People in Bloomington who use drugs now have an additional horror to deal with. Xylazine, a non-opioid drug adulterant authorized only for use in veterinary settings, is associated with skin lesions and it's in the local drug supply.
Last year, the U.S. Drug Enforcement Agency warned it had seized deadly mixtures of fentanyl and xylazine in 48 out of 50 states. The warning came just months after the DEA issued a report that xylazine was spreading.
Fentanyl and heroin users across the country now are often getting xylazine as well. Within hours of exposure, some of those people will develop lesions, whether they smoked, snorted or injected the drug. The wounds can grow, exposing tendon or bone, heal slowly and sometimes even require amputation.
“It does scare me a lot,” said Scott Pietrovich of the Indiana Recovery Alliance, a nonprofit that works toward harm reduction for drug users. “No one asked for it.”
Through the IRA, people in Monroe County can get wound care supplies, clean needles, and fentanyl or xylazine test strips for free. Alongside facilitating harm reduction, the IRA offers something else: compassion, something Pietrovich said is hard for people who use drugs to come by, but is essential to their recovery.
Xylazine-fentanyl combinations are just one iteration of an ever-evolving drug crisis in the country’s biggest cities and smallest towns. The nature of the problem makes it difficult to solve through legislation, leaving local organizations like the IRA to adapt quickly.
What is xylazine?
The illicit use of xylazine goes back to the early 2000s, when the drug was sold separately and intentionally mixed with fentanyl to provide an extended high. In 2019, its usage in Philadelphia shot up, and the region soon became the epicenter of the current crisis.
People who take drugs with xylazine mixed in are often unaware of the additive.
“We know that many people who overdose on opioids, especially fentanyl, were not even intending to take fentanyl,” said Jon Agley, deputy director of research at IU’s Prevention Insights. “And it’s the same thing with xylazine.”
As a sedative, xylazine slows the heart, drastically lowers blood pressure and depresses respiration. The result is reduced oxygen to skin tissue, which causes the initial lesion. With repeated use, the lack of oxygen slows wound healing, increasing the risk of infection and worsening the condition.
Unlike the substances it's often mixed with, xylazine is not an opioid and does not respond to naloxone, a medicine that reverses opioid overdose. However, naloxone should still be administered if an overdose is suspected because it will still be effective on opioids in the mixture.
Agley used the example of the wooden cup-and-ball toy to describe how naloxone acts during an overdose. If the opioid receptors are the cup and the opioid is the ball, Agley said, naloxone acts like a rock blocking the ball from entering the cup.
“If it’s a non-opioid substance, then it’s a different game entirely,” he said.
Though less dangerous than fentanyl, xylazine can kill when used in excess. It can also lead to severe withdrawal that cannot be managed with standard opioid withdrawal treatments like methadone.
The physical wounds associated with xylazine are concerning for groups like the IRA, which fears its spread may lead to increased stigma toward people who use drugs.
“These folks need love and compassion and connection,” Pietrovich said.
U.S. officials have observed illicit forms of xylazine enter the U.S. in solid form from China, in liquid form purchased from veterinary supply chains and, less commonly, mixed with fentanyl seized at the southern border, according to the DEA and Department of Homeland Security. Other evidence indicates xylazine may be mixed with other drugs by dealers rather than during the manufacturing process.
How prevalent is xylazine?
Xylazine is now firmly here in Indiana. The chemical was present in 22% of urine samples containing fentanyl, according to data from drug-testing laboratory Millennium Health, putting Indiana 10th in the nation for xylazine-positive samples.
Anecdotal evidence finds a similar pattern. According to the IRA, xylazine is prevalent in the Bloomington area, and it's beginning to show in coroner data.
Four people in Monroe County have died from overdoses that included xylazine since October 2023, according to Coroner Joani Stalcup. The Herald-Times also reached out to Greene, Lawrence, Brown, Morgan and Owen counties, finding one xylazine-related death each in Morgan and Owen and none in Greene. Brown County’s coroner said they don’t test for xylazine, though they’re required by Indiana law to do so. Lawrence County’s coroner did not respond to an email or multiple phone calls seeking information.
In comparison, xylazine was a factor in 32 overdoses in Marion County last year.
Indiana legislators have responded by criminalizing the drug, an action the IRA worries will simply punish people who use it. Instead, they advocate for drug-checking programs with sophisticated machines called Fourier transform infrared (FTIR) spectrometers. While test strips can indicate the presence of a single drug in a sample, FTIR machines can test the levels of multiple drugs and cutting agents at once, giving people who use drugs the ability to know exactly what they are putting in their bodies.
“What if we could tell people there’s a lethal amount in that stuff?” said IRA Executive Director Nick Voyles. “So much in it, you do it once and then you die.”
No “magic bullet” for the opioid epidemic
The opioid epidemic has evolved rapidly, from the proliferation of prescription painkillers in the mid-1990s to today’s far deadlier fentanyl mixtures. It adds another dimension to an already complex problem and makes policymaking more difficult, Agley said.
One example of the change is the speed at which an overdose progresses. While heroin overdoses may take several hours between onset and death, fentanyl overdoses can happen in minutes, Agley said.
“Sometimes that overdose can even happen faster than when first responders can get there,” he said.
That makes survival dependent on whether someone equipped with and trained to use nalaxone can get to a person within minutes, he said.
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“I think the idea that there’s, like, a magic bullet for the whole crisis is probably not true,” he said.
Harm reduction, reducing stigma and signs of progress
Overdose deaths in Indiana decreased 18% in 2023, one of the most dramatic decreases in the nation according to the CDC. The IRA, which supplies one-fifth of naloxone in the state, was instrumental to the decrease, Voyles said.
Harm reduction has been proven effective by multiple studies, including one that specifically cited fentanyl-focused harm reduction, naloxone distribution and recovery support as the three strategies most likely to save lives.
Pietrovich said he sees folks with xylazine wounds refuse to go to the hospital for treatment due to the stigma associated with using drugs.
“And it never gets treated,” he said.
Voyles said the problem of stigma crosses all parts of society, but agreed it is present in the healthcare system.
“I’ve literally watched stuff I wouldn't think would happen to a dog happen in a hospital,” he said.
Though the IRA distributes xylazine test strips, some people may not want to throw out substances they’ve already purchased, even if they discover it contains xylazine. Other times, people unwittingly grow dependent on the xylazine, further complicating future recovery.
The IRA’s mission is to reduce the harm associated with drug use and offer a path to recovery. That’s where lives are truly being saved, Pietrovich said.
“No parent deserves to get a phone call at 2 o’clock in the morning that their son overdosed in a bathroom,” he said.
Responding to an overdose and debunking myths
Signs a person may be overdosing include:
blue lips and extremities,
pale skin,
a limp body and
choking or gurgling noises.
If someone is exhibiting these signs, check to see if their chest is rising and falling or if their nostrils are flaring. Try to shout to wake them up, and if that doesn't work, rub your knuckles hard against their breastbone to determine if the person is conscious and possibly stimulate breathing.
Next, call 911. Indiana Good Samaritan Laws protect people who call 911 for an overdose from prosecution or arrest for drug possession and use.
After calling for help, begin rescue breathing. To do this, ensure nothing is in the person’s mouth or throat, tilt their head back, pinch their nose and make a seal against their mouth with your mouth. Give two quick breaths and then continue to give one quick breath every five seconds until help arrives.
Then administer naloxone by tilting their head back and spraying it into one nostril. If you have the injectable version, inject it into the individual's thigh muscle.
Naloxone alone is not enough – rescue breathing is critical to survival and must be administered continuously until the overdosing person can breathe on their own again.
The IRA suggests waiting around five minutes before attempting to give more naloxone, as too much can make the person feel incredibly sick when they wake up and could lead them to overdose again to get rid of their withdrawals. Other sources recommend administering another dose after two to five minutes.
Naloxone should still be administered even when xylazine may be mixed with the opioids. Do not administer more naloxone than necessary.
Like fentanyl, xylazine is a central nervous system depressant, which can exacerbate respiratory depression during an overdose. But unlike fentanyl and other opioids, Xylazine does not respond to the emergency opioid reversal agent naloxone.
Stay with the person after they wake to tell them what happened and ensure they do not immediately use more opioids, as the effects may return when the naloxone wears off. If you cannot stay, turn the person on their side to prevent choking.
To receive free naloxone, learn more about how to use it and get an official training, contact the IRA at 812-567-2337 or go to their office at 118 S. Rogers St. or mobile unit. Their hours are available at indianarecoveryalliance.org.
Even when the office is not open, people can get naloxone 24/7 in front of the building. The IRA accepts donations and volunteers at its website and can provide information and referrals to other Monroe County resources.
How to care for xylazine-related wounds
A guide from the Philadelphia Department of Public Health suggests cleaning basic xylazine-induced wounds with saline or soap and water, applying a petroleum-based salve and applying two dressings. Avoid using alcohol or peroxide, as these can dry the wound too much.
If a wound contains exposed tendon or bone, decreases range of motion or shows signs of infection, the individual should seek professional medical care.
The IRA also can provide guidance on how people who use drugs can advocate for themselves in a healthcare setting.
This article originally appeared on The Herald-Times: Xylazine-laced fentanyl worsens opioid epidemic in Bloomington
