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Problems with the veterinary sedative xylazine -- also known as "tranq" -- appeared to be concentrated in the eastern U.S. but were spread across the entire country, a cross-sectional study found.

At least 43 states reported at least one xylazine-related overdose death from 2019 to 2022, Manuel Cano, PhD, of Arizona State University in Phoenix, and colleagues reported in .

State forensic or overdose death reports involving xylazine increased over time, the researchers found. In 2019, 16 states had no xylazine forensic reports but by 2022, only two states had no such reports, Cano and colleagues found. By that year, xylazine in forensic reports had risen in all but three states, they reported.

"Although xylazine is not currently one of the top drugs contributing to overdose deaths in the U.S. overall, xylazine-related overdose deaths are relatively high within certain communities, rapidly increasing, and likely underestimated due to limited testing," the researchers wrote.

Xylazine is sometimes added to fentanyl to extend its high and this has been tied to complications in recent years, including necrotizing wounds that can lead to amputation. Last year, several federal agencies started investigating how to mitigate the growing xylazine problem.

Despite the threat to public safety, data on xylazine that could help inform public health and harm reduction strategies are limited. For instance, xylazine-involved overdose deaths do not yet have an ICD-10 code, the researchers said.

To get a better handle on xylazine-related overdose deaths, Cano and colleagues relied on data from the National Forensic Library Information System (NFLIS), the National Center for Health Statistics, and state medical examiner or public health agency reports, all from 2019 to 2022.

Overall, only 21 states had yearly totals of xylazine-related deaths. Among these, Vermont and Connecticut had the highest burden at 10.5 and 9.8 deaths per 100,000 residents in 2022, respectively, the authors wrote.

Delaware had the highest percentage of xylazine drug reports at 16.17% of all NFLIS reports in 2022. Connecticut, Maryland, Washington D.C., New Jersey, and Rhode Island also had high levels, between 5.95% and 7%.

However, xylazine was involved in less than 1% of NFLIS reports in 35 states, they found.

Eight states had no official records of xylazine-related overdose deaths: Alaska, Hawaii, Idaho, Montana, North Carolina, South Dakota, Utah, and Wyoming.

The study was limited by several factors, including the fact that not every drug seized is analyzed in NFLIS reports; nor does this system represent a random sample of the U.S. illicit drug supply. Also, state-level data on xylazine-related overdose deaths were located via an online search, and these tend to be underreported due to limited testing in many jurisdictions, they noted.

Better information is critical to treating the xylazine problem, they maintained.

"Information about xylazine's presence in street drug supplies and in overdose deaths within individual states is necessary to inform local public health agencies' and clinicians' implementation of xylazine-specific harm reduction strategies," Cano and colleagues wrote.

They encouraged expanding and standardizing xylazine testing and reporting to improve research. Future studies also should look into optimizing treatment care protocols, especially since xylazine-related skin ulcerations and withdrawal symptoms complicate treatment, they wrote.

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