New drug mixes are worsening overdoses
Rescue workers modify approach amid pervasive use of powerful sedative
The moment she saw him, Kelly Celata feared the man was dead from a drug overdose.
It was a warm July morning last summer, and a man in his 30s was stretched out on the pavement near downtown Brockton, cold and motionless but still breathing. Celeta and a street outreach nurse repeatedly shook him and gave him a shot of the emergency medication naloxone, which can reverse overdoses quickly. Yet he remained unresponsive as paramedics put him on a stretcher and whisked him to a nearby hospital.
“We were baffled,” said Celata, homeless services program manager at the Brockton Neighborhood Health
Center, which operates a mobile services unit. “He was out cold like he was sleeping, but no one who is just sleeping could have slept through all that.”
A new and more powerful wave of overdoses is spreading rapidly across Massachusetts, and it’s putting severe pressure on front-line medical workers trying to save lives. In some cases, overdose victims are so heavily sedated on a toxic mix of substances that they can remain in a blackout stupor for hours. In other cases, victims overdose so quickly that there’s not enough time to revive them.
These new and complex cases are confounding health agencies and leading front-line workers to rethink how they respond to overdoses. First responders are learning that even multiple sprays of
‘We used to have minutes to an hour to respond. Now we have seconds to minutes.’
— Traci Green, epidemiologist and director of the Opioid Policy Research Collaborative at Brandeis University
naloxone, a drug effective at reversing most opioid overdoses, are not enough to revive someone and can do more harm than good. So, outreach workers are deploying multiple tools and techniques, including pulse oximeters to check oxygen levels in the field, plastic mouth guards for mouth-to-mouth resuscitation, and test strips to help people identify the drugs they are taking before they use them.
Xylazine, a powerful animal tranquilizer used by veterinarians, is the chief culprit behind the prolonged overdoses. Known by the street names “tranq” or “tranq dope,” xylazine is not an opioid, which means that its effects cannot be reversed with naloxone, a medication also known by the brand name Narcan, that targets the brain’s opioid receptors. In the first quarter of this year, xylazine was detected in an alarming 49 percent of the state’s illicit drug supply, double the percentage from the same period last year, according to samples tested through Brandeis University’s drug-checking program.
Doctors and first responders say it’s particularly challenging to rouse a person sedated with xylazine. Some victims pass out and do not move for several hours, which can be especially dangerous if they are alone or outside in the extreme cold, say street outreach workers. It also renders users especially vulnerable to rape and robbery. In addition to causing breathing and heart rates to drop, xylazine injections have been linked to severe skin wounds. The sedative is increasingly being mixed into street drugs such as fentanyl and heroin that can be injected, snorted, or inhaled.
“People are so heavily sedated [from xylazine] that they’re not responding in ways you would expect from an overdose,” said Jessie Gaeta, a physician and former medical director at the nonprofit Boston Health Care for the Homeless Program.
The hard-to-reverse overdoses also reflect a broader shift in drug-using habits among those struggling with addiction, say health researchers. More people are mixing opioids with stimulants like cocaine and antianxiety medications such as benzodiazepines (known as “benzos”), a practice known as “polysubstance use.” In many cases, people are taking multiple drugs to counteract their different side effects, or to prolong the experience, say addiction treatment specialists.
Many of these drugs are now laced with fentanyl, a fast-acting and highly potent synthetic opioid that is lethal even in tiny amounts. Fentanyl has become a leading cause of death in the United States and has been driving the relentless death toll from overdoses across New England. In 2022, overdose fatalities in Massachusetts reached 2,359 — the highest on record. While highly effective, naloxone is sometimes not enough to contend with the speed at which people overdose on fentanyl, which moves through the system much faster than other opioids. With fentanyl, breathing can stop within several minutes, compared with up to an hour with heroin, researchers have found.
“We used to have minutes to an hour to respond” to overdoses, said Traci Green, an epidemiologist and director of the Opioid Policy Research Collaborative at Brandeis University. “Now we have seconds to minutes.”
Derrick Cormier, 50, a recovering addict and former warehouse worker from Worcester, recalled nearly dying from xylazine-laced heroin last summer. He injected a small amount of the mixture in a park and then passed out for several hours, before waking drenched in sweat and shaking with abdominal pain. Days later, he developed black-and-purple flesh wounds on his arms — a sign that he had injected tranq dope.
“Tranq is everywhere, and it’s pure poison,” said Cormier, who said the incident led him to seek counseling for his drug use. “The stuff that’s out there ... just a little bit can knock you out for hours.”
In many cases, simply spraying Narcan, the over-the-counter nasal spray that contains naloxone, into a victim’s nose and calling 911 is no longer enough.
First responders are now stressing the importance of ensuring that a person who has overdosed has adequate oxygen, to reduce the risk they will die or suffer brain damage. They recommend making sure the person’s airway is clear and providing mouth-to-mouth resuscitation, also known as rescue breathing, after administering Narcan and while waiting for rescue crews to arrive.
Harm reduction groups are also distributing more plastic mouth guards for mouth-tomouth resuscitation as well as drug-testing supplies, including paper strips that can be dipped into drugs to detect if they contain fentanyl or xylazine. People who discover fentanyl using the strips are more likely to take steps to reduce the risks of a deadly overdose, such as slowing their intake or using with someone else present, studies have found.
“Having an unregulated drug supply presents us with a constant challenge,” said Eliza Wheeler, co-director of Remedy Alliance/For the People, a national network of harm-reduction programs based in Berkeley, Calif., that distributes naloxone. “We are learning as we go as harm reductionists — sometimes blindly.”
For a time, it was widely believed that giving multiple doses of naloxone was necessary if someone didn’t immediately start breathing again after an overdose. But too much of the overdose-reversal drug can send someone into severe withdrawal, and possibly reduce their willingness to carry the life-saving drug, say harm-reduction specialists and health researchers.
A study released this month by the federal Centers for Disease Control and Prevention found that a higher-dose nasal spray for reversing opioid overdoses did not save more lives than the previous standard dose, but it did cause more withdrawal symptoms, including vomiting and disorientation.
“In the past, people had this mentality that the only goal in these situations was to reverse the overdose,” said Allyson Pinkhover, director of substance use services at Brockton Neighborhood Health Center. “But there is actually a two-fold goal: You have to reverse the overdose, but you have to do it in a way that doesn’t cause unnecessary pain and suffering.”
As director of the state’s overdose prevention hot line, Stephen Murray has a rare, inside look at evolving drug use patterns.
The frequent mixing of drugs poses challenges for operators of the state helpline, which has trained staff to monitor people by telephone while they use drugs. Even if someone says they are using a stimulant such as cocaine, Murray noted, operators track the person’s speech pattern to detect if the drug is laced with a potentially lethal opioid. Someone who suddenly becomes drowsy or less talkative on the helpline could have taken cocaine laced with fentanyl, he noted.
In the past, treatment professionals often would ask people seeking help for addictions to identify their so-called drug of choice, so they could tailor therapies based on the symptoms. Now, that question has become less relevant, he said, because people are routinely using several different types of drugs. “Very rarely is substance use just about using one substance,” Murray said.
Outreach workers at the Brockton Neighborhood Health Center’s mobile unit have kept expanding the number of tools they carry in response to growing intensity of the overdoses they encounter. They are now equipped with pulse oximeters to track victims’ blood-oxygen levels, CPR face shields, and naloxone. People can also bring samples of their drugs to the mobile unit to have them checked for fentanyl and other toxic substances.
On a frigid weekday morning, the medical trailer pulled into a parking lot behind the Universal Missionary Church in Brockton. Within minutes, a line of people — a couple of them clutching drug samples to be checked — formed outside the van’s window. Each interaction was a fresh opportunity for outreach workers to hand out harm-reduction supplies and to educate visitors about the increasingly contaminated drug supply. Often, visitors pass along the information they glean from the drug tests to their peers so they know what to avoid, she noted.
“Knowledge is power,” Pinkhover said. “The same people we are trying to save are the ones who are saving others.”
‘The stuff that’s out there . . . just a little bit can knock you out for hours.’ DERRICK CORMIER, who is seeking counseling for his drug use