Paterson police and sheriffs officers performing a sweep along the railroad tracks in Paterson on Feb. 13, 2023. (Daniella Heminghaus for New Jersey Monitor)

Johnny has struggled with addiction for so long and overdosed so often his friends call him “Johnny Narcan.”

He’s well aware of all the substances dealers sneak into drugs to deepen both their profits and their customers’ cravings.

“They’re going to sell you confectionary sugar if they can,” said Johnny, who lives in Atlantic City.

So when dealers started mixing the horse tranquilizer xylazine into fentanyl to form an adulterated street drug known as “tranq,” he unwittingly tried it. He didn’t like it.

“You do a shot, and you just crumble where you’re at. When you wake up, you can’t move,” he said. “A horse weighs 700 to 800 pounds. We weigh 150 pounds, 200 pounds, if that. If they’re giving this to horses to put them down, what is it doing to a person that’s 150 pounds?”

Xylazine first crept into the illicit drug trade in the U.S. more than two decades ago. But it didn’t widely catch on until recent years, with New Jersey’s drug fighters first clocking it around 2018.

Even now, it’s not nearly as ubiquitous — or dangerous — as another adulterant, fentanyl, that hiked overdose deaths and transformed emergency response.

Still, xylazine has been linked to gruesome, lingering sores that, left untreated, can raise the risk of amputation and even death. Such rotting wounds, along with the stupor xylazine typically induces, have driven some to dub tranq “the zombie drug.”

Xylazine also complicates the overdose response because it’s a non-opioid sedative that doesn’t respond to naloxone, the drug that reverses opioid overdoses.

And because xylazine is a legal drug repurposed for illegal use, regulations haven’t caught up with it yet, making it tough for law enforcement to stem the supply.

All of that, combined, is why the Biden administration last month declared tranq an “emerging drug threat,” a designation that requires a national response that will include expanded health interventions, research and data collection, and crackdowns on suppliers. The Food and Drug Administration also issued an alert in November warning health care professionals about xylazine.

“This started out as a small problem and then it blossomed, probably because there weren’t great controls put on the availability of xylazine,” said Dr. Lewis Nelson, chair of Rutgers University’s Department of Emergency Medicine and chief of its medical toxicology division. “They’re cracking down on it now. But obviously, it’s going to be tough to do.”

In New Jersey, xylazine is most common in Camden, migrating there from Philadelphia, where 90% of the street opioid samples as of 2021 contained xylazine, according to the city’s health department.

The sedative has been found in about 30% of New Jersey’s opioid samples in recent years and 7% of overdose fatalities, said Capt. Jason Piotrowski, who heads New Jersey State Police’s drug monitoring and analysis office.

“We’ve been tracking it for a long time,” Piotrowski said. “There’s a lot of confusion right now, and I’m not sure anyone has a really good handle on it yet.”

Nelson echoed that sentiment, saying: “There’s a lot of debate in my world, to be honest, about some of the repercussions of xylazine.”

What’s not disputed is that fentanyl continues to be the primary killer of people who use drugs.

“There’s nothing more dangerous about tranq, really, than fentanyl,” Nelson said. “The 800-pound gorilla here is the fentanyl. Even though people die with xylazine in their bodies, it has very little to do with the reason they die. It’s fentanyl, or the analogs of fentanyl, that’s the culprit in the vast amount of cases. Xylazine is, I wouldn’t quite say an innocent bystander, but it’s a bystander.”

‘Weird silver lining’

State officials say drug deaths in New Jersey are actually at their lowest since 2017, with just under 2,900 tallied last year, down from the epidemic’s high of 3,124 in 2021.

But Nelson cautioned that doesn’t mean drug use has fallen. Instead, more people are dodging death because of naloxone, which is now free at safe syringe sites and pharmacies, with those incidents creeping upward since 2017. Almost 14,000 people received Narcan or another naloxone last year, up from about 11,500 in 2017, data shows.

“I’ll tell you a dirty little secret — the vast majority of people who overdose don’t die. We know this because we know that in a city like Newark or Philadelphia, there’s hundreds of people who overdose every night,” Nelson said. “If we don’t get them into treatment and get them to stop using opioids, they’re going to die the next time, or the time after.”

Piotrowski pointed to the declining death rate as “a weird silver lining to xylazine.”

“The more xylazine they put in a drug and the more fentanyl they take out, it becomes less and less deadly. Also coupled with that is the fact that xylazine lasts a lot longer, which means they’re probably going to use less doses,” he said.

Still, xylazine complicates the overdose response because someone using naloxone to revive an unresponsive person tends to administer too much when the person doesn’t awaken — not realizing that someone who’s unconscious because of xylazine, which isn’t an opioid, will remain unconscious because naloxone only affects the opioid in their system, Nelson said.

“What we need to remember is that the endpoint for naloxone administration is not arousal. It’s not awakening. It’s breathing,” he said. “People who take xylazine don’t stop breathing. People take opioids do. So if you give somebody a naloxone, and they breathe, you’re done. You don’t have to give them more to wake them up, because the risk of giving too much is you might actually injure them.”

Too much naloxone can trigger withdrawal, which creates new problems, he added.

“A big part of opiate withdrawal is vomiting — if they don’t wake up because they also have xylazine in their bodies and they start to vomit, that leads to downstream complications, particularly pulmonary aspiration of vomit, which is life-threatening potentially,” Nelson said.

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Legislation pending

New Jersey’s policymakers have made small steps toward tackling tranq.

Several New Jersey lawmakers introduced legislation to tighten oversight of veterinary medications. A bill sponsored by Assemblymen Kevin Rooney (R-Bergen) and Robert Auth (R-Bergen) would require veterinary medications to be issued in the name of the animal owner and included in the state’s Prescription Monitoring Program.

But it has been introduced four times since 2017 without lawmakers acting on it.

Rooney said he was driven to introduce that legislation by concerns that people were hurting their pets to get Tramadol, a synthetic opioid used to treat pain in dogs, cats, and other small animals.

“They’d get the prescription for Fluffy for Tramadol, and then they’d go to another vet and bring that same injured dog, and Fluffy would get more Tramadol, and go to another vet and get more Tramadol — because there was no registry,” Rooney said.

Rooney and his wife own horses, so he also watched with horror early in the pandemic as people began using the horse dewormer Ivermectin to fight COVID-19.

“There’s been an abuse of certain drugs that are not necessarily related to just horses but dogs, cats, cows, pigs, sheep, across the board, and we need to make sure that we’re aware of what the implications are if you misuse those particular drugs,” Rooney said.

He hopes the recent attention on xylazine will help the stalled bill move, as well as a new bill he introduced this month to require reporting of xylazine prescriptions and classify it as a Class III controlled dangerous substance.

“There’s such a national spotlight on it right now, on both sides of the aisle,” he said. “We have to be on the side of protecting lives and helping our law enforcement. And this is the reason that these bills were created, to do that.”

Test strips and affordability

Harm reduction workers also are expanding their efforts to counter tranq’s toxic effects, distributing bandages and other wound-care supplies to people they encounter in street outreach and at their centers.

Jenna Mellor, co-founder of the New Jersey Harm Reduction Coalition, also has advocated for the state to expand its use of test strips.

Health officials already distribute test strips that enable people to determine if the drugs they buy contain fentanyl. Mellor said the state also should distribute test strips that detect xylazine, as well as do more to decriminalize drug use to ensure people feel safe to use the test strips without fear of prosecution.

Nelson called test strips “a misguided idea.” While the strips reveal what’s in the drug, they don’t indicate how much, he said.

“There could be one speck of fentanyl in there, or the whole thing could be fentanyl. You have no idea,” he said. “So what do you do with that information? Do you really believe in your heart of hearts that somebody says: ‘Oh, there’s fentanyl in my heroin, so I’m gonna throw it out and go buy some more?”

Nelson prefers to see policymakers continue focusing on ways to make naloxone more accessible and affordable — not just for people, but for the hospitals who treat them. He pointed to a state requirement that hospitals discharging patients who are on opioids must give them naloxone.

“If you know the way health care works, we run on very thin margins. So it’s an unfunded mandate, which puts maybe $100,000 in added expense in my hospital that I don’t know that we can really afford,” Nelson said. “Maybe the state should be paying for that. If they want me to give naloxone, which is a great idea, maybe they should be paying for it.”