Tracking “Tranq” Laws: The state of policy responses to the growing xylazine crisis

By: Olivia Sugarman and Hridika Shah

Xylazine, a non-opioid large animal tranquilizer, is rapidly spreading in the illicit drug supply and is increasingly responsible for fatal drug overdoses and severe wounds that may sometimes result in amputations. Recent reports found that xylazine was present in the drug supply in 48 of 50 states by November 2022 and associated with nearly 11% of all fentanyl overdoses, a threefold increase from 2.9% in 2019. More details about xylazine and its effects are described in a previous blog post: Xylazine 101.

Drug control policies have not historically been applied to xylazine because it is a veterinary drug not approved for human consumption and thus considered to have relatively low abuse potential. However, the uptick in xylazine detection and related overdoses has sparked a flurry of new proposed policies to address xylazine as a public health emergency. New federal policy and research opportunities have already been passed or initiated earlier this year, including the TRANQ Research Act, which has passed both the House and Senate as of June 2023. The Office of National Drug Control and Policy (ONDCP) declared xylazine an “emerging drug threat” on April 12, 2023, followed by the Biden administration’s xylazine response plan on July 11, as required by the  SUPPORT Act.

The Principles for the Use of Funds from the Opioid Litigation provide guidance to state and local governments when considering investment of opioid settlement dollars into programs and interventions to address xylazine and other emerging adulterants in the rapidly evolving drug supply. The Principles encourage states to ensure that existing policies align with evidence-based interventions (Principle 2). By using the Principles to inform processes to address new adulterants, policymakers and funders can allocate resources to have the greatest public health impact. 

To understand the current state of policy responses to the growing xylazine crisis, the Bloomberg Overdose Prevention team at the Johns Hopkins Bloomberg School of Public Health conducted a search of xylazine-related legislative measures to track which bills or other policy measures address xylazine as a public health problem.

What we found

As of July 14, 2023, there were 32 total, and 25 unique, xylazine-related legislative measures. Four measures were federal and twenty-one measures were found in 16 states (DE, FL, IL, IN, LA, MA, MI, NH, NJ, NY, OH, OK, PA, TN, VT, WV). Only two states, Florida and Massachusetts, had laws prior to 2023 that directly or indirectly scheduled xylazine. All other measures were introduced in 2023 legislative sessions.

Most bills attempt to address the tension between maintaining appropriate use in veterinary practice and penalizing people who knowingly sell xylazine. Policies were categorized in one of four groups: (1) scheduling, (2) paraphernalia, (3) research/grants, or (4) other (including policies related to coroner reporting).

1. Scheduling: Drugs are scheduled based on their acceptable medical use and potential for abuse and dependence; drugs in Schedule I are the most tightly regulated. The federal Combatting Xylazine Act, if passed, would establish xylazine as a schedule III drug nationally. Sixteen of the 25 legislative actions would have scheduled xylazine, most as a Schedule III substance. Prior to the 2023 legislative session, Florida established xylazine as a Schedule I substance in 2016, and xylazine may fall under Massachusetts’ Schedule VI designation. Schedule VI is unique to Massachusetts and  applies to prescription drugs that are not scheduled or considered controlled substances in other states. 
2. Paraphernalia: Other bills explicitly decriminalized xylazine test strips and paraphernalia (DE, IL). Xylazine test strips may already be decriminalized under existing drug paraphernalia and testing laws in at least 23 states. 
3. Research/grants: Legislation also proposed strengthened research and surveillance, such as the federal TRANQ Research Act, which provides funding and additional permissions for xylazine-specific drug surveillance research. Specifically, the TRANQ Research Act requires the National Institute of Standards and Technology (NIST) to support research and surveillance activities to identify xylazine, new synthetic opioids, and other emerging substances that might threaten public health.
4. Other:  Indiana’s Toxicology Screening for Xylazine (HB1286) newly requires coroners to test for xylazine in autopsies for suspected overdoses. Many states did not test for xylazine during autopsies until recently, and some still don’t.

Considerations

Legislative measures are mostly in states on the East Coast, where xylazine is most prevalent. States on the West Coast and in the Great Plains region have not introduced their own legislation, but representatives and senators from these states have co-sponsored federal bills.

What’s next?

As the overdose crisis continues, new adulterants in the drug supply are constantly emerging. While legislative action about xylazine continues to evolve, opioid settlement funds are an opportunity for additional funding to support existing interventions and strengthen drug survey surveillance efforts and infrastructure. We recommend that policymakers consider the following:

1. Scheduling or other criminal penalties should not deter people from seeking care for xylazine use or exposure. People who use drugs may not seek care if they fear arrest for unknowingly testing positive for or carrying xylazine. The deterrent effect may affect more people than just those who intentionally use or seek xylazine. Xylazine is often added without the user’s knowledge or in some cases, is so prevalent in the drug supply that it is unavoidable.
2. Provide xylazine wound care and withdrawal tools in jails and prisons. Given the high rates of incarceration of people who use drugs, criminal-legal facilities should be given additional funding and resources to support xylazine-related wound care and withdrawal while people are incarcerated as it continues to permeate the drug supply.
3. Use settlement funds and other funds to invest in proactive surveillance and monitoring of drugs prone to abuse. The emergence of xylazine has revealed pervasive weaknesses in local and national drug surveillance infrastructure and policy. Many states and localities are ill equipped to surveil existing drug threats, let alone emerging adulterants. New funding mechanisms must be used to strengthen drug surveillance infrastructure, including equipment and personnel, to be proactive in identifying and addressing new adulterants. Funds should complement rather than divert existing resources to combat fentanyl.
4. Build infrastructure to enhance syringe service programs. on-the-ground anonymous reporting, testing, and care. Harm reduction and other community hubs that serve people who use drugs have first-hand experience observing and treating people who use xylazine, some for over a decade. Funding and resources might be used to enhance community organizations to provide anonymous reporting, testing, and care for people who are exposed to xylazine.
5. Scheduling should not be a barrier to doing clinical research about xylazine. Xylazine samples are needed to conduct research that informs treatment methods. Scheduling could make it harder for researchers to get xylazine samples. Clinical guidance to treat xylazine withdrawal, wounds, and develop antidotes to reverse xylazine-involved overdoses are desperately needed.
6. Ensure policies for licit use in veterinary environments come with enforcement. Xylazine may be diverted from veterinary offices and large animal farms, and xylazine purchased through online veterinary supply stores. Though a veterinarian’s prescription is increasingly needed to purchase xylazine online, additional steps should be taken to ensure prescribing authority is not abused. For example, adding other non-opioid sedatives such as xylazine might be reported to prescription drug monitoring programs.

About the authors:

Olivia K. Sugarman is a health behavior and policy researcher. She is a second year Postdoctoral Fellow with the Bloomberg Overdose Prevention Initiative.

Hridika Shah is a Senior Research Coordinator with the Bloomberg Overdose Prevention Initiative and a second year MSPH candidate.