Martha Bebinger, Author at �鶹Ů�� Health News

They Call It ‘Tranq’ — And It’s Making Street Drugs Even More Dangerous

Martha Bebinger — Thu, 11 Aug 2022 09:00:00 +0000

Approaching a van that distributes supplies for safer drug use in Greenfield, Massachusetts, a man named Kyle noticed an alert about xylazine.

“Xylazine?” he asked, sounding out the unfamiliar word. “Tell me more.”

A street-outreach team from delivered what’s becoming a routine warning. Xylazine is an animal tranquilizer. It’s not approved for humans but is showing up in about half the drug samples that Tapestry Health tests in the rolling hills of western Massachusetts. It’s appearing mostly in the illegal fentanyl supply but also in cocaine.

“The past week, we’ve all been just racking our brains — like, ‘What is going on?’” Kyle said. “Because if we cook it up and we smoke it, we’re falling asleep after.”

(NPR and KHN are using only first names in this article for people who use illegal drugs.)

Kyle’s deep sleep could also have been triggered by fentanyl, but Kyle said one of his buddies used a test strip to check for the opioid and none was detected.

Xylazine, which is also known as “tranq” or “tranq dope,” surged first in some areas of Puerto Rico and then in Philadelphia, where it was found in in the most recent reporting period. Data from January to mid-June shows that xylazine was in 28% of drug samples tested by the , a state-funded network of community drug-checking and advisory groups that uses to let people know what’s in bags or pills purchased on the street.

Whatever its path into the drug supply, the presence of xylazine is triggering warnings in and for many reasons.

As Xylazine Use Rises, So Do Overdoses

Perhaps the biggest question is whether xylazine has played a role in the recent increase in overdose deaths in the U.S. In a , xylazine was detected in fewer than 1% of overdose deaths in 2015 but in 6.7% in 2020, a year the U.S. set a record for overdose deaths. The record was broken again in 2021, which had . The study does not claim xylazine is behind the increase in fatalities, but study co-author Chelsea Shover said it may have contributed. Xylazine, a sedative, slows people’s breathing and heart rate and lowers their blood pressure, which can compound some effects of an opioid like fentanyl or heroin.

“If you have an opioid and a sedative, those two things are going to have stronger effects together,” said Shover, an epidemiologist at UCLA’s David Geffen School of Medicine.

In Greenfield, Tapestry Health is responding to more overdoses as more tests show the presence of xylazine. “It correlates with the rise, and it correlates with Narcan not being effective to reverse xylazine,” said Amy Davis, assistant director for rural harm-reduction operations at Tapestry. Narcan is a brand name of naloxone, an opioid overdose reversal medication.

“It’s scary to hear that there’s something new going around that could be stronger maybe than what I’ve had,” said May, a woman who stopped by Tapestry Health’s van. May said that she has a strong tolerance for fentanyl but that a few months ago, she started getting something that didn’t feel like fentanyl, something that “knocked me out before I could even put my stuff away.”

A Shifting Overdose Response

Davis and her colleagues are ramping up the safety messages: Never use alone, always start with a small dose, and always carry Narcan.

Tapestry Health Systems’ harm reduction team hands out pipes, filters, and other supplies for safer drug use from a van. (Jesse Costa/WBUR)

Davis is also changing the way they talk about drug overdoses. They begin by explaining that xylazine is not an opioid. Squirting naloxone into someone’s nose won’t reverse a deep xylazine sedation — the rescuer won’t see the dramatic awakening that is common when naloxone is administered to someone who has overdosed after using an opioid.

If someone has taken xylazine, the immediate goal is to make sure the person’s brain is getting oxygen. So Davis and others advise people to start after the first dose of Narcan. It may help restart the lungs even if the person doesn’t wake up.

“We don’t want to be focused on consciousness — we want to be focused on breathing,” Davis said.

Giving Narcan is still critical because xylazine is often mixed with fentanyl, and fentanyl is killing people.

“If you see anyone who you suspect has an overdose, please give Narcan,” said Dr. Bill Soares, an emergency room physician and the director of harm reduction services at Baystate Medical Center in Springfield, Massachusetts.

Soares said calling 911 is also critical, especially when someone has taken xylazine, “because if the person does not wake up as expected, they’re going to need more advanced care.”

‘Profound Sedation’ Worries Health Providers

Some people who use drugs say xylazine knocks them out for six to eight hours, raising concerns about the potential for serious injury during this “profound sedation,” said Dr. Laura Kehoe, medical director at Massachusetts General Hospital’s Substance Use Disorders Bridge Clinic.

Kehoe and other clinicians worry about patients who have been sedated by xylazine and are lying in the sun or snow, perhaps in an isolated area. In addition to exposure to the elements, they could be vulnerable to compartment syndrome from lying in one position for too long, or they could be attacked.

“We’re seeing people who’ve been sexually assaulted,” Kehoe said. “They’ll wake up and find that their pants are down or their clothes are missing, and they are completely unaware of what happened.”

In Greenfield, nurse Katy Robbins pulled up a photo from a patient seen in April as xylazine contamination soared. “We did sort of go, ‘Whoa, what is that?’” Robbins recalled, studying her phone. The image showed a wound like deep road rash, with an exposed tendon and a spreading infection.

Robbins and Tapestry Health, which runs behavioral and public health services in Western Massachusetts, have created networks so clients can get same-day appointments with a local doctor or hospital to treat this type of injury. But getting people to go get their wounds seen is hard. “There’s so much stigma and shame around injection drug use,” Robbins said. “Often, people wait until they have a life-threatening infection.”

People who use drugs can drop off samples to be tested at Tapestry Health Systems’ office in Greenfield, Massachusetts. (Jesse Costa/WBUR)

That may be one reason amputations are increasing for people who use drugs in Philadelphia. One theory is that decreased blood flow from xylazine keeps wounds from healing.

“We’re certainly seeing a lot more wounds, and we’re seeing some severe wounds,” said Dr. Joe D’Orazio, director of medical toxicology and addiction medicine at Temple University Hospital in Philadelphia. “Almost everybody is linking this to xylazine.”

This article is part of a partnership that includes , , and KHN.

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Addiction Medicine Mostly Prescribed To Whites, Even As Opioid Deaths Rose Among Blacks

Martha Bebinger — Wed, 08 May 2019 19:08:11 +0000

White drug users addicted to heroin, fentanyl and other opioids have had near-exclusive access to buprenorphine, a drug that and . That’s according to a study out Wednesday from the University of Michigan. It appears in JAMA Psychiatry.

Researchers reviewed two national surveys of physician-reported prescriptions. From 2012 to 2015, as overdose deaths surged in many states so did the number of visits during which a doctor or nurse practitioner prescribed buprenorphine, often referred to by the brand name Suboxone. The researchers assessed 13.4 million medical encounters involving the drug but found no increase in prescriptions written for African Americans.

“White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,” said , an assistant professor of medicine at the University of Michigan Medical School and the study’s lead author.

The dominant use of buprenorphine to treat whites occurred while opioid overdose deaths were .

“This epidemic over the last few years has been framed by many as largely a white epidemic, but we know now that’s not true,” Lagisetty said.

What is true, Lagisetty added, is that most of the white patients either paid cash (40%) or relied on private insurance (35%) to fund their buprenorphine treatment. The fact that just 25% of the visits were paid for through Medicaid and Medicare “does highlight that many of these visits could be very costly for persons of low income,” Lagisetty said.

Doctors and nurse practitioners can demand cash payments because there’s a shortage of clinicians who can prescribe buprenorphine, according to , co-director of Opioid Policy Research at Brandeis University’s Heller School for Social Policy and Management. Only about 5% of physicians have taken the special training required to prescribe buprenorphine.

“The few that are doing it are really able to name their price, and that’s what we’re seeing here and that’s the reason why individuals with more resources — who are more likely to be white — are more likely to access treatment with buprenorphine,” said Kolodny, who was not involved in the study.

Kolodny wants the federal government to eliminate the required special training for buprenorphine and a related cap on the number of patients a doctor can manage on the drug.

Some physicians who’ve studied racial disparities in addiction treatment say the root causes date to 2000, when buprenorphine was approved. At that time, proponents argued that buprenorphine was needed to help treat suburban youth, according to at New York University. Those young patients didn’t see themselves as addicted to heroin in the same way as hard-core urban heroin users who went to methadone clinics for treatment.

“Buprenorphine was introduced as private-office treatment, for a private market with the means to pay,” said Hansen, an associate professor of psychiatry and anthropology. “So the unequal dissemination of buprenorphine for opioid dependence is not accidental.”

Hansen added that the fix must include universal access to treatment in a primary care setting, an end to the criminalization of opioid dependence (which puts more blacks in prison for drug use than whites) and more federal funding to expand access to buprenorphine for all patients.

Several leaders in the fight to reduce opioid overdose deaths say the study results are disturbing.

“It really demands for us to be looking at equitable treatment for addiction for African Americans as we do for white Americans,” said , director of the Grayken Center for Addiction at Boston Medical Center and the former director of the Office of National Drug Control Policy.

Botticelli identified key issues that may contribute to the racial treatment gap and deserve further investigation. For example, he wants to know if Medicaid reimbursement rates are simply too low to entice more doctors to work with low-income patients, or if there are too few inner-city doctors prescribing buprenorphine or if African Americans themselves are somehow reluctant to seek this form of treatment.

Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, called the findings surprising and disturbing. Surprising because the disparity is so large, and disturbing because her agency has prioritized educating doctors about the value of prescribing buprenorphine.

Volkow also expressed disappointment that federal parity laws, which are supposed to guarantee equal access to all types of medications, don’t seem to be working for buprenorphine.

“We need to ensure that we have capacity to provide these treatments,” Volkow said, “because if you say you have to pay for them, but there are no services that can provide the treatments, then the issue of paying for them is secondary.”

Volkow has noted that fewer than half of Americans with an opioid use disorder have access to buprenorphine or two other medications used to treat opioid addiction: methadone and naltrexone. Volkow said she’s glad that the use of buprenorphine is on the rise, but the U.S. needs to understand why this lifesaving treatment isn’t benefiting all patients who need it.

This story is part of a partnership that includes ,�� and Kaiser Health News.

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A Tale Of Two Health Insurance Extremes

Nicole Cohen — Mon, 19 Mar 2012 17:04:00 +0000

This story comes from our partner ‘s SHOTS blog.

The U.S. spent $2.6 trillion on health care in 2010 — more than the entire economy of France or Britain. But the amount spent and how it’s used varies from state to state.

And, at the opposite ends of the spectrum: Texas and Massachusetts. At 25 percent, Texas has the highest rate of uninsured people in the nation. Massachusetts, where a 2006 law made coverage mandatory, has the lowest rate — less than 2 percent of people are uninsured. Here’s a look at two Americans who are living the reality of that difference:

Walking A Health Care ‘Tightrope’

For six million uninsured Texans, having health problems can mean an anxious scramble for care at overcrowded charity clinics or the local emergency room. Melinda Maarouf knows that experience all too well. She’s a teacher’s aide at the Faith Christian Academy, a private school just outside of Houston.

“Unfortunately, we’re a small school and the budget doesn’t allow for insurance for the employees,” she says.

Maarouf is divorced and has a daughter in college. The school where Maarouf works can’t afford to bring her on full time right now, so she makes just over $11,000 a year. That income puts her right around the federal poverty line, and it makes for some hard health choices.

Melinda Maarouf, 55, works part time at a small Texas private school that doesn’t provide her with health insurance (Photo by Carrie Feibel for NPR).

She has high blood pressure, and has skipped pills to make her prescriptions last longer. “I can always tell when the blood pressure’s elevated,” she says. “I feel uncomfortable. I feel edgy and kind of shaky, and my ears ring.”

Maarouf knows that if she doesn’t keep her blood pressure under control, she could have a stroke, heart attack or kidney damage. She recently found help at a charity clinic where she pays only $25 per visit. Even so, Maarouf says the blood pressure is all she can afford to treat right now.

“I haven’t had a Pap smear — goodness, I couldn’t even tell you — probably since my daughter was born, and she’s 26,” she says. “I haven’t had a well-woman exam. And I’m sure it’s time for some routine blood work.”

Maarouf has never had a mammogram and she’s continued to push off some needed dental work — but medical bills scare her. In 2010, she went to the emergency room with chest pain. Doctors didn’t find anything wrong, but she ended up with $3,000 in bills.

Maarouf couldn’t keep up with the payment plan, so she simply shoved the bills into the bottom of a drawer and swallowed her anxiety.

“Oh, my credit’s pretty much shot, as far as that goes. But there’s not much I can do about it,” she says. “You just have to move on, do what you have to do to survive.”

Like millions of other working Texans without minor children, Maarouf can’t get Medicaid. And she’s years away from Medicare.

Hospitals in Texas spend over $4 billion a year treating uninsured patients like Maarouf. Some of the cost gets absorbed by county taxpayers, and some gets shifted onto insured Texans, who pay higher premiums for their own coverage.

Maarouf says she feels stuck and exposed. “It’s like you’re sort of walking a tightrope. I sometimes feel like I’m on the edge of a cliff. As long as everything is status quo and there’s no glitches or bumps in the road, I feel OK,” she says. “But I sometimes feel like I’m one emergency room visit away from a catastrophe.”

In Massachusetts, Relief For The Uninsured

Five years before Massachusetts started offering free and subsidized coverage, Peter Brook couldn’t afford health insurance or the daily insulin and needles he needs to treat his diabetes. Things have changed for Brook since the Massachusetts health care law, the same one that helped shape the federal Affordable Care Act.

“When I didn’t have health insurance, I’d use a needle for 30 days, like 150 shots or something, so it gets a little bit dull,” says Brook, who does odd jobs like landscaping to cover his basic needs.

When he had health complications related to his diabetes, he didn’t have money for care. The worst was a digestion problem that would bring on crippling stomach pain.

“I would tend to hole up in a fetal position at home, and then over the course of week or two, my skinny body would lose 25 to 30 pounds and then I’d end up looking like a death camp survivor,” he says.

Handyman Peter Brook, 51, pulls weeds outside his church in Boston. Before 2006, Brook says he couldn’t afford health care (Photo by Martha Bebinger for NPR).

And then there was the time Brook fractured his pinky and set it by taping the broken section to his ring finger. The pinky is still crooked, but today Brook has free health insurance and a regular doctor at the South Boston Community Health Center. His only expense is a $3.65 co-pay for prescriptions, which adds up to about $14 a month.

“I now have good health care, so that is a weight off of my mind,” he says. “It’s been a year and half since I’ve been in a hospital, and for the first 50 years of my life I never went six months without an inpatient hospital stay for one thing or another.”

Brook’s care is free, but Massachusetts — with help from the federal government — spends roughly $182 million more every year on health coverage for low-income residents than it did before 2006, according to the . And Brook worries about those costs.

“Who’s paying for it? Where’s that money coming from?” he asks. “If society were a human being, then they’re dragging a ball and chain down the street on their ankle.”

Brook has joined the in lobbying Massachusetts legislators to control health care cost increases so that coverage will be affordable. And as lawmakers finalize bills, there’s a vigorous debate underway about what state government can or should do to about limiting spending.

These stories by Carrie Feibel (Texas) and Martha Bebinger (Massachusetts) are part of a reporting partnership between , , NPR and Kaiser Health News.

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