Why are overdoses fatalities dropping? There has been much speculation and the answer probably doesn’t lie with one factor but with many, including increased availability of naloxone, the efforts of harm reduction workers, the end of the COVID isolation, the trend away from injecting to snorting or smoking, a less toxic drug supply, and expanded treatment. Some have even speculated the drop represents simply the thinning of the herd, meaning many of those at highest risk for death have in fact died.
Today, I want to examine one possible factor — the increasing presence of xylazine in the drug supply, which I have written about before
Xylazine Decreases Overdose Deaths?
Xylazine gained much media attention as the zombie drug and it was officially declared an emerging threat to the United States by the White House in April 2023. But while it has caused horrible skin lesions in many users, it does not seem to have added to the death toll. To the contrary, a study of emergency department patients found that those who tested positive for both xylazine and fentanyl were less likely to die that those who simply tested positive for fentanyl. The theory is that rather than adding xylazine to fentanyl mixtures, dealers are adding xylazine to partially replace fentanyl, thus making the batch less lethal as fentanyl is far more dangerous than xylazine due to its ability to rapidly block breathing receptors in the brain. Additionally, because fentanyl prolongs sedation, it makes the “high” last longer so users may be administering fentanyl fewer times a day, decreasing the opportunities for overdose.
Here is some interesting data to add to the argument that xylazine has had a protective effect rather than a more lethal effect in overdose deaths.
According to the CDC’s State Unintentional Drug Overdose Reporting System (SUDORS), in 2020, the three states with the highest prevalence of xylazine in overdose fatalities were Maryland, Pennsylvania, and Connecticut. West Virginia was not far behind. Guess which states had their peak overdose numbers (highest 12-month rolling total of overdose deaths) reached earliest? Number One Pennsylvania, which reached its peak in September 2017, Number 3 West Virginia, which reached its peak in April 2021, Number 4 Maryland (July 2021) and number 6 Connecticut (November 2021). #5 Kentucky did not submit data. All have seen declining fatal overdose rates.
Let’s look specifically at Connecticut which began testing for xylazine in 2018. Here are three charts: overdose deaths, overdose deaths involving xylazine and percentage of overdose deaths involving xylazine. Since 2021, xylazine deaths (overdose patients who test positive for xylazine–they all almost always also test positive for fentanyl) are on an upward trend, the proportion of xylazine deaths to overall overdose deaths is rising, and guess what? Overdose deaths are down significantly. How about that! I suspect other states’ data will show the same thing.
Drug Overdose Report
Does this mean xylazine is the reason for the downturn in overdose fatalities? Maybe not the only reason, but worth considering. Xylazine has risen; overdose deaths have dropped. It certainly argues the presence of xylazine is a significant factor in the dropping rate and it also that lays bare a simple truth.
The more toxic the drug supply, the greater the deaths. More fentanyl in a $3 bag is more likely to produce a death than less fentanyl plus xylazine in the same $3 size bag. Wouldn’t it be nice if those who used drugs for whatever reason didn’t have to buy poison on the streets, but could get a pharmaceutically measured dose much in the same way when someone goes to a bar or liquor store they are getting a clean product with exactly the alcohol content in it, it advertises on the label with no unknown additives? Whatever your politics or view on drug use, if you are simply looking to lower the deaths, work to make the supply less toxic. We should all be talking about safe supply.