U.S. policy responses to xylazine: Thinking bigger

In the July 2024 issue of The International Journal of Drug Policy, Dr. Sugarman and colleagues identified and characterized policy initiatives aimed at addressing the potential harms associated with xylazine adulteration of the illicit drug supply (Sugarman et al., 2024). They found that the proposed policy initiatives largely reflected the expanding impact of xylazine across the United States, with an initial impetus in the Northeast, followed by the South and Midwest, and a surge of proposed initiatives in 2023. The majority of the policy initiatives were focused on scheduling xylazine as a controlled substance- a mechanism whereby the Drug Enforcement Administration categorizes substances by their degree of medical usefulness and perceived potential for misuse. However, the results of this legal policy analysis underscore the need for a more in-depth discussion of the potential intended and unintended consequences of these policy changes.

Much of the strategy used to address xylazine has been adapted from strategies used to combat illicitly manufactured drugs such as fentanyl, an adulterant that went on to monopolize the illicit drug supply. However, in contrast to illicitly manufactured fentanyl, xylazine is widely available and has been used in veterinary medicine for many years. It may be possible, therefore, to regulate the legal manufacture and distribution of xylazine and prohibit the distribution of xylazine for non-veterinary use. This approach, which, as the authors describe, has recently been applied in South Carolina (H.B. 4617/S.B. 849) and is in progress in New York (S.B. S6084A) and other states, requires proof of use from purchasers and enforces civil penalties on individuals or corporations in violation. While it is too early to determine the impact of this legislation, the approach recognizes the licit uses of xylazine and is likely more easily enforced than prohibition entirely or singular regulation of non-veterinary use of xylazine. Moreover, this approach can be expanded and adapted as other veterinary drugs, such as medetomidine, infiltrate the illicit drug supply. (Center for Forensic Science Research & Education, 2023)

Likewise, drug scheduling has far-reaching consequences that may exacerbate health equity issues and limit study of this new phenomenon. Strict scheduling limits researchers’ access to a substance, which hinders further scientific inquiry and delays work addressing priority research areas, such as a better understanding of the manifestations of xylazine toxicity and withdrawal, areas where we currently have limited data (Comer et al., 2021; Harvey et al., 2023). Likewise, scheduling also entails increased criminal penalties for individuals using or distributing the substance. There are data to support that class-wide drug scheduling increases mass incarceration and exacerbates the already significant racial disparities in our carceral system (Human Rights Watch, 2022; St John & Lewis, 2019). Potential consequences of supply restrictions through scheduling also include the unintended introduction of even more toxic synthetic alternatives. Some describe this push down-pop up phenomenon as a game of “whack-a-mole”, where, for instance, recent restrictions on fentanyl and fentanyl analogues have given rise to the even more potent and lethal 2-benzyl benzimidazole family, and the analogs referred to as nitazene analogs (National Institute of Justice, 2023). Moreover, there is little evidence to suggest that scheduling substances effectively decreases use or reduces the risk of overdose or other potential harms. As the authors describe, scheduling fentanyl analogues reduced the number of new analogues that reached the illicit drug supply but did nothing to address the existing fentanyl and fentanyl analogues that were already present (Weedn et al., 2021). And, notably, fentanyl overdose mortality remains at historically high rates.

Perhaps most concerningly, few of the policy initiatives sought to increase access to harm reduction services or substance use treatment. The emphasis on scheduling and criminalization neglects evidencebased harm reduction strategies, including drug checking and xylazine test strips and reducing barriers to accessing wound care and medications for opioid use disorder (Green et al., 2022; Reed et al., 2022; Shuda & Lam, 2022; Zagorski et al., 2023). Rather than amplifying punitive measures, which can lead to unintended consequences, we encourage policymakers to consider this issue from a public health perspective and dedicate resources to expanding harm reduction services instead (Carroll et al., 2018; Ray et al., 2023).

We congratulate the authors on this comprehensive overview of policies intended to curb the proliferation of xylazine in the United States. However, these results emphasize the need for further research around the impact of these policies, particularly through a health equity lens, and we urge policymakers to support other interventions that may have more lasting and direct benefit to people affected by xylazine in the drug supply.