How the Emergence of Xylazine Impacts Overdose Prevention Policy overdose prevention policy, overdose crisis, fatal overdoses, emergence of xylazine, illicit drug supply, toxicological testing, withdrawal symptoms, xylazine test strips, drug paraphernalia laws, drug checking, legislative action, drug supply, substance use disorders, controlled substance, opioid use disorder, centers for disease control, health care, harm reduction services, psychoactive substances, department of public health, illegal drug, type of drug, opioid crisis, prescription opioid, astho, association of state and territorial health officials JoAnne McClure, Victoria Pless How states are considering overdose policy changes as xylazine continues to emerge in the illicit drug market. Developing and adopting policies to reduce fatal overdoses can help public health leaders address the ever evolving and complex national overdose crisis. More than 109,000 fatal overdoses occurred in 2022, with the majority involving illicitly manufactured fentanyl. Adding to the overdose challenge is the emergence of xylazine, a non-opioid tranquilizer (i.e., sedative), that is being increasingly mixed with fentanyl in the illicit drug supply. As of November 2022, xylazine was found in the illicit drug supply in 48 of 50 states and Puerto Rico. Xylazine is currently associated with one in ten fatal fentanyl (11%) overdoses, a near-threefold increase from 2.9% in 2019. Toxicological testing for xylazine is not uniform and, as a result, its involvement in fatal overdoses may be underestimated. Some states have taken initiatives such as Indiana (HB 1286) and South Carolina, to improve the consistency of toxicological testing for xylazine. With xylazine’s addition to the overdose crisis, states are beginning to adopt laws to better regulate the supply of xylazine and detect its presence in the illicit drug supply. What is Xylazine? Xylazine, also known as “tranq” or “tranq dope,” is a central nervous system depressant causing drowsiness, slowed breathing, reduced heart rate, and hypotension, which can increase the risk of a fatal overdose. Xylazine is approved for veterinary use in the United States but is not FDA-approved for human medicine. Xylazine, can be added to substances that are ingested orally, snorted, sniffed, or—mostly commonly—injected intravenously, and has been added to or used to cut heroin and fentanyl to prolong their effects. People who use drugs may be unaware of xylazine’s presence, which can put them at a higher risk of fatal overdose. Xylazine use is associated with skin ulcers, lesions, abscesses that left untreated, can lead to amputation. People who develop a physical dependency on xylazine may develop severe withdrawal symptoms. Although symptoms of xylazine use and opioid use are similar—making it difficult to differentiate whether someone has used one or both substances—overdose reversal agents (e.g., naloxone) do not counteract the effects of xylazine. Public health leaders still recommend that naloxone be administered for a suspected opioid overdose because xylazine has been detected in substances alongside fentanyl. For a person experiencing a xylazine-involved overdose, public health leaders emphasize the need to seek treatment beyond naloxone. In addition to public health’s work to address xylazine in the illicit drug supply, some state and territorial legislatures are expanding or protecting access to xylazine test strips as well as steps to limit access to xylazine through the state drug schedule. Legalizing Drug-Checking Equipment Drug-checking equipment, such as fentanyl test strips, are evidence-based interventions that allow a person who uses drugs to test their supply for an adulterated substance. State drug paraphernalia laws historically prohibited drug checking equipment, limiting the possession, distribution and use of items like fentanyl test strips. To make fentanyl test strips more widely available to prevent overdose, legislatures rapidly changed their laws to either explicitly legalize fentanyl test strips or generally legalize drug checking equipment. As of July 5, 2023 more than 33 jurisdictions legally authorize the use of fentanyl test strips, 12 of which (Alaska, Colorado, Guam, Maine, Maryland, Nebraska, New York, the Commonwealth of the Northern Mariana Islands, Pennsylvania, South Carolina, Utah, and Vermont) generally authorize the possession and use of drug-checking equipment. Similar to fentanyl, people may not know whether they are exposed to xylazine when using other substances, increasing the risk for harm. New test strips can detect the presence of xylazine, however state drug paraphernalia laws that criminalize drug checking equipment may limit the accessibility of xylazine test strips to prevent overdose. In 2023, at least three states—Illinois (HB 3203), New Hampshire (HB 287), and Utah (SB 86)—enacted legislation to authorize or decriminalize use of drug-checking equipment for fentanyl and xylazine, ensuring that xylazine test strips are lawful and able to be distributed. Additionally, states that previously passed legislation to allow for fentanyl-specific drug checking are amending their statutes to include all drug checking to ensure the legal possession of xylazine test strips. For example, Delaware enacted (SB 189) that specifically legalized xylazine test strips. Two other states—Vermont (H 222) and New Jersey (SB 3957)—enacted laws expanding the authorization of fentanyl test strips to allow for all harm reduction supplies, including drug checking equipment, which would permit the use of xylazine test strips. The Question of Scheduling Drugs are scheduled based on their acceptable medical use and potential for misuse and severe psychological and/or physical dependence, with drugs in Schedule I being the most tightly regulated. Xylazine is not a controlled substance under the federal Controlled Substance Act so it is not DEA scheduled or controlled. Nevertheless, xylazine is subject to FDA regulation under the federal Food, Drug, and Cosmetic Act and state law. Prior to 2023, only two states directly or indirectly scheduled xylazine. Florida codified xylazine as a Schedule I substance in 2016, and xylazine could fall under Massachusetts’ Schedule VI designation, which applies to prescription drugs. As state and territorial leaders take steps to schedule xylazine, policymakers should consider whether scheduling or other criminal penalties will deter people from seeking care if they fear being arrested for unknowingly testing positive for exposure or xylazine use. Another consideration for leaders before scheduling xylazine is whether scheduling will also make possession of test strips illegal under the jurisdiction's drug paraphernalia law. In 2023 at least nine states–Delaware (SB 189), Illinois (HB 3873), Louisiana (HB 106), Michigan (HB 4913), New Jersey (A 5448), New York (A 5914), Oklahoma (SB 668), Rhode Island (HB 5922), and West Virginia (SB 546)—considered legislation to schedule xylazine as a controlled substance. Of those, Delaware, Rhode Island, and West Virginia enacted laws scheduling xylazine in 2023. In addition to legislative action, at least two governors (Ohio and Pennsylvania) took executive action to schedule xylazine. ASTHO’s overdose prevention and state health policy teams continue to monitor these important public health issues. website yes