The Tip of the Iceberg

Aegis recent panelist, Ryan S. Alexander, DO, MPH, has released an op-ed where he expresses the need for testing in an uncertain drug landscape.

Recently, I have developed a numbness from hearing patients recount disturbing histories of trauma, abuse, and pain. I work as an addiction medicine physician in East Tennessee for an organization that primarily serves the uninsured, unhoused, and low-income populations. Nearly all my patients end up in my office because of fentanyl, reporting that it is the easiest, most accessible, and most economical reprieve from the intense challenges in their everyday lives. Unfortunately, fentanyl is the tip of the iceberg.

The drug supply is not what people think it is. Heroin is actually fentanyl (a synthetic opioid), which is actually various manmade analogs of fentanyl with drastically variable potencies. But fentanyl is too potent to take alone and is mixed with other substances. Some are inert – like baking soda – but recently we have seen an increase in fentanyl’s being “cut” with other psychoactive substances, heightening danger for drug users.

We are living through the worse opioid epidemic in history. More young people die from fentanyl overdose than any other single cause. Treating severe opioid use disorder is already challenging. How can things get worse? Xylazine.

Xylazine is one of the novel psychoactive substances being added to fentanyl, taking the deadliest substance ever widely distributed and making it even more addictive and more difficult to treat.

I work in multiple addiction medical settings – the emergency department, an inpatient medically monitored withdrawal setting (detox), and an outpatient setting. Xylazine negatively impacts patients in all areas. I try to help ease the suffering of individuals who are hoping to end the cycle of addiction in their lives through the most effective treatment available – typically medication treatment with suboxone, methadone, or vivitrol.

However, my ability – and the ability of all providers – to offer treatment is compromised due to the uncertainty of the current drug landscape and spread of xylazine and other mixed substances. When the drug supply contains more non-opioids than opioids, we can’t adequately treat withdrawal, which leads to poor outcomes, like patients’ leaving treatment or returning to use because their symptoms aren’t managed.

The reality is we are undertesting drugs. The drug supply is always changing based on supply of components, local resources, or individual dealer practices. Rather than monitoring for spikes in overdoses, we need to monitor the supply side to predict and prevent “bad batches” before overdoses can occur. We also need to know what we are treating to appropriately manage symptoms. I recently collaborated with Aegis Sciences Corporation to test for xylazine in our clinic, expecting about 10% of drug tests with fentanyl to also contain xylazine. Instead, over half of patients who were using fentanyl also had xylazine in their system – usually unbeknownst to the patient.

I recently participated in a discussion panel on the impact of designer drugs on providers hosted by Aegis. As I spoke with other experts on this panel, it became clear that reaction isn’t enough. In Tennessee, evidence-based medications are scarcely available for my patients – most of whom are uninsured due to the absence of Medicaid expansion. Most of my patients are also suffering from the stigma due to lack of understanding that is overshadowing evidence-based treatments.

Many say that people need to stop using drugs or that it’s a choice – but addiction is much more complex than that. Let’s recognize that, outside of our moral beliefs, there is a problem that needs to be addressed. We could reduce crime, increase the workforce, restore financial stability, reduce the number of people incarcerated, and save lives by treating opioid use disorder more aggressively. Only with compassion and prevention can we stem the tide of this crisis.

Now is the time to be aggressive in treating the opioid epidemic. Now is the time to increase access to effective treatments, including medications as well as preventive solutions like adequate testing and social support systems. Now is the time – before xylazine and other novel psychoactive substances render all treatments ineffective.


Ryan Alexander, D.O., MPH, is an addiction medicine physician and medical director for SUD Services at McNabb Center in Knoxville, Tenn. He serves on clinical faculty at the LMU-DeBusk College of Osteopathic Medicine and the University of Tennessee Graduate School of Medicine.