it's, let's say, injected, it probably just takes several minutes really to start working. But it lasts much longer than fentanyl, so not only do you have a combined sedation or coma from fentanyl and the xylazine, but the xylazine also acts a lot longer. So when someone may be waking up or recovering from the fentanyl, now they're having a much even longer, prolonged sedation. So the chance of somebody stopping breathing, the chances of someone having a a problem due to a really low breathing or low heart rate, is just really, not only is it combined, but it's also now prolonged.

And this is why people are still dying. I mean, people are still dying mostly from fentanyl, but now we're trying to understand better how is the xylazine also playing a role in this? Most of the deaths from opioids have fentanyl in it and still not xylazine, most of them. But we're seeing now xylazine be part of the equation now. So certainly fentanyl, in and of itself, is still very deadly on its own. But we have this other bad actor now, coming into our supply.

[00:05:52] Host Amber Smith: How does xylazine affect the cocaine or the heroin? You know, if a person is purchasing cocaine to use, but it has xylazine in it, does that affect how the cocaine works?

[00:06:05] Ross Sullivan, MD: No. I mean, the drugs themselves still work the same. I'm not too sure if we've seen xylazine in cocaine yet. It's possible that it could be in cocaine in the future. I don't think we've really seen too much of that. We've seen it really in the heroin and fentanyl, so the heroin and fentanyl or even the cocaine, theoretically, it would all still be working itself the same, but then you have this extra added drug in it, which is just causing a whole another host of problems. So you have the drug doing, its own work, which can be deadly. And then you have another drug doing its work, which also can be deadly.

[00:06:39] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. My guest is Dr. Ross Sullivan, an emergency physician and director of medical toxicology at Upstate.

Can naloxone or Narcan reverse an overdose with xylazine in it?

[00:06:57] Ross Sullivan, MD: It does not reverse xylazine. At all. They're very different drugs. Xylazine is not an opioid. It works completely differently. But the big message we tell everyone is, though, to keep giving naloxone, or Narcan, because it's still in the fentanyl. You still have to reverse the fentanyl portion of an overdose.

Because remember, like I said a little bit before, fentanyl is still the deadly or deadliest illicit drug in our area. And since we know the xylazine is predominantly or only mixed with fentanyl, you still have to give it to take the fentanyl away. And you might give it, and someone might not look like they're waking up, but maybe they're breathing again. And so when people are saying things like, "well, the naloxone's not working," it is most likely working, but you'll still be sleeping from the xylazine. So that's why we say, look at the breathing if you can. I know not everyone's trained to do this, but if someone's breathing again, their chest going up and down, that's what you need.

They might not wake up. They won't wake up if there's xylazine in it. But they'll probably start breathing again because you'll block the fentanyl with the Narcan. So it's still very important to still give.

[00:08:07] Host Amber Smith: So if you can get them breathing again, or feel secure that they are breathing, then maybe that will be what helps save them?

[00:08:15] Ross Sullivan, MD: Absolutely. That will be most likely what can and will save them. You know, obviously we want you to call 9 1 1 as well, so that's really important for people in the community: if you see this, if you happen to have naloxone with you, or Narcan, to spray the bottle in someone's nose, but still call 9 1 1. And they might not wake up because of xylazine.

[00:08:35] Host Amber Smith: So call 9 1 1. Use Narcan if you've got it. Anything else that a person should do, if they come upon someone who's overdosed? There's no way to really know what they've overdosed on?

[00:08:45] Ross Sullivan, MD: There's really no way. Those are the two most important things, really. I mean, you can advocate for rescue breathing, but that's if you're comfortable. And I understand not doing that. Rolling people on their side sometimes is important because we don't want people to maybe vomit and choke on their vomit, which is also a big problem. But the main thing is call 9 1 1, give them the naloxone and Narcan, and let the 9 1 1 people who are trained to come and take it from there. Those two things are the most important things.

[00:09:13] Host Amber Smith: Is there any way to tell ahead of time, if you purchased an illegal drug, can you tell whether it has xylazine or fentanyl in it?

[00:09:21] Ross Sullivan, MD: Well, we're really not there yet in terms of xylazine. There are some point-of-care or, I should say, a test strip that's being developed or is in early use in some parts in the country. I'm not aware of us having necessarily that capability locally. Certainly we don't at Upstate University Hospital or the local addiction treatment centers, we don't have access to these xylazine test strips.

What we do have access to in our community, though, are fentanyl test strips. And those are really important because, again, there's a whole host of people that are using drugs that are not heroin, so people using methamphetamines and cocaine, that don't want to be using fentanyl. And test trips are very important for those patients. They can get them from certain programs for the county. The Upstate Bridge Clinic has them, Helio Health has them. I'm sure others do as well. But that's a real important tool that we have locally as well.

[00:10:14] Host Amber Smith: Can you talk about the longer term complications from xylazine? I've heard about skin ulcers and abscesses.

[00:10:21] Ross Sullivan, MD: Yeah. You know, the real long term we probably don't even know yet, but absolutely, one of the things we're seeing are these skin wounds, or I should say, tissue wounds.

It goes through the skin, right? It actually can go down into the tissue and sometimes down to the bone. It's not just necessarily even an infection. We use the word necrosis, which just really means tissue breakdown, right? And it's not necessarily even due to an infection. Infection might be part of it. But there's something about this drug, maybe, or whatever it's in, that's causing damage locally, right to the tissue where the people are injecting. And over some time they develop a very aggressive wound that's difficult to treat. It's difficult to treat wounds. I mean, think of maybe a little cut sometimes that you say, "oh man, it's taking a long time to heal." You know, these can be this large, the size of a baseball or palm of someone's hand, or larger, on someone's arm, on their legs or anywhere, really.

It's terrible, right? And the people who are using, they don't want these, right? Of course they don't. These wounds cause terrible complications and infections and a lot of other problems. Again, we don't know exactly why, but it's causing damage locally. And it's pretty terrible for the patient.

[00:11:37] Host Amber Smith: Well, Dr. Sullivan, thank you so much for making time for this interview.

[00:11:40] Ross Sullivan, MD: Yeah, it's been my pleasure, as always.

[00:11:42] Host Amber Smith: My guest has been emergency physician Dr. Ross Sullivan. He's director of medical toxicology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.