Testing Used Drug Gear in Maryland: Fentanyl Dominated, and 80% Held Xylazine

Maryland recorded a record 2,912 drug overdose deaths from July 2020 to June 2021, and illicitly made fentanyl or fentanyl analogs were involved in 84%. Quickly spotting changes in the illicit drug supply — such as fentanyl replacing heroin — can improve warnings about new substances. So in June 2021, the Maryland Department of Health's Center for Harm Reduction Services (CHRS) and the National Institute of Standards and Technology (NIST) launched the Rapid Analysis of Drugs (RAD) program.

How RAD works

1. Staff at syringe services programs (SSPs, also called needle exchanges), wearing gloves, wipe or swab used drug paraphernalia — not syringes, for safety — from registered participants, who can also answer a short deidentified questionnaire about what they meant to buy.
2. Samples are mailed to NIST.
3. NIST analyzes them by direct analysis in real time mass spectrometry (DART-MS), which takes seconds per sample and can identify more than 1,100 drugs, cutting agents and related substances.
4. Within 48 hours, NIST reports results to CHRS and the SSPs, which share them with the participants.

Twelve SSPs near known trafficking routes were invited; eight joined. The other four cited political pushback and not enough staff or safe ways to handle paraphernalia.

What the tests found

From November 19, 2021, to August 31, 2022, staff collected 496 samples — mostly from plastic bags (54.8%), cookers (16.3%), capsules (11.7%), vials (6.9%) and pipes or straws (6.0%). No overdoses happened on-site during sampling.

Among the 364 fentanyl-positive samples, 84.4% also held another stimulant, sedative or benzodiazepine:

The analogs fluorofentanyl (23 samples) and fentanyl carbamate (6) nearly always appeared alongside fentanyl.

Substances found in paraphernalia samples, Maryland, November 2021–August 2022. From CDC's MMWR.

What people thought they were buying

Of 212 participants who meant to buy an opioid, 46.7% sought fentanyl alone, 50.9% fentanyl and/or heroin, and 2.4% heroin alone. Yet 87.7% were exposed to fentanyl, and 85.8% were unknowingly exposed to xylazine. More than half expected heroin might be present, but it turned up in fewer than 2% of samples.

Why it matters

• Xylazine was a surprise to program staff and participants alike. Combined with opioids, it may raise the risk of fatal breathing suppression and of soft tissue wounds, which can appear away from the injection site and even with smoking or snorting. Naloxone does not reverse xylazine, but it still reverses fentanyl and should be given for any suspected overdose.
• In response, Maryland updated overdose-response training for xylazine, strengthened wound care at SSPs — training and certifying nurses and setting standards for treating wounds in low-resource settings — and is studying links between skin infections and the drug supply.
• Because fentanyl is fast and potent, fentanyl-specific education remains vital: inject slowly, don't use alone, use fentanyl test strips, carry naloxone, and seek medical help for an overdose.
• After the pilot's success, CHRS opened RAD to all Maryland SSPs in 2022; 14 programs were taking part as of April 2023.

Timely, reliable data can help harm reduction programs respond faster, build participants' trust, and may make them likelier to seek treatment.

Limits: samples came from eight SSPs mostly serving people who inject opioids, so results may not apply elsewhere; syringes weren't tested; and DART-MS doesn't measure how much of each substance is present.

Sources

Based on Russell E, Sisco E, Thomson A, et al., "Rapid Analysis of Drugs: A Pilot Surveillance System To Detect Changes in the Illicit Drug Supply To Guide Timely Harm Reduction Responses — Eight Syringe Services Programs, Maryland, November 2021–August 2022," Morbidity and Mortality Weekly Report 72(17), CDC; a work of the United States government in the public domain.