By Heidi Perez-Moreno

heidiperez-moreno@borderbelt.org

Carissa Collins-Caddle figured it was only a matter of time before xylazine showed up in Robeson County’s drug supply. As an outreach worker, she read about the powerful sedative being found in illicit drugs in other parts of the country and educated local users about its dangerous effects. 

Then, some people in Robeson County struggling with drug misuse told Collins-Caddle their fentanyl highs were lasting hours longer than usual, they dozed off more and started seeing open sores on their bodies. Some said it would take longer to bounce back after an overdose. 

Rural southeastern North Carolina matters. That’s why we dig deep into the power and people of Bladen, Columbus, Robeson and Scotland counties. Sign up for our free newsletter.

Collins-Caddle sent five fentanyl samples collected from the community to the UNC Street Drug Analysis Lab in Chapel Hill in late 2022 to find out if xylazine or other substances had been mixed in. 

They all contained xylazine, which is approved by the U.S. Food and Drug Administration only for veterinary care. 

“I was waiting on it, ” said Collins-Caddle, who now serves as director of the Beloveds CommUNITY Initiative in Robeson County. “It was here the whole time.” 

It’s been nearly two and a half years since she had the drugs tested, and Collins-Caddle said xylazine has become even more prevalent in Robeson County since then. 

More than 67% of all drug samples sent from Robeson County to the UNC lab through November 2023 showed large amounts of xylazine, data shows. That’s one of the highest percentages among the 23 North Carolina counties from which the lab detected the drug. 

Nabarun Dasgupta, a senior scientist at UNC Chapel Hill whose team conducts the lab analyses, said there were trace amounts of xylazine reported in 78% of samples from Robeson and Cumberland counties.

A new study by Fayetteville State University and the Cumberland County Department of Public Health’s Cumberland-Fayetteville Opioid Response Team will study the impacts of xylazine and its prevalence in North Carolina. Researchers want to recruit 900 people across North Carolina who misuse drugs and 300 health care professionals to analyze 900 drug samples. Through the study, which is funded by the North Carolina Collaboratory, researchers hope counties will develop plans to address the drug overdose epidemic in North Carolina. 

“This research is going to power us to be able to share information more widely with medical systems,” said Greg Berry, a coordinator on the C-FORT team and a co-investigator for the study. Health care workers at urgent care centers, for example, would gain knowledge and resources for treating patients who use xylazine. 

Robeson County, one of the poorest and most diverse counties in the state, has long ranked among the worst in North Carolina for fatal overdoses. The county had an overdose death rate of 100.5 per 100,000 people in 2023, nearly two and a half times the statewide rate. 

Health officials have said fentanyl, a synthetic opioid that can be 50 times more powerful than morphine and 100 times more powerful than heroin, has contributed to a rise in fatal overdoses across the United States.  

Xylazine, primarily used to tranquilize horses, cattle and other large animals functions as a central nervous system depressant by lowering heart rate, blood pressure and respiratory function. People who consume xylazine, which is typically cheap and easily mixed with street drugs, can experience effects such as prolonged sedation, extreme drowsiness, disorientation, memory loss and impaired motor function, Dasgupta said. 

Such effects can put someone at higher risk for being assaulted or having a serious accident, Collins-Caddle said. That’s especially worrisome for people who are unhoused.  

Health care professionals and harm reduction advocates say they are particularly concerned about open sores that can develop on the skin of people who take xylazine. They can appear anywhere on someone’s body, not just at injection sites, and they start as small sores but can rapidly progress to large, necrotic ulcers. 

Berry said the biggest danger of an open wound is infection, which can lead to complications like sepsis, gangrene, and in extreme cases, paralysis.

While open wounds are often associated with xylazine exposure, not everyone who uses the drug will develop them. Researchers are still looking into health factors that could help explain why some people develop sores and some don’t. Dasgupta said his team’s early research suggests gender may play a role, with a 20% rate among women and 5% among men. 

“I had a participant and her father living in the same house, using the same drugs from the same dealer, with the same method of administration,” Collins-Caddle said. “She nearly lost both of her legs twice, while he never had a single wound. We still don’t fully understand why this happens.”

C-FORT and the North Carolina Harm Reduction Coalition are leading a wound care initiative.

“We distribute wound care kits, antiseptics, and educational materials so people can care for their wounds themselves,” Berry said. “But we need medical providers to be trained on how to recognize and treat xylazine wounds properly.”

Although awareness and education have improved in the last few years, more work is needed to fully understand how medical providers can address overdoses and treat open wounds caused by xylazine. Health officials previously thought that the drug didn’t respond to naloxone, which can quickly reverse an opioid overdose. But now it is known that naloxone is effective in overdoses involving xylazine but might take up to 45 minutes to work, Dasgupta said. 

“That’s why monitoring the person after naloxone administration is important,” he said. 

More than 4,400 people died of drug overdoses in North Carolina in 2023, including 118 in Robeson County, according to the state Department of Health and Human Services. That was down from a record-high 127 overdose deaths in Robeson in 2021. 

Overdose deaths are now on the decline. Across the country, the Centers for Disease Control and Prevention predicts a 24% drop for the 12-month period ending September 2024 compared to the previous year. 

What’s interesting, Dasgupta said, is that xylazine use was on the rise during the same time. 

“What we can observe is that when xylazine prevalence goes up, overdoses go down, and this is very consistent with the data from around the country,” he said. “In our lab, we know that if you give mice xylazine plus fentanyl, they’ll use less fentanyl. Even though xylazine causes skin wounds, it also leads to less fentanyl use.”