Contraceptive Pearl: Opioids, Xylazine, and Pregnancy
Written by Meghan Hynes
This Pearl is the second part of a three-part String of Pearls series that examines the effects of different substances on fetal development and recommends harm reduction strategies to reduce risks involved with substance use during pregnancy. You can read the first part on our website.
Numerous factors over recent years have led to an influx of novel illicit drugs in the US, including the “iron law of production,” in which intensifying law enforcement leads to a more potent drug supply. For example, government crackdown on prescription opioids and heroin in the early 2000s, higher costs of production, and other factors have led to the introduction of illicit fentanyl in the drug supply. Subsequent efforts to restrict the production of fentanyl have resulted in dozens of new analogues and adulterants entering the drug market. Xylazine, or “tranq”, is the newest and fastest-growing of these adulterants. Every emerging substance presents new, unknown risks for people who use drugs during pregnancy.
Opioids
Neonatal opioid withdrawal (NOW) can occur in infants exposed to opioids during pregnancy; however, NOW is treatable. There is conflicting evidence on whether opioids cause congenital abnormalities; in studies where a correlation was found, abnormalities remained rare and represented only a minute increase in absolute risk.1 People are more likely to overdose during pregnancy because their tolerance levels fluctuate. Some experts believe naloxone (Narcan) can cause fetal distress, although there is no documented evidence of this. Overdose response in pregnant people should follow standard protocols as the benefits of using naloxone far outweigh the risks.
Xylazine
Xylazine is a sedative used in veterinary medicine that is not approved for use in humans. Between 2021 and 2022, the number of fentanyl overdoses involving xylazine increased by more than 103% in the northeast and between 517% and 1,127% in the rest of the country.2 The effects of Xylazine on pregnancy have not been studied, but similar alpha-adrenergic agonists can decrease heart rate and blood pressure. Xlyazine can cause large, severe skin ulcers that can appear anywhere on the body, accompanied by necrotizing fasciitis. Xylazine increases the risk of overdose and complicates overdose response.
Recommendations
The abrupt cessation of opioids during pregnancy can cause fetal distress and increase the risk of early pregnancy loss. Clinicians should encourage patients who use opiates to initiate opioid agonist treatment. These medications are safe to use during pregnancy and throughout breast/chestfeeding.
Most people who find contaminants in their drugs change their behavior to avoid overdosing. Syringe Service Programs (SSPs) distribute xylazine and fentanyl test strips, and some SSPs have drug-checking machines that can produce detailed reports of contaminants. SSPs also offer free risk-reduction supplies, naloxone, care coordination, testing, and referrals to treatment.
Finally, the drug supply will continue to become increasingly toxic unless drugs are standardized, monitored, and regulated. Clinicians around the globe are joining the movement to decriminalize drugs to improve health outcomes for their patients.
Partner Resources:
- CDC Syringe Service Program Factsheet, CDC
- Syringe Service Program Finder, NASEN
- Decriminalize Drugs, Invest in Health Services Overview, Drug Policy Alliance
Sources:
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