As San Francisco struggles to tackle its fentanyl-driven overdose crisis, officials are on high alert that another drug colloquially known as “tranq” — an animal sedative typically used in large cattle — could infiltrate the street supply and cause more death and disability.
The pharmaceutical drug xylazine has already appeared in East Coast cities, further devastating those communities. The drug can increase the risk of overdose, worsen withdrawal and boost the risk of wounds leading to amputation for those who inject it.
While it has not yet landed at obvious scale in San Francisco or California, the Office of the Chief Medical Examiner told The Chronicle Tuesday that it is developing a method for universal xylazine testing that it will begin using early this year for all fatal drug overdoses. The office also plans to retrospectively test all 2022 suspected overdose cases to see if the drug was present in any of the deceased.
“It’s certainly on our radar,” a spokesperson for the Medical Examiner said in an email. “We have been in communication with our colleagues at the San Francisco Department of Public Health as well as colleagues at other forensic laboratories in California.”
San Francisco sees one to two overdose deaths daily on average, largely from fentanyl, the super powerful opioid that’s highly addictive. The introduction of xylazine into the city’s drug supply could be a catastrophic new phase in the city’s opioid epidemic, which has already overwhelmed public health officials and divided city leaders on how to address it.
Those on the ground say they’re keeping an eye out for any reports of xylazine being mixed into the drug supply, and several drug users interviewed Tuesday in the Tenderloin — a neighborhood with the highest concentration of drug use, dealing and overdoses — said they are aware of the risks and are becoming increasingly worried about it.
Cosmo, 65, who lives in the neighborhood and declined to give his full name, said he plans to be more careful about what he injects because his drug of choice — crack cocaine mixed with fentanyl — is what xylazine is commonly mixed with on the East Coast.
“If it’s back East, you can bet it’s here already,” he said. “I’m going to have to be very careful about what I buy.”
In East Coast drug hot spots like Philadelphia, the veterinary tranquilizer is being mixed into fentanyl and has made the impact of the highly potent opioid even more horrific. The sedative, which is also an analgesic and muscle relaxant, can cause devastating skin wounds that, if left untreated, can lead to amputation. Because xylazine is not an opioid, the overdose reversal drug Narcan doesn’t work for it.
That means that if someone were overdosing on both fentanyl and xylazine, the Narcan would reverse the effects of the fentanyl, but not of the xylazine.
Entering recovery could also be more difficult if xylazine enters the supply. A Drug Enforcement Administration report says “users may develop a physical dependence to xylazine itself, with some users reporting the withdrawal symptoms from xylazine as, or more, severe than from heroin or methadone; symptoms include sharp chest pains and seizures.”
With reports circulating about the infiltration of xylazine in the East Coast drug supply, San Francisco officials are in a tricky position of both not overplaying — or underplaying — the potential risk. Since it is has not shown up in any noticeable way, officials are still in the early stages of planning for it and mostly focusing on increasing surveillance and education.
At the same time, though, the drug crisis on the East Coast tends to be a bellwether for what is to come on the West Coast. For example, fentanyl showed up on the East Coast a few years before it took over San Francisco’s drug supply.
Now, the opioid has been found in the majority of all overdose deaths in San Francisco.
“Because we are in the late stages of the fentanyl epidemic… people are becoming tolerant and (drug dealers) are going to combine it with other drugs,” said Daniel Ciccarone, a professor of family community medicine at UCSF. He said that’s particularly alarming because “we still haven’t figured out the overdose crisis that we’re in.”
The San Francisco Aids Foundation, a harm reduction nonprofit, said it’s drug-checking program tested a street drug sample this fall that contained a “trace amount” of xylazine in it. While it was just one sample among hundreds tested over the past six months, the discovery led the foundation to increase its education and monitoring, knowing that the drug supply could shift at any moment.
Xylazine “is something we’re super mindful of and have an eye out for,” said Ro Guliano, senior director of health services for people who use drugs at the San Francisco AIDS Foundation. “Just like what happened when we had that big shift to fentanyl, this would inform how we do health education for people who use drugs, including overdose prevention.”
Currently the San Francisco AIDS Foundation has two machines that people can use to test their drugs before they take them. These machines, which cost about $70,000 each, give people a clear picture of what is in the street drugs they’ve taking and also provide officials a snapshot of trends overtime. One of the machines is in a mobile van, while another will operate in their SoMa site in February.
The Department of Public Health said in a statement that it is “closely monitoring the situation” and it is also continuing to collaborate with organizations around the city and “preparing in the event it becomes more rampant.” Officials are also working on developing care options, including treatment that are specific to xylazine.
Still, while the city prepares for the potential new phase of the opioid epidemic, the shortcomings in the current system have become even more evident. San Francisco does not have enough treatment options and the city’s law enforcement agencies and criminal justice system have struggled to address the drug dealers that operate openly.
Mayor London Breed has also reportedly backtracked on opening a safe consumption site in the city. Such a site would provide a place for people to use drugs around medical professionals who would help reverse overdoses and save lives.
Guiliano, of the San Francisco AIDS Foundation, said the risk of xylazine adds more urgency to the need to open up one of these sites.
“The larger issue is how is the city providing healthcare for these large numbers of people who are also experiencing homelessness?” she said. “You can’t speak about one without the other.”
The DEA report said the presence of the drug in fatal overdoses may be more widespread than reported because many labs don’t include it in their toxicology tests.
The San Francisco medical examiner’s decision to retroactively test overdose cases from 2022 will help officials gain a better understanding of how widespread the drug currently is in the city, if at all. But increased real-time testing of the current supply would help outreach workers respond faster to any shifts, Guliano said.
In the Tenderloin, Andy Berger, 31, said Tuesday that he’s afraid he may have injected xylazine — which he said is sometimes referred to as “zombie drug.” While it’s unclear whether he has inadvertently taken the drug, he said he has developed oozing, widespread abscesses along his legs, arms and hands in the past few months that are different from anything he’s had before.
He said he’s been to three different hospitals or clinics since September for treatment of the sores, “and they always tell me it’s cellulitis or something like that. They say they haven’t heard of zombie drug.”
Berger sat in a red tent near the corner of Leavenworth and Ellis streets, and rolled up his left pant leg to show a cluster of deep, angry red abscesses. He held a syringe ready for his next hit in one hand, but it was hard to grip because of the gaping, swollen sores on his fingers.
“I’ve been using a long time and never had anything like this,” he said, referring to his wounds. “I know other people who have this too…. I don’t know what to do. It’s pretty freaky, man.”
Trisha Thadani and Kevin Fagan are is a San Francisco Chronicle staff writers. Email: tthadani@sfchronicle.com, kfagan@sfchronicle.com Twitter: @TrishaThadani, @KevinFagan