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Risks of the Unregulated Drug Market/Xylazine

Risks of the unregulated drug market

All substance use has some level of risk. However, there are unique health risks from illegal/unregulated drugs due to their variable potency and unknown ingredients. Examples of unregulated drugs include cocaine from a friend or Kratom from the gas station.

Read more about the different types of drug supplies at the bottom of this page. We are using the term unregulated here as it includes illegal drugs as well as those with psychoactive effect that are legal but not monitored for quality and content by the FDA.

Potency and unknown ingredients

Potency

Unregulated drugs can vary in how strong, or potent, they are. For example, one pill can have almost no fentanyl, while another can have a deadly amount. Fentanyl and related drugs are the most variable because they are very potent. Heroin can also range in how strong or weak it is, but it’s less variable than fentanyl.

Learn more about fentanyl potency in the handout Detailed fentanyl drug testing results for King County, WA Medical Examiner samples from Spring 2023.

In WA State most benzodiazepines (benzos) confiscated by law enforcement were counterfeit. The strength of these counterfeit benzos can vary but is often 2-3 times as strong as prescription benzodiazepines.

The unknown potency of unregulated drugs can make it difficult for someone to control the dose of the drug.

Unknown ingredients

Unregulated drugs may contain different substances than advertised, or ingredients you don’t expect. These can be added at many steps throughout manufacturing and distribution and a dealer/seller may not know what they’re selling.

Sometimes other things are mixed into drugs. This can be as filler, other times it’s to enhance or balance out the effect of a drug. These can raise the risk of overdose or have other bad effects.

Xylazine

Xylazine is an animal tranquilizer that has shown up in combination with fentanyl sold on the streets or online. Xylazine may increase the risk for overdose because of its sedating effects. It has other risks, like skin infections and wounds, even if you don’t inject it.

Why these wounds happens is not completely understood but may be related to poor circulation. Wounds may occur in different spots, not just near sites of injection. These wounds have developed in people who smoke and do not inject. For more information about wounds and other complications of xylazine exposure, consider attending this regular training hosted by Boston Medical Center.

What to do for an overdose if you suspect xylazine

In case of an overdose, give naloxone and call 911. Xylazine may make it so that someone doesn’t wake up right away, so it’s important to do rescue breathing and call 911.

What’s happening with xylazine in WA State?

As of January 2023, data indicate that xylazine is present at low levels in WA State, and appears to usually be in combination with fentanyl.

Where has xylazine been detected?

  • Xylazine has been identified in less than 1% of fentanyl-involved overdose deaths in 2021 and 2022 in WA State.
  • King County Medical Examiner preliminary data indicate that between 1/1/2023 and 9/6/2023 there were three deaths involving xylazine in combination with the 733 fentanyl involved deaths (<1%).
  • Xylazine was seen in 1% of police evidence that has also tested positive for fentanyl in between 1/1/2023 and 6/30/2023, and 1% of all cases since the beginning of 2021. Note that xylazine is underreported in crime lab data.
  • In drug testing among those in treatment for opioid addiction in Vancouver WA between 1/1/22 and 6/20/23, less than 10% of those who tested positive for fentanyl tested positive for xylazine.
  • Community based drug checking data to date indicate 8 cases of xylazine (5%) among 170 fentanyl positive results per secondary testing using GCMS chemical analysis from 7/22/2022 through 9/11/2023.

Learn more about xylazine from these resources:

Xylazine handout from Public Health Seattle & King County

Xylazine

Harm reduction tips for individuals

Follow these steps to reduce your risk of dying from overdose, or be ready to help someone else:

  • Start low and go slow.
  • If you can, use around other people. Or, let someone know you are using.

If you’re

interested, learn more about the medications for treating opioid use disorder. Buprenorphine and methadone can cut your risk of overdose in half.

Test your drugs. If you know what’s in it, you can take extra steps to stay safe.

What can organizations do?

Educate

  • Educate patients and clients about the risks of the unregulated drug supply.
  • Provide overdose education, including for emerging substances like xylazine.
  • Provide information about the overdose prevention and health benefits of methadone and buprenorphine.

Connect

  • Distribute naloxone, the opioid overdose antidote.
  • Distribute fentanyl test strips.
  • When possible, connect patients or clients with drug checking.
  • If appropriate, connect people to treatment for opioid or stimulant use disorder. Find locations through the WA Recovery Help Line.

Drug checking

Overview:

Drug checking uses different technologies to provide insight on what’s in the drug supply, and help people take steps to stay safe.

Benefits of drug checking:

  • Empowers people who use drugs to make informed decisions about how they use and steps they can take to reduce overdose risk.
  • Allows public health and harm reduction groups to expand access to care and education to prevent overdose and other harms from substances.
  • Is an effective way to engage and connect with people who use drugs. This is particularly important nowadays as most fatal overdoses involve drugs that were smoked, but most harm reduction programs provide primarily supplies to reduce risks associated with injecting drugs, so additional resources for community members can be important to reach more people.

WA State drug checking:

ADAI is contracted with the Washington State Health Care Authority to implement a comprehensive drug checking program in collaboration with community partners throughout Washington.

This program will offer a combination of three technologies:

  1. onsite immunoassay test strips,
  2. onsite infrared spectroscopy, followed by
  3. secondary comprehensive testing conducted at a partner lab with gas chromatography–mass spectrometry.

Drug checking is provided in harm reduction settings alongside access to safe use supplies, overdose prevention education, onsite services, and other referrals or linkages to care. We will share more information as services and drug checking results become available to provide current data about the unregulated drug market in Washington State.

Read the handout for the general public.

Read the handout for drug checking participants.

Learn more about drug checking:

UNC Street Drug Analysis Lab

Drug Checking, European Monitoring Centre for Drugs and Drug Addiction

Regulation vs. unregulated drug markets

The drug market is made up of two parts, regulated and unregulated.

Legal or regulated drugs include alcohol, pharmaceuticals, and in some states regulated cannabis products. These drugs are legal at the state and/or federal level. Their production is regulated and they have standardized dose and ingredients. Legal drugs have risks, but these are not due to unknown ingredients or potency.

Unregulated drugs are those that are manufactured and distributed outside of the regulatory systems in the United States. Illegal drugs have criminal penalties associated with their use, distribution, and manufacture.  Unregulated drugs may be legal e.g. Kratom/mitragynine or illegal e.g. heroin, methamphetamine, black market cannabis, or illicitly manufactured fentanyl. Illegal drugs do not have standardized production, packaging, labeling or markings. The contents are unknown in terms of the ingredients and their strength.

Legal Illegal
Examples Alcohol, tobacco, prescription drugs, cannabis*, OTC medications Heroin, methamphetamine, illicitly made fentanyl, illicitly made benzodiazepines.
Potency/quantity Known Unknown
Contents Known contents and ingredients. Unknown ingredients. May have other substances added that can increase overdose risk or other health issues. May not be what it looks like.
Production Standardized, controlled throughout production process. Not standardized, may be handled and added to during manufacturing or  distribution, may have cross contamination. (Example fentanyl in cocaine or meth due to being produced or mixed in same place).
Criminal penalties No criminal penalties for use within legal limits, or if using own prescription. Criminal penalties for use, distribution, and manufacture.
*cannabis regulations differ state by state