A Content Analysis of Xylazine-associated Stigma in Web-based Media Driven by the Zombie Term and Stigmatizing Imagery

Abstract

Background:

Drug use–related stigma amplifies the harms faced by people who use drugs (PWUD). Media often dehumanizes PWUD, particularly those using xylazine, a veterinary sedative and opioid adulterant, by labeling them with terms like “zombie.” This perpetuates discrimination and stigma, distracting from the public health crisis. To assess this, we conducted a content analysis to quantify the prevalence of stigmatizing terms like “zombie” and related imagery in xylazine-related web-based media.

Methods:

We analyzed web-based news media reporting on xylazine from October 1, 2022, to September 30, 2023, using Google News. “Stigmatizing term” was defined as the use of the word “zombie,” and “stigmatizing imagery” was defined as an embedded image of nonsterile or discarded drug use supplies, visibly intoxicated individuals, unhoused persons, or necrotic wounds. Two trained reviewers followed a standardized protocol to examine article titles, text, and images. Articles using stigmatizing term and/or imagery were coded as stigmatizing; and data were aggregated by month to assess any temporal changes in relation to federal xylazine alerts.

Results:

In a 12-month period, 910 news articles mentioned xylazine, 23.9% featured stigmatizing content, of which 57% (124/217) used “zombie” only, 26.3% (57/217) had stigmatizing imagery only, and 16.6% (36/217) had both. Stigmatizing articles peaked in March and July 2023, coinciding with federal alerts about xylazine in the opioid supply. Of the 601 articles with embedded images, 15% had stigmatizing imagery.

Conclusions:

Stigmatizing content in web-based news media about xylazine continues to proliferate, highlighting the need for more efforts to challenge these narratives.

People who use drugs (PWUD) face rising harm from the unregulated US drug supply, worsened by stigma that causes social isolation, avoidance of care, and hinders evidence-based policies.¹ Most US residents rely on web-based media for public health information, which, due to its accessibility and perceived credibility, can perpetuate sensationalized, stigmatizing portrayals of PWUD.² Exaggerated portrayals of PWUD in headlines, imagery, and provocative language can drive negative public perceptions and create moral panic, like the sensationalized depiction of methamphetamine use as an epidemic, distracting from the complex realities of drug use and discouraging care-seeking behavior.^1,3,4 Despite progress in the addiction medicine community, mainstream media lags in addressing stigmatizing language. While stigmatizing news articles decreased from 2017 to 2021, the evolving drug supply continues to challenge these efforts.¹

Xylazine, a veterinary sedative found in the opioid supply,⁵ has been framed by the media as a zombie drug, due to its sedative effects and necrotic wounds. This fear-driven, sensationalized portrayal perpetuates harmful stereotypes and shifts attention from the risks posed by this new adulterant.⁶ The rising presence of xylazine prompted federal agencies to issue alerts and classify fentanyl combined with xylazine as an emerging threat, resulting in the National Xylazine Response Plan in July 2023. Building on the work by Bowles et al.,⁶ which demonstrated how media use of the term “zombie” in relation to xylazine can intensify stigma against PWUD, we aim to conduct a content analysis to quantify the prevalence of the stigmatizing term “zombie” and stigmatizing imagery among xylazine-related web-based media over time.

METHODS

We searched Google News for US web-based written media articles published between October 1, 2022, and September 30, 2023, containing the term “xylazine.” We chose this starting time point as this was the first federal-level mention of xylazine. Two trained reviewers (M.G. and S.I.) identified eligible articles through title and body review (Supplement Fig. 1, Supplemental Digital Content 1, http://links.lww.com/JAM/A638) and excluded those behind paywalls, non-English, government reports, duplicates, or lacking xylazine mentions in the body. Articles were coded as using a “stigmatizing term” if they included the word “zombie.” We recognize that other stigmatizing terms exist, but we focused on the undeniably stigmatizing singular term “zombie” for the scope of our content analysis. Articles were coded as “stigmatizing imagery” if embedded image(s) included nonsterile or discarded drug use supplies, visibly intoxicated or unhoused person(s), and/or drug-related wounds,⁷ as such images perpetuate stereotypes, dehumanize PWUD, and exacerbate fear. While we aimed to explore the regionality of articles, challenges arose due to the lack of geographic identifiers in web-based media, unlike print media. Coding followed a standardized protocol of reviewing article titles, text, and images. Two trained reviewers (M.G. and S.I.) independently coded 30 articles, resolving discrepancies and refining codes, achieving over 96% agreement after 3 rounds of double-coding (Cohen’s κ > 0.93). The remaining articles were single-coded, and counts were combined in 2-week periods to capture fluctuations over time and stratified by type of stigmatizing content. We manually calculated Kappa⁸ and completed descriptive analyses using Microsoft Excel (version 2403). We aggregated articles by calendar month and mapped stigmatizing content to dates of federal alerts regarding xylazine to see if there was any temporality of the prevalence. Given that we were utilizing publicly available web-based data, our study was IRB exempt.

RESULTS

We identified 4603 articles mentioning xylazine over 12 months, with 910 meeting eligibility criteria (Supplement Fig. 1, Supplemental Digital Content 1, http://links.lww.com/JAM/A638). Overall, 23.9% (217/910) featured stigmatizing content, of which 57% (124/217) used stigmatizing terms only, 26.3% (57/217) had stigmatizing imagery only, and 16.6% (36/217) had both. Examples of the stigmatizing term “zombie” in articles include descriptions like, “the flesh-eating ‘zombie drug’ is causing alarm on the U.S. streets, literally rotting people’s bodies.”⁹ Over time, there was an increase in volume of xylazine-related articles, which peaked in July 2023 when the National Xylazine Response Plan was released. The first use of “zombie” in our data was in November 2022. The volume of stigmatizing articles increased over time and peaked twice, in March and July 2023, driven primarily by articles with stigmatizing language (Fig. 1).

FIGURE 1.

Trends of xylazine web-based media articles. DEA, Drug Enforcement Agency; FDA, Food and Drug Administration; ONDCP, White House Office of National Drug Control Policy.

Of 601 articles with embedded images, 15.5% (93/601) were considered stigmatizing. Of these, 32.2% (30/93) contained multiple types of stigmatizing imagery. Nonsterile or discarded drug use supplies were most prevalent (53.8%, 50/93) and drug use–associated wounds were least prevalent (23.7%, 22/93) (Fig. 2).

FIGURE 2.

Xylazine articles stigmatizing imagery by content type (n=93)^a. ^aCategories are not mutually exclusive as some articles or embedded images featured multiple types of stigmatizing imagery (30 of the 93 images contained more than 1 stigmatizing content category).

DISCUSSION

Almost a quarter of xylazine-related articles contained stigmatizing content based on our operationalization of the term “stigma.” We identified peaks in the use of the stigmatizing term in March and July 2023, coinciding with federal alerts. While previous literature suggests a reduction of stigmatizing language in news articles,¹ our findings indicate that the changing drug supply may influence such trends. Media’s use of “zombie” to fuel nonscientific, fear-based narratives is not new, as it has been applied to other psychoactive substances like flakka and krokodil.¹⁰ These sensationalized portrayals vilify PWUD, exacerbating the harms of a rapidly evolving drug supply. Web-based media should prioritize evidence-based, person-first language (eg, “person who uses xylazine-adulterated opioids”) and consult experts on the real-world impacts of media representation on substance use, harm reduction, and drug policy.^11,12

We identified a rise in stigmatizing imagery in the latter half of the study period. Imagery often evokes stronger emotional responses than language, reinforcing explicit and/or implicit biases and perpetuating harmful, dehumanizing rhetoric that ignores the social determinants of health affecting PWUD. Such portrayals can undermine public support for harm reduction and drive public backing for harmful policies, like scheduling xylazine as a controlled substance or criminalizing its possession.^4,13 Web-based media should prioritize images that respect PWUD’s dignity and emphasize harm reduction’s positive impact.¹² Accurate, nonstigmatizing visuals can foster informative content, especially for those seeking health information online. Our findings highlight the impact of government alerts and emphasize the need for collaboration between public health, medical sectors, and the media to ensure accurate and responsible reporting.³ This should include co-creating journalistic standards with addiction medicine professionals, harm reduction experts, and people with lived experience, focusing on inclusive language and nonstigmatizing imagery.¹⁴ Anti-stigma interventions, including national media campaigns, are also needed to reduce sensationalism and stereotype reinforcement. While the National Xylazine Response Plan mentions integrating xylazine-specific messaging into existing media campaigns, more transparency and detailed action plans are necessary to incorporate harm reduction–oriented, nonstigmatizing language into state and federal responses. National Institute on Drug Abuse language guidelines should be updated to include emerging adulterants and terminology to guide journalistic standards, aligning efforts with future federal alerts and emerging threats.

Limitations include using only 1 news aggregator service, omitting paywalled articles (though freely accessible ones have higher readership), and focusing solely on web-based media, excluding print, social, or broadcast outlets. In addition, while we used “zombie” as a proxy for a stigmatizing term, other terms like “flesh-eating” and “addict” may also be stigmatizing, potentially underestimating the prevalence of stigmatizing articles. Future research should expand the context, apply stigma frameworks, and explore the downstream effects on public perception, drug policy, and PWUD experiences.¹⁵

CONCLUSIONS

Stigmatizing content about xylazine in web-based news continues to proliferate, highlighting the need for collaborative efforts between the journalistic, medical, and public health sectors to challenge these narratives.

Supplementary Material

adm-20-126-s001.docx ^{(192.5KB, docx)}