The wounds are the tipoff. They can show up anywhere on the body. They look like burned skin, dark dead tissue. Wounds that smell. Wounds that hurt. Wounds that won't heal.
Melody Kingsley, health educator with Greene County Public Health, west of Columbus, told me that throughout 2022, she noticed an increase in such wounds. They showed up on the bodies of people who had done everything to prevent them (used new syringes and alcohol swabs) and yet, here they were. One woman she saw had a wound that became necrotic – meaning the tissue was dying.
"If she had come in a week later," Kingsley said, "her foot would have been amputated."
Around the same time, Kingsley said, she learned about something called xylazine from harm reduction workers around the country. Fentanyl that was cut with xylazine (also called "tranq") was causing intense wounds, extended withdrawal and prolonged sleep – sometimes for six or more hours in unsafe places, exposing people to theft or physical harm. More importantly, it was causing overdoses that couldn't be reversed with naloxone alone.
This matched what Kingsley was hearing about in Greene County. People overdosing and not waking up even though they were breathing. People saying they’d sleep all day after injecting. And at the local syringe program, she was seeing the wounds.
Xylazine is a large-animal tranquilizer, not an opioid, and it's not approved for human use in the U.S. But it’s showing up as an additive to fentanyl. One theory is that because fentanyl doesn't last long, people are cutting it with xylazine to give it legs. Xylazine first appeared in the illicit drug supply in Puerto Rico in the early 2000s and then in Philadelphia – with overdoses involving the drug as . It began showing up regularly during the pandemic. Across the country, it's showing up more in DEA seizures and in overdose deaths but seems to be mostly concentrated in the Northeast. Research last April indicates that xylazine is widespread around the country but is especially prevalent in overdose deaths in Philadelphia, Maryland and Connecticut.
There is no widely available and simple mechanism for xylazine testing yet. And because it's not a scheduled drug, coroners and medical examiners aren't always looking for it. But there's some data. The office of the Franklin County Coroner told me that there were 35 overdose deaths involving xylazine in 2022. According to data from the Montgomery County Coroner's Office and the Miami Valley Regional Crime Laboratory, xylazine has been found throughout the state in a variety of cases (including postmortem studies, impaired drivers and research studies). In 2022, it was detected 54 times, up from one time in 2018.
Much of the information about xylazine is coming from people who use drugs and their allies – frontline harm reduction workers. Sources in Athens, Cuyahoga, Hamilton, Mahoning, Montgomery and Scioto counties have told me there's evidence of xylazine in their communities. We're still not sure how pervasive it is.
For now, Kingsley said, people need to practice harm reduction – go slow, have naloxone available, don't forget the importance of rescue breaths when someone is overdosing, and take care of wounds. It's really all we can do, she said.
Trying to keep up with the changing drug supply, Kingsley told me, is like playing “whack-a-mole.”
Billy Golden knows what playing "whack-a-mole" with the drug supply looks like. Golden is chair of the board of Harm Reduction Ohio and remembers working in harm reduction when carfentanil showed up in Cincinnati in 2016.
"It was awful," Golden said. "Everyone was so scared." He told me that he can't remember how many people died or overdosed, but he can remember that people were terrified. At the time, the organization he was working with didn't have enough naloxone for everyone who needed it. No one did.
“Speaking for myself, the takeaway is that we have an unregulated drug supply, and the harder we try to crackdown on adulterants and criminalize these things, it opens the door for something worse," Golden said. "It’s a direct result of the war on drugs. We’re going to continue to have this issue."
And sadly, in his recent State of the Union address, President Biden called for more war rather than less. "Let’s launch a major surge to stop fentanyl production, sale, and trafficking," he said, "with more drug detection machines to inspect cargo and stop pills and powder at the border. Working with couriers like FedEx to inspect more packages for drugs. Strong penalties to crack down on fentanyl trafficking."
And three Republican house members have called on the DEA to schedule xylazine.
To be clear, xylazine, and the wounds it fosters, are a hellscape created by prohibition. Supply side solutions don't work. Ohio should know that. In 2011, when the state shut down the pill mills, people switched to illicit opioids, including heroin, and since then rates of overdose have been climbing.
Now we have wounds, a kind of leprosy, a physical manifestation of the stigma of substance use.
If there was a safe supply of drugs, this would not be happening.
This is the result of prohibition, of an unregulated market, of the war on drugs: It is prolonged overdoses. It is anxious withdrawal. It is a wound that will not heal.