What xylazine is, treatment options and how the White House is responding with Rahul Gupta, MD, MPH


AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

The Biden-Harris administration designated fentanyl combined with xylazine as an emerging threat to the U.S. Rahul Gupta, MD, MPH, director of the White House Office of National Drug Control Policy, joins to discuss what xylazine is, the threat is poses, the White House’s plan to combat it and how physicians can help. AMA Chief Experience Officer Todd Unger hosts.


  • Rahul Gupta, MD, MPH, director, White House Office of National Drug Control Policy

AMA Recovery Plan for America’s Physicians

After fighting for physicians during the pandemic, the AMA is taking on the next extraordinary challenge: Renewing the nation’s commitment to physicians.

Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the dangers of fentanyl combined with xylazine and what physicians need to know. Here with me to discuss this today is Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy in Washington, D.C. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Gupta, thanks so much for being here.

Dr. Gupta: Thanks for having me, Todd.

Unger: Dr. Gupta, can we start with a little bit of background on xylazine? Can you tell folks out there just exactly what xylazine is and why people are using it?

Dr. Gupta: Yeah. Xylazine is an animal tranquilizer. It was approved many, many years ago for use in animals as a sedative but has never been approved for use in humans. And what we find today is that this drug called illicit fentanyl on the streets is being cut with or mixed with this particular tranquilizer, which brings with it along a very different set of challenges because this is an alpha-2 agonist as opposed to an opioid or other forms of drugs.

Unger: And so it's not something that people were necessarily seeking to use on their own, but it's being actually put into the illicit fentanyl is your point.

Dr. Gupta: Yeah. That's exactly right.

Unger: So the Biden administration has designated the combination of fentanyl and xylazine as an emerging threat to the United States. What prompted that designation? And what does it mean for the government's efforts to address this threat?

Dr. Gupta: Yeah. So earlier this year, I made that designation. And part of the reason is that we have seen a consistent increase in drugs when we check for xylazine being found along with fentanyl. But we've also seen almost 300% increase in deaths associated with this combination of fentanyl and xylazine.

It has certainly complicated not only our response efforts, the mixture of fentanyl and xylazine, it's made it more dangerous and lethal, but it's also made it more difficult to treat people who have now addiction potentially from both substances as opposed to just one. So this is one that we've—I've seen in my 25 years of practice that we are always behind in reacting to substances. We wanted to make sure in this administration that we were designating as an emerging threat a substance not unlike very much what we do with pandemics and other agents so that we can get ahead of it and develop those plans so we can save more lives more quickly.

Unger: Well, let's talk a little bit more about the plan. You announced the designation in April and developed a response plan in July. Did you have particular short-term goals in mind? And have there been any notable achievements since April that you can tell us about?

Dr. Gupta: Well, certainly. There were some things we found certainly that are different than just fentanyl use. For instance, as I mentioned, the response efforts are complicated because while we should still use naloxone or Narcan, the antidote for opioids, to reverse overdoses, people may not respond as quickly. So it's important for awareness to be there.

Similarly, we've seen these terrible wounds, flesh wounds, some of the most difficult ones to treat that I've seen across my career, but also the need for more oxygen supply and other ways to resuscitate individuals as well as to manage them. So having said that, Todd, in June, we've got a framework of a response plan. And in September, we've got the full response from all of the federal agencies that are going to now work along with state, local and community partners.

We've had listening sessions through subject matter experts all across the United States to talk about how to manage these flesh wounds, how to manage an acute intoxicated patient, how to do an ICU management of patients who are suffering from the dual use of fentanyl and xylazine. And those are the types of treatment protocols standards as well as more testing needs with xylazine test strips and others that are being funded now that we're developing.

Unger: And we're going to talk a little bit more about that. But that's fast and significant progress. Dr. Gupta, we know that the drug overdose and death epidemic and the gaps in access to treatment for opioid use disorder have had severe impacts on historically minoritized communities and contribute to the U.S. maternal mortality rate. How does this affect health equity and maternal health? And are there elements of the administration's response plan that will help address these issues?

Dr. Gupta: Well, I think you're so correct and the fact that this epidemic affects no more any other community than those in communities of colors, other minorities. But also, some of the worst outcomes happen oftentimes in people who are pregnant. So it's important to focus on the mom and the baby. In some ways, this is an extension of my past work at the March of Dimes where we looked at the infant and maternal mortality epidemic that our country so uniquely faces, but also one of preterm birth. One out of 10 babies being born preterm. But for women of color, it is three to five times more likely to happen.

So with that, we developed, with some of the experts across the nation, a guidance as well as some of the model state laws about how to approach a pregnancy when we're talking about substance use, how to get people into treatment, how to make sure that that mother-baby dyad is kept whole throughout post-pregnancy times, knowing that in postpartum periods substance use is one of the rapidly increasing causes of death and contributing to maternal mortality as well as infant complications.

So these are important pieces. And this is so important to this administration to make sure that we're addressing the mother-child epidemic that is within the overall epidemic of substance use, but especially that combined with mental health as well.

Membership Moves Medicine™

  • Free access to JAMA Network™ and CME
  • Save hundreds on insurance
  • Fight for physicians and patient rights

Unger: And Dr. Gupta, you mentioned earlier in the conversation that naloxone may not work as quickly. Of course, that's something the AMA has been working to increase access to naloxone. I wanted just to ask you a follow up question about decriminalizing some of the drug checking supplies. You mentioned fentanyl test strips. What's the situation there?

Dr. Gupta: Yeah. I'm glad, Todd, you asked that question because this administration is the first in the entire federal government's history to include harm reduction policies as part of the federal policies. What that means is recognition that now we're dealing with a largely a synthetic epidemic in addition to organic drugs like cocaine and heroin. That means that we're dealing with some of the most lethal drug supply ever known to man or woman.

That also means that we must meet people where they are and help them move forward in terms of saving lives and connecting people to treatment. But we cannot save lives if we do not have access to drugs like naloxone or Narcan, which are antidotes, of course, for opioid overdose. But then again, having that ability with fentanyl and xylazine test strips for individuals to be able to test their drug supply to be aware that these drugs that often aren't intended from a patient perspective are in their drug supply because, oftentimes, people aren't even aware that these drugs are making it into their drug supply.

This gives them the ability to know that as well as take the appropriate countermeasures to make sure that they're saving their own life or having the ask for someone else to help them do that. It's an important policy. And I think decriminalizing those test strips as well as making sure naloxone is available, it's such an important part when three out of four people that are dying are because of opioids like fentanyl. And we had over 110,000 overdose and poisoning deaths last year.

Unger: Those are pretty harrowing statistics. Dr. Gupta, if a physician becomes aware or suspects that some of their patients are ingesting fentanyl with xylazine, what's your advice? What can they do about that?

Dr. Gupta: One of the things that I've learned is that all of us in the house of medicine and in communities are first responders. That means that addiction impacts about 46 million Americans today. So for all of us practicing medicine, they're part of your panels, whether you know it or not. It's really important to start with asking those questions in a way that people don't feel stigmatized, in a way that they feel that they can get the help for you to come to.

But if you do find someone who is utilizing or using fentanyl with xylazine or just fentanyl, it's really important to have a compassionate approach, which one with the ability to say, "OK, how can we help you? What is the next step you're thinking about?" You remember we learned this from our smoking education classes. Meet people where they are and help them move to the next stage.

So the first thing would be to make sure that they are carrying with them naloxone, those patients, and they're aware that someone else knows that naloxone is in the home or wherever they might be so that they can be saved in time of an overdose or poisoning. But then again, fentanyl and xylazine test strips. Some of those are now being funded by the federal dollars to make sure that they have a way to go to.

Go to your local health department or your state health department is a good place to be connecting people. And then finally, if people do want to seek treatment, not only going to a harm reduction clinic, which is important to get syringe service programs and naloxone and others, but also then making sure you get that treatment access when you need to.

We want to make sure that we worked hard to remove these unprecedented barriers to things like the X waiver. Myself, being an X waiver physician, was so happy that we were able to remove that. So now about 2 million providers across this country who have a DEA license can also prescribe people treatment with suboxone or buprenorphine. We want to make sure that physicians are aware of that, they're able to help and contribute to saving lives like they do for so many other diseases. They should do the same for addiction.

Unger: Dr. Gupta, it's an honor to have you here. And thank you so much for all the work that you're doing to address this epidemic. That's it for today's segment. We'll be back soon with another AMA Update. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. And please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.