Thread by @SyringeAccess

(1/21) 🧵So, it’s time we had a conversation about the war on drugs, capitalism, & xylazine.

Now, if you’re coming across this tweet, odds are good you have some familiarity with the 1st 2 things but might be wondering, "what’s xylazine?"

Well, it's complicated. #HarmReduction

(2/21) Xylazine was originally designed as a veterinary tranquilizer. It was never meant to be ingested by humans but, 20 years ago, some Puerto Rican folks who use drugs started using it as a heroin additive & the drug found its way to Puerto Rican neighborhoods in Philadelphia.

(3/21) According to the literature I was able to find, the main reasons for adding xylazine (known as Anastesia de Caballo or “horse anesthetic” in PR) were a mix of cost efficiency for dealers & enhanced effects for the user, but neither were big enough to create market changes.

(4/21) Then, fentanyl happened. Or, rather, fentanyl was given the space it needed in the US drug supply after prohibitionist drug policy led to crackdowns on Rx opioids & heroin, forcing suppliers to look for a less bulky, more profitable way to transport product to consumers.

(5/21) From the perspective of large illicit drug manufacturers, fentanyl & fentanyl related substances were a boon for business. They could transport significantly higher potency product in much smaller, less detectable containers & avoid sunk costs through shipping & seizures.

(6/21) For people who use drugs, fentanyl & fentanyl related substances were more of a mixed bag. Some people liked the intensity of the high fentanyl gave them. Some preferred the longer, mellower high from heroin. But they all liked the lower prices they were seeing.

(7/21) There was just 1 big problem with fentanyl: it didn’t have "legs". You shoot up, get relief, & in an hour or 2 you find yourself needing to use again to feel well. The individual doses you took were cheaper, but you need more of them to stay high. It was a balancing act.

(8/21) More doses means more injections. More injections mean more chances for getting HIV, viral hepatitis, abscesses, endocarditis & a whole host of nasty medical issues. And, on top of all that, more injections means more hustling and fewer veins to inject into.

(9/21) Now, there was a market opening for some drug combination that could take advantage of the potency and affordability of fentanyl highs, while maintaining some of the “legs”, or duration of effect of heroin. This is where xylazine, anestasia de caballo, gallops in.

(10/21) Starting in the mid-2010s, harm reductionists & people who use drugs started noticing xylazine being increasingly added to the drug supply in Philadelphia. That this was happening as fentanyl use was rising is likely not coincidence. Puerto Ricans in Philly knew xylazine.

(11/21) They knew xylazine as the stuff they were able to get back on the island which could really extend the half-life of the drug & create a product that people might like. It wasn’t a “new” product--it had been around since the early 2000s--but it was the “right” product.

(12/21) Xylazine turned out to be a good additive to fentanyl to give it the longevity it lacked & PWUD desired. With heroin increasingly harder to find & more expensive to purchase, adding xylazine to fentanyl just made sense for all parties involved. The market had spoken.

(13/21) The only thing was, there’s a catch (there's always a catch): xylazine is some seriously dangerous, debilitating stuff.

For starters, people who use xylazine report the drug can have severe tranquilizing effects, causing folks to nod off & black out for hours after use.

(14/21) In addition to being overly sedative, xylazine has also been reported to make users much less responsive to naloxone, as the drug is not an opioid. Xylazine has also been known to cause hypotension & bradycardia, possibly exacerbating overdose risk.

(15/21) But, the worst side effect of xylazine is the necrotizing skin & soft tissue injury. The injection related injuries people experience with this drug are truly horrifying. It is not so much a matter of if you will generate abscesses or skin ulcers with xylazine, but when.

(16/21) Images of xylazine-associated skin lesions are some of the most disturbing I have ever seen. People who use drugs are quite literally rotting away, & all because of a Frankenstein’s monster of a drug supply that was created not by people, but by markets.

(17/21) Because, ultimately, that is what the emergence of xylazine and fentanyl are all about: illicit free market economies driven by the prohibitionist drug policies that make drug manufacturers, suppliers, & users adapt to external forces looking to stop their use & profit.

(18/21) No one just sat around the streets of Philadelphia one day & thought, “You know what? Heroin is rubbish. I think I’d like to inject a mixture of synthetic opioids & horse tranquilizer into my veins for a shorter, more intense high that could rot my arm off.”

(19/21) No, xylazine exists & proliferates because prohibitionist drug policies till the ground from which they grow. We cannot anticipate how much further xylazine use will spread (it's already in 6.7% of OD deaths) or if the public will soon know it as well as they do fentanyl.

(20/21) But what I can guarantee you is that the forces that brought xylazine forth into the US drug supply will be the same forces that create the next deadly drug combination leaving chaos in its wake. We need a safe supply. Without it, we’re just jumping from crisis to crisis.

(21/21) Huge thanks to all the amazing researchers & harm reductionists who are doing the difficult work of investigating the emerging xylazine crisis & serving those impacted. You can read more here: medrxiv.org/content/10.110…