Xylazine has been persistently present in one Deep South County, first arriving in 2019 and becoming consistently prevalent since January 2021. This is concordant with increasing prevalence elsewhere, in the Midwest, and along the East Coast (2). Fentanyl was co-detected in 100% of deaths, consistent with current understanding that xylazine is used mainly as a “cutting” agent in illicit fentanyl preparations. Stimulants were the next most common category of drug associated with fatal overdose. Amphetamine was frequently detected, likely reflecting its status as a metabolite of methamphetamine. In the minority of cases where amphetamine was detected alone, it was most likely being used to treat attention deficit disorders rather than as a substance of abuse. Benzodiazepines and other drug classes were rarely detected.
Unlike larger northeastern and midwestern municipalities with well-developed drug surveillance and public health infrastructure, many jurisdictions in the Deep South lack a robust public health response to this growing threat, with proximal barriers including a lack of access to legal syringe service programs (SSP’s) and other harm reduction supplies like xylazine test strips (8). More globally, high levels of stigma, limited avenues for dissemination of harm reduction techniques, poor data collection practices, limited surveillance of emerging substances with overdose potential, and heavy criminalization continue to represent major barriers to harm reduction practice implementation in nearby rural communities (10).
Significantly, many Deep South states lack an apparatus for comprehensive death evaluation, which may be leading to significant undercounting of both the number of overdose deaths along with poor detection of xylazine and other novel adulterants (e.g. medetomidine). Most death investigations in rural jurisdictions are conducted by a Coroner, an elected lay official who has limited training in death examination compared to Medical Examiners (ME’s), who are most often appointed pathologists (or forensic pathologists) with additional training in medicolegal death investigations. The accuracy of reporting of drug related fatalities depends largely on the Medicolegal Death Investigation (MDI) system that covers the region. The training and experience of coroners vary greatly throughout the United States (11). A review of information from deaths that occurred in 2014 and in 2018 showed that coroner systems were associated with a greater likelihood of not indicating what drug (or drugs) caused an overdose death. Furthermore, this was statistically significant when comparing rural and urban counties (12). Coroner systems had a lower likelihood of performing an autopsy in suspected drug related deaths. In addition, a coroner system is associated with a lesser likelihood of recording opioid related deaths. These data indicate that accurate reporting of overdose deaths depends greatly on the MDI system (11). In Alabama, coroners oversee death investigations in all counties except Jefferson County, Alabama and most death investigations in the state occur in Coroner jurisdictions.
There were several limitations to this study: most notably, only cases referred to the ME were evaluated. Approximately 19% of deaths in Jefferson County are referred for formal death examination, so the prevalence of xylazine-associated overdose may be higher, especially in certain populations and regions that may be less likely to receive a comprehensive formal death investigation like ethnic minorities and males (11). Additionally, this is a single county experience. However, Jefferson County is the most populous county in Alabama, containing some 13% of the total state population by 2020 census numbers, but an outsize 26% of the state’s reported overdose fatalities (13). Our study is strengthened by the routine use of a high-quality detection method (i.e. mass spectrographic methods) that were capable of identifying xylazine, through NIST library searching, even before routine surveillance for the compound was nationally available. Thus, the first appearance of the compound can be inferred with high certainty.
We recommend several steps to better prepare Deep South states for the xylazine/fentanyl syndemic. First and foremost, immediate legalization of xylazine test strips should be pursued in jurisdictions where they are currently illegal. People who use drugs (PWUD) generally prefer to avoid xylazine-containing fentanyl (14) when able, and empowering them to do so with a tool similar to fentanyl test strips could be a powerful tool in reducing harm from xylazine. Second, more consistent testing is needed for xylazine and other concerning contaminants, and results must be conveyed to both communities and providers to inform educational initiatives and an appropriate public health response. Recent efforts to expand drug checking improve awareness of PWUD and empower them to be vigilant for substances like xylazine (8, 9). Implementation of these services in the Deep South is necessary. Next, the use of coroners rather than medical examiners in many parts of the Deep South including Louisiana, Alabama, South Carolina, and Georgia, limits the ability to detect trends in overdose death in general, especially emerging drug trends like xylazine overdose. More standardized protocols and funding to pursue toxicology testing in rural coroner systems may yield more accurate estimates of xylazine- and opioid-related overdose death. Finally, educational initiatives should be undertaken directed at both medical providers and PWUD to educate them on the best harm reduction practices associated with xylazine. Early recognition of xylazine-related wounds, in particular, could potentially prevent the development of limb threatening soft tissue destruction. In addition to improved clinic-focused interventions to improve xylazine wound recognition and treatment currently underway, coroners and ME’s should be aware of the characteristic features of these wounds as well so that they can request appropriate toxicologic testing and contribute to community awareness of this important topic.
Xylazine is a rapidly emerging and serious public health threat that merits aggressive intervention and continued close monitoring (15). It has been prevalent in one Deep South County for at least 3 years and may be more widespread given resource availability in different MDI systems across the region. Future research should focus on establishing the role of xylazine adulteration in promoting clinical diseases outside of soft tissue infection and improving implementation of best harm reduction practices in order to empower PWUD to avoid this dangerous adulterant.