Emerging Adulterants in the Street Drug Supply

By: Henry Larweh

In 2022, more than 74,000 fatal overdoses involved fentanyl and other synthetic opioids, and a tenth of those deaths involved xylazine. Fentanyl and xylazine proliferated in the United States’ illicit drug market in the past decade, increasing overdose fatalities and causing injury to people who use drugs.

As the drug supply continues to evolve, fentanyl and xylazine will likely not be the last adulterants to enter the illicit drug market. Trends are already showing newly emerging substances. Funding and programs to identify emerging contaminants in an ever-evolving drug supply can help states and local jurisdictions be proactive about their response to the overdose crisis. Staying well informed of emerging contaminants may require policy changes and updating strategies to support programs like community drug checking and harm reduction organizations. Jurisdictions may consider utilizing settlement dollars to support these activities.

New Contaminants, Same Defenses

Many of the new and emerging adulterants in communities’ supplies are similar classes of substances in the existing drug supply but with varying potency. Potency defines how much a substance is required to produce its effects in a person, such that the more potent the substance, the less is needed to affect an individual. In most cases, the emerging adulterants in the illicit drug market can be mitigated using harm reduction tools and care strategies already part of existing overdose remediation efforts.

Nitazenes and Naloxone

Nitazene is a compound of substances that was originally developed as an opioid analgesic that was never released on the market. Now developed illicitly and introduced into the drug market, this opiate is ten times as potent as fentanyl, and has already been observed in some fatal overdoses in the United States. In Tennessee, there were 42 nitzazene involved fatal overdoses in 2021. Despite its higher potency, nitazenes are still a form of opioid drugs that can be acted against by using naloxone. Unfortunately, of the fatalities identified in Tennessee, just over a fifth of them reported naloxone being administered in response to the overdose. Expanding the availability of naloxone and teaching people how to administer it may help reduce the fatalities caused by nitazene involved overdoses. More so, increasing the availability of medications for opioid use disorder may further reduce overdoses, and lower the risk for people with opioid use disorder to come into contact with an opiate like nitazene.

Benzodiazepines

Benzodiazepines are a group of substances commonly prescribed to help patients with a variety of mental health issues, reduce seizures, and relax muscle tissue. These drugs are increasingly associated with overdoses, despite trends showing a decrease in drug overdose deaths in the past year. Between 2019 and 2020, there was a 34.4% increase in emergency department overdose visits involving both benzodiazepines and opioids. During the first half of 2020, 92.7% of fatal overdoses from benzodiazepines also involved opioids. Younger adults, aged 18 – 25, were found to be the most likely to use both opioids and benzodiazepines between 2015 – 2019. One analysis revealed the specific factors associated with combined use of opioids and benzodiazepines, including other mental health conditions contributing to their likelihood for polysubstance use. States should consider how to investigate polysubstance use and public health strategies to mitigate their effects. Prioritizing youth education and prevention, as detailed in Principle 3, and the treatment of mental health disorders through tailored treatment and recovery services for youth and young adults may help reduce the risks associated with co use of benzodiazepines and opioids among young people.

Medetomidine

A type of animal tranquilizer that is 200 to 300 times more potent than xylazine, variants of medetomidine have begun appearing in drugs offered through the illicit market increasing risk for an overdose. Between 2021 and 2023, there was a 97.6% rise in medetomidine detected in the illicit drug supply in Maryland. Early identification can allow for proactive preparation and responses to emerging adulterants in community illicit drug supplies. Supporting public health surveillance of street drug supplies through funding community drug checking programs and other harm reduction organizations may help jurisdictions mitigate the potential harms presented by medetomidine and xylazine.

Summary

Fentanyl and xylazine are not the first adulterants to find their ways into the illicit drug supply and they won’t be the last. While new and emerging threats like nitazenes, benzodiazepines, and medetomidine can increase risks for overdoses among people who use drugs, existing harm reduction strategies and public health tools can already mitigate the harms caused by these new substances.

States and jurisdictions should consider how their opioid settlement funds can expand access to treatment and recovery care services, increase availability of life-saving medications like naloxone, establish or bolster community drug checking programs, and support harm reduction activities, such as overdose prevention centers, to protect people who use drugs and access street drug markets.