Alabama will be the first state to use nitrogen in an execution. If it goes smoothly, other states are likely to follow.The planned execution of a death row inmate by the state of Alabama on Thursday evening will be carried out by a procedure that has never been used for capital punishment in the United States. The inmate, Kenneth Smith, who was convicted in a 1988 stabbing murder, will be put to death by inhaling nitrogen gas, a method known as nitrogen hypoxia.Supporters of the method say it is fast and painless. But earlier this month, the United Nations Human Rights Office urged Alabama to stop the execution, saying it could amount to torture and be in violation of human rights treaties that the United States has agreed to.Alabama would be the first state to use nitrogen hypoxia, but other states are interested in employing the method.What is nitrogen hypoxia?Hypoxia is a medical term for a state of insufficient oxygen in the body. Nitrogen, a colorless, odorless gas, makes up about 78 percent of the air inhaled by humans. But under the method of nitrogen hypoxia, the person breathes in only nitrogen, leading within minutes to unconsciousness and then death from lack of oxygen.How will the nitrogen be administered?According to the protocol released by Alabama prison officials, members of the “execution team” will strap Mr. Smith to a gurney in the state’s execution chamber in Atmore. A mask will be placed on his head and nitrogen will be released into it, depriving him of oxygen. Many experts compare this process to putting a plastic bag over someone’s head, although in that situation, the person would be inhaling carbon dioxide rather than nitrogen.Why is this method being used now?The standard method of execution since the 1980s has been lethal injection of drugs that stop the heart. But states have had problems with lethal injections for years.Some states have had trouble obtaining sufficient quantities of drugs for lethal injections.Even when they have the proper dosage, many executions have been botched because the team that administers the injection has been unable to locate appropriate veins.This is what happened to Mr. Smith in Alabama. He was to be executed by lethal injection in November 2022, but a team of people repeatedly failed to properly insert an intravenous line.This problem often occurs because medical ethics rules prohibit doctors and other health care professionals from assisting in an execution. So the injections are usually administered by inexperienced prison workers, said Dr. Joel Zivot, an associate professor of anesthesiology at Emory School of Medicine and an expert on physician participation in lethal injection.Lethal injection also involves drugs that, if given incorrectly, can result in significant pain and suffering.Supporters of using nitrogen hypoxia believe it is an easier and more humane alternative because it does not require an injection and is swift and painless.Has nitrogen hypoxia been used in other situations?Several years ago, Dr. Philip Nitschke, an Australian doctor and founder of Exit International, which advocates medically assisted suicide, developed a pod in which a patient could flip a switch and release the flow of nitrogen. He recently told The New York Times that he had witnessed about 50 deaths due to nitrogen hypoxia.Is there research on the impact of nitrogen on humans?Very little, which is why some people feel it should not be used in state executions. Most of the reports in medical journals are about nitrogen exposure in leaks and industrial accidents that killed workers, and in suicide attempts.In a 1963 experiment to study the effect of brief hypoxia on three healthy volunteers, “most of them had seizures within 15 to 20 seconds of breathing pure nitrogen,” Dr. Zivot said.What are the drawbacks to this method?Doctors say that the prisoner could vomit in his mask, not only causing him to choke but also loosening the seal, which would allow oxygen to rush in, diluting the nitrogen.Mr. Smith’s lawyers have argued that this is a likely scenario for Mr. Smith, who, they said, has been vomiting continuously in recent days, which they associate with the PTSD he has suffered after the 2022 botched execution.Alabama corrections officials said that Mr. Smith would not be given food within 20 hours of the execution, to reduce the likelihood of vomiting.Mr. Smith’s head and body will be tightly bound to the gurney, to prevent thrashing and a displacement of the mask. It is not known whether he will be given a sedative before the execution, which would further reduce the likelihood of thrashing. But Dr. Zivot noted that sedating a patient is a medical procedure and would typically require a physician’s involvement.Veterinarians have generally stopped using nitrogen to euthanize animals, who showed severe signs of distress. Critics and supporters of the method strongly disagree over whether a human would feel distress with nitrogen.“Nobody really knows what’s going to happen,” said Dr. Jeffrey Keller, president of the American College of Correctional Physicians. “So will he choke? Will he vomit? Will the mask fit or will the nitrogen leak out? Will that nitrogen harm anybody else who is standing nearby? Nobody knows any of this. It’s an experiment.”

Tianeptine, found at convenience stores, at smoke shops and online, can mimic an opioid. It is among a growing class of substances that are difficult to control.The young father headed across the parking lot to join the other parents meeting their children’s new preschool teachers. After a few steps, he began sweating and twitching. As the sky reeled, he staggered back to the car, desperate to lie down in the back seat and breathe, hidden by tinted windows.“Did you take something?” his wife, Anne, shouted at him while dialing 911. Eric, 26, had completed rehab earlier in the summer.“The shot! The shot!” he groaned, just before he hit the ground and blacked out.In the emergency room of a nearby hospital in southern New Jersey, doctors tried to revive him with a defibrillator.“What’s he on?” they yelled at Anne.She showed them a shot-size bottle of the cherry-flavored elixir she had fished out of the car. It was labeled Neptune’s Fix, which Eric had bought at a local convenience store.“What the hell is that?” a doctor asked.Neptune’s Fix features an ingredient called tianeptine — popularly known as gas-station heroin.Often sold as a dietary supplement and promoted by retailers as a mood booster and focus aid, tianeptine is among a growing, unregulated class of potentially addictive products available in gas stations, convenience stores and smoke shops and across the internet. They typically include synthetic pharmaceuticals and plant-derived substances.Some, like kratom and phenibut, can be addictive and, in rare cases, fatal. They often originate in other countries, including Indonesia and Russia, where they are commonly used, even prescribed, for mood management. But the Food and Drug Administration has not approved them as medicines in the United States.“Tianeptine is an emerging threat,” said Kaitlyn Brown, clinical managing director of America’s Poison Centers, which represents and collects data from 55 centers nationwide. “We have people who are able to get a substance that’s not well regulated, that has abuse potential and that, in high doses, can cause similar effects to opioids, leading to really harmful outcomes.”At least nine states have banned or severely restricted tianeptine, including Florida, Michigan and Ohio. In late November, the F.D.A. issued a nationwide alert about Neptune’s Fix specifically and tianeptine in general, telling people not to take it and warning that it had been associated with overdoses and deaths.Tianeptine, which also appears as a concentrated powder or an ingredient in products such as Tianaa, Zaza and Pegasus, “is illegally sold with claims to improve brain function and treat anxiety, depression, pain, opioid use disorder and other conditions,” the agency’s warning said.The F.D.A. loosely oversees dietary supplements, an expanding universe of some 50,000 products that includes minerals, vitamins and compounds like melatonin. But the agency does not evaluate supplements for safety or effectiveness; it can only forbid manufacturers to market them as medical treatments. It requires product labels making health claims to list ingredients and include boilerplate disclaimers, such as noting that the product has not been reviewed by the F.D.A. The agency does not review those labels before a product is released.Because the F.D.A.’s enforcement powers are limited by law, many products with tianeptine have long skirted labeling requirements. Although the F.D.A. has explicitly said, for example, that tianeptine does not qualify as a dietary supplement, the labels of some brands, like Tianaa, still make that claim.“There are now at least a dozen different products that are foreign drugs being openly marketed as dietary supplements right under the F.D.A.’s eyes, without them being able to stop the sales,” said Dr. Pieter Cohen, an associate professor at Harvard Medical School who studies the regulation of supplements.Tianeptine is a drug developed by French researchers in the 1960s as an antidepressant. It is approved in low doses for that use in many European, Asian and Latin American countries.But at higher doses, it also works much as an opioid does, delivering short-lived euphoria. In the United States, many people take tianeptine under the widespread, mistaken belief that it is a safe alternative to street opioids like fentanyl or heroin, or even a way to taper off using them. On social media sites like Reddit, its merits are hotly debated, with more than 5,000 people subscribing to a “Quitting Tianeptine” forum.“People develop a tolerance very quickly, and so they rapidly start advancing the dosing,” said Dawn Sollee, a clinical toxicologist and director of the Poison Control Center in Jacksonville, Fla. “They will set alarms to wake themselves every two hours to take tianeptine pills so they do not go into withdrawal. And then they have to keep taking more and more just to stay functional.”Kratom leaves for sale in a market in Bangkok in 2021.Narong Sangnak/EPA, via ShutterstockExpenses can mount swiftly, along with dangers. At a convenience store in Montclair, N.J., recently, 15 capsules of Tianaa Red cost $34. A bottle of Neptune’s Fix, which comes in lemon, tropical, cherry or chocolate-vanilla flavor, runs about $16. A salesman at a roadside smoke shop farther west said customers typically purchased 12-bottle boxes. A salesman at another roadside shop said that one customer bought 10 boxes each week — whether for resale or personal use, he did not know.Determining the number of cases of tianeptine abuse is challenging, because hospitals do not test for it. Reports to poison-control centers are voluntary, typically made by a worried relative, so officials say the numbers represent a drastic undercount.But case reports are increasing. In 2013, only four cases of tianeptine exposure were reported nationwide. In 2023, 391 cases were reported, according to America’s Poison Centers. New Jersey, which typically has one report a year, received 27 in 2023, with patients ranging in age from 20 to 69.“Some people apparently think it can help with chronic pain instead of having to use an opioid, which might explain the older demographic,” said Dr. Diane Calello, medical director of the New Jersey Poison Control Center.Similarly to many illicit drugs, tianeptine is often sloppily mixed with unlabeled ingredients, such as potent synthetic cannabinoids. That is one reason overdose symptoms appear to range widely, poison-control medical directors said, including clamminess, nausea, low blood pressure and unconsciousness as well as seizures and severe stomach cramps.Sometimes naloxone, a drug that reverses opioid overdoses, can be effective in reviving patients, they said — and sometimes not. At least four deaths have been associated with tianeptine.About a year ago, Dr. Raymond Pomm, an addiction psychiatrist at Gateway Community Services in Jacksonville, saw his first tianeptine patient. To treat the patient’s withdrawal symptoms, he tried buprenorphine, a medication that dulls opioid cravings. He said he found that it helped patients to manage withdrawal from tianeptine and to maintain abstinence. “Since it was being sold in stores, I thought, It can’t be that bad,” said Eric, a man who suffered severe tianeptine symptoms, about Neptune’s Fix.Hannah Beier for The New York TimesLast summer, after Eric completed rehab for kratom, a potentially addictive herb from Southeast Asia that is readily available in convenience stores and smoke shops, doctors recommended medication for anxiety and depression. But Eric, a corporate salesman from a suburb in South Jersey, was determined to stay away from mood-altering prescriptions, to which he had been addicted in the past.At a tobacco shop, he spotted Neptune’s Fix. A salesman said it could help with his mood and would not hook him.“Since it was being sold in stores, I thought it can’t be that bad,” said Eric, who, like Anne, asked to be identified by his middle name to protect his family’s privacy. “You know, an energy drink type of thing.”After tossing back a shot, he felt better almost immediately: more talkative, happy, confident.But soon, Eric said, “I couldn’t stop taking it.”Within a few weeks, he was up to five bottles a day, spending over $400 a week. His energy was flagging. Though he was a former college athlete still accustomed to working out daily, he now could not even get himself to the gym.When he tried quitting cold turkey, withdrawal hit him with cold sweats, muscle aches, restlessness and irritability.Weeks after he collapsed in the preschool parking lot, doctors from the New Jersey Poison Control Center tested the contents of his Neptune’s Fix bottles. Results included synthetic cannabinoids and other unlisted ingredients as well as tianeptine.The F.D.A. sent warnings in 2021 and 2022 to two companies that it said were “illegally marketing tianeptine products as dietary supplements and unapproved drugs.”But enforcement requires huge resources, in part because manufacturers and purveyors can be difficult to track down. An inquiry from The New York Times to the makers of Neptune’s Fix submitted through its website received no response. The Sheridan, Wyo., location listed on the company’s bottles is an address for a registration agent for numerous companies.Regulatory experts disagree about how the F.D.A. should grapple effectively with tianeptine and other supplements. Some say the agency should establish a strict registry of approved supplements.In interviews, some poison-center directors did not endorse a full ban of tianeptine, saying that could lead to dangerous underground trafficking. Educating emergency responders and consumers about inherent risks in such products would be a more effective course, they said.Getting tianeptine off store shelves, they added, would be not only a staggering task but also of limited utility because customers could simply buy it from the most convenient store of all — the internet.While Eric was recovering from tianeptine poisoning, Anne stormed over to the local smoke shop where he had bought it.“My husband’s in the hospital because of this product and you’re still going to keep it on the shelves?” she yelled.“Yes,” she said the owner replied, “because people want it and we need to make money.”

The court will decide whether Purdue’s owners can gain permanent immunity from future opioid lawsuits in exchange for payments up to $6 billion.In 2014, when the first opioid lawsuits were filed against Purdue Pharma, Tiffinee Scott’s daughter was still years away from her fatal overdose from addictive prescription painkillers, including Purdue’s OxyContin, which she was taking to manage sickle cell pain.That year, Dede Yoder’s teenage son was struggling with an addiction that began with an OxyContin prescription for a sports injury. He would die from an overdose in 2017, after attempting rehab eight times.It would be years before Gary Carter’s son, who had been filching his grandparents’ OxyContin, would die from an overdose of fentanyl, an illicit opioid that many people who became addicted to prescription painkillers eventually turned to over the past decade.The three families and others who have ended up suing Purdue shared their stories in letters to the Supreme Court, which will hear oral argument Monday on the remaining sticking point in the yearslong effort to settle litigation that has ballooned into nearly 3,000 cases. A multi-billion-dollar agreement is at stake.A ruling upholding the disputed provision would finally start the flow of payments from the company and its owners — members of the billionaire Sackler family — to cities, states, tribes and individuals to help them cope with the costs of the ongoing opioid crisis. It would also allow Purdue to emerge from bankruptcy restructuring as a public benefit company.A ruling against the measure could blow up the painstakingly negotiated settlement, leaving the fate of the company and the urgently sought payments up in the air.The court will consider the legality of a condition demanded by the Sacklers and approved by a bankruptcy judge: In exchange for paying up to $6 billion, the Sacklers insist on being shielded from civil lawsuits that anyone else might want to bring against them involving Purdue and opioids.That liability shield is standard for businesses that file for bankruptcy, as Purdue has done. But the Sacklers have not filed for bankruptcy. Still, they argue that because the Purdue settlement relies on their personal contributions, Purdue’s liability protection should also extend to them.The situation has created an agonizing irony for many who have lost loved ones to opioids. Desperate for funds to pay off their debts and address the addiction crisis, many support giving the Sacklers the sweeping legal pass.“NO ONE wants to see the Sacklers pay the full price more than me,” Cheryl Juaire, who organized grieving parents, wrote to the court. “I lost TWO SONS as a result of their actions. But the only thing that will make my personal tragedy worse is to know that others will suffer the way I do every day.”The Stamford, Conn., headquarters of Purdue Pharma, which is awaiting a Supreme Court ruling on whether nearly 3,000 opioid lawsuits against it can be settled.Frank Franklin II/Associated PressAn overwhelming majority of claimants reached that conclusion more than two years ago, voting in favor of the settlement plan, including liability immunity for the Sacklers. They said they feared that protracted litigation would devour money that they have long needed.But an arm of the Justice Department that monitors bankruptcy proceedings objected, along with a handful of other parties, arguing that precluding people from having their day in court was both unconstitutional and outside the power of a bankruptcy court.Last summer, after a federal appeals court upheld the Sackler shields, the Justice Department division, the U.S. Trustee Program, petitioned the Supreme Court to take up the matter.The speed with which the court scheduled the case may reflect its awareness of the opioid problem. But legal experts said its ruling would be unlikely to dwell on the public health crisis. The court, they said, will focus narrowly on the liability shield, an increasingly popular, though contentious, bankruptcy tactic.“I’m sure, though, that even if the opioid crisis doesn’t show up anywhere in the opinion, the court has to be bearing in mind that cities, states and individuals have been desperately waiting for these funds. They need to know the answer to this question so they can figure out what to do next,” said Adam Zimmerman, who teaches mass tort law at the University of Southern California’s Gould School of Law.Though numerous pharmaceutical companies have been sued for their roles in the opioid epidemic, the Sacklers and Purdue loom large in the story of the complex, decades-old crisis. Their signature drug, OxyContin, approved by the Food and Drug Administration in late 1995, became a game changer in a new market hungry for prescription painkillers. To the medical establishment that was then beginning to recognize pain as a “fifth vital sign,” long-acting OxyContin looked like a wondrous medication.Purdue became known for lavish sales conferences, at which pain medicine physicians, trained and hired by the company, would falsely claim that the risk of addiction to OxyContin was extremely low. By 2007, Purdue and three of its top executives had paid fines of $634.5 million and pleaded guilty to federal criminal charges for misleading regulators, doctors and patients about the drug’s potential for abuse.The steep fines did little to deter Purdue from continuing to aggressively market OxyContin.Eventually, attention became focused on the Sacklers themselves, some of whom served as Purdue board members and made large charitable donations to medical schools and museums. In exchange, the institutions renamed buildings after the Sacklers. But as the family saga became featured in books, television series and documentaries and their notoriety grew, most stripped the Sackler name from their properties and dissociated themselves from Purdue’s owners.The size of the Sacklers’ fortune from OxyContin has long been a mystery. An independent audit commissioned by Purdue for the bankruptcy court found that the Sacklers withdrew about $10.5 billion from Purdue between 2008 and 2017, of which they paid more than 40 percent in taxes. The $6 billion settlement offer, the Sacklers say, represents most of the profit from the drug during that period.As lawsuits against Purdue and the Sacklers rapidly accrued, in 2019 Purdue sought restructuring in bankruptcy court, a move that automatically suspended all lawsuits against the company. The tactic was the first step on the path leading toward the Supreme Court.Dan A. Polster, a federal judge in Cleveland, was assigned to manage thousands of opioid cases nationwide.Maddie McGarvey for The New York TimesMost other companies that have been sued over their role in the opioid crisis — drug manufacturers, distributors and retailers — have reached settlements and are starting to make payments. But the opioid tragedy has not receded. Though production of prescription painkillers slowed, cheap heroin and then fentanyl rushed in to fuel an ever-growing demand. During a 12-month period ending in June, overdose fatalities from opioids and other drugs, including cocaine and methamphetamine, were predicted to surpass 111,000, according to provisional federal data.Whether the billions of dollars in the Purdue settlement and others will have a meaningful impact on addiction and overdose fatality rates remains to be seen. In January 2018, Dan A. Polster, a federal judge in Cleveland assigned to oversee nationwide opioid settlements, asked whether a court was, in fact, the proper place to grapple with a public health crisis that had passed through the hands of federal and state regulators, physicians, hospitals and insurers as well as the pharmaceutical industry.“The federal court is probably the least likely branch of government to try and tackle this, but candidly, the other branches of government, federal and state, have punted,” he said.Now, nearly six years after his remarks, with the Supreme Court about to wade in, the national opioid litigation may be edging toward conclusion. But many health and legal experts believe it will not resolve the addiction crisis that it was intended to address.“It’s easy for people to think, ‘Hey, we’ll go to court, and we’ll solve the problem,’ but that also assumes that the way you solve a public health crisis is just by handing out money,” said Abbe R. Gluck, a Yale Law School professor and an author of a forthcoming article on unorthodox uses of bankruptcy.Congress and oversight agencies need to step up, Ms. Gluck said. “When it comes to opioids,” she added, “there’s a lot more that has to happen that litigation can’t touch.”

As states and counties spend the first wave of billions of dollars from the pharmaceutical industry, public health groups are challenging how some funds are being used.After years of litigation to hold the pharmaceutical industry accountable for the deadly abuse of prescription painkillers, payments from what could amount to more than $50 billion in court settlements have started to flow to states and communities to address the nation’s continuing opioid crisis.But though the payments come with stacks of guidance outlining core strategies for drug prevention and addiction treatment, the first wave of awards is setting off heated debates over the best use of the money, including the role that law enforcement should play in grappling with a public health disaster.States and local governments are designating millions of dollars for overdose reversal drugs, addiction treatment medication, and wound care vans for people with infections from injecting drugs. But law enforcement departments are receiving opioid settlement money for policing resources like new cruisers, overtime pay for narcotics investigators, phone-hacking equipment, body scanners to detect drugs on inmates and restraint devices.“I have a great deal of ambivalence towards the use of the opioid money for that purpose,” said Chester Cedars, chairman of Louisiana’s advisory opioid task force and president of St. Martin Parish. The state’s directives say only “law enforcement expenditures related to the opioid epidemic,” added Mr. Cedars, a retired prosecutor. “That is wide open as to what that exactly means.”On Monday, 133 addiction medicine specialists, legal aid groups, street outreach groups and other organizations released a list of suggested priorities for the funds. Their recommendations include housing for people in recovery and expanding access to syringe exchange programs, personal use testing strips for fentanyl and xylazine, and medication that treats addiction.They expressly stated that no funds “should be spent on law enforcement personnel, overtime or equipment.”“Law enforcement already gets a lot of funding, and I’m sure they would say it’s never enough,” said Tricia Christensen, an author of the proposed priorities, who is the policy director at Community Education Group, which has been tracking opioid settlement money across Appalachia. But the opioid money, she said, “is really unique.”Law enforcement departments have been receiving opioid settlement money for policing resources like new cruisers, overtime pay, phone-hacking equipment, body scanners and restraint devices.Whitney Curtis for The New York TimesGroups that monitor opioid settlements use various criteria to estimate the total payout. But even employing the most conservative tabulation, the final amount could well be north of $50 billion when pending lawsuits are resolved, notably the multibillion-dollar Purdue bankruptcy plan, which the Supreme Court temporarily paused last week.At first glance, that looks like a fabulous trove of money. In reality, it will be parceled out over 18 years and is already dwarfed by the behemoth dimensions of the opioid crisis, now dominated by illicit fentanyl and other drugs.The spectacle of states as well as thousands of cities, counties and towns all struggling to determine the most effective uses of these desperately needed funds is raising many questions.Underlying the wrangling is a push for greater transparency in awarding the money and a determination not to repeat the mistakes of the Big Tobacco settlement 25 years ago. State governments have used most of the $246 billion from tobacco companies to plug budget holes and pay for other projects, and reserved relatively little to redress nicotine-related problems.Now, states and local governments have committees to determine appropriate allocation of the opioid money. Sheriffs and police officials comprise less than a fifth of the members on those task forces, according to a recent analysis by KFF Health News, Johns Hopkins University and Shatterproof, a national nonprofit that focuses on addiction.But public sentiment in many communities favors ridding the streets of drug dealers as a means of abating the crisis.When Samuel Sanguedolce, the district attorney of Luzerne County in Pennsylvania, presented his budget to the County Council in November, he made a pitch for some of the county’s settlement money, about $3.4 million so far.“With 10 more detectives, I could arrest those cases around the clock,” he said, referring to drug dealers. “I think this is a good way to use money that resulted from this opioid crisis to assist those detectives without putting it on the taxpayers.”“And I’ve asked not just for detectives,” he continued. “But hiring people, of course, costs money, in the way that they need guns and vests and computers and cars.”In many areas of the country, the lines between law enforcement and health care can be somewhat blurred: Police and sheriffs’ departments are also emergency responders, trained to administer overdose reversal drugs. Louisiana is dedicating 20 percent of its opioid money to parish sheriffs.OnPoint NYC, an overdose prevention center and safe injection site.Seth Wenig/Associated PressSheriff K.P. Gibson of Acadia Parish, who represents sheriffs on Louisiana’s opioid task force, said that he intended to use the $100,000 his department is set to receive for “medical needs” of people in the jail, including various opioid treatments and counseling. The goal, he said, is to help inmates become “productive citizens within our community,” once they are released.Public health officials and addiction treatment specialists are also concerned about another use of the money: grants for faith-based rehab programs that prohibit federally approved medications like Suboxone and methadone, which blunt cravings for opioids.“I would be open to a faith-based cancer program, but not one that doesn’t let you take effective medicines to treat the cancer,” said Dr. Joshua Sharfstein, a professor at Johns Hopkins Bloomberg School of Public Health, which has released its own guidance principles for the settlement funds.Throughout the years of negotiating opioid settlements, lawyers for states, tribes and local governments and those defending drug distributors, manufacturers and pharmacy chains struggled to avoid the pitfalls that emerged from the Big Tobacco litigation.This time, local governments have struck agreements with state attorneys general over the allocation of the money. Legislatures are largely excluded from most of the funds.Johns Hopkins praised Rock County, Wis., as a jurisdiction that strove to get a full picture of local needs for the money: It put together a working group to review evidence-based literature and conducted surveys and meetings to elicit community suggestions.In North Carolina, county governments receive 85 percent of the funds, which have reached nearly $161 million so far. Having signed onto the core principles worked up with the attorney general, the counties have great discretion in spending their allotments.“When you look at who addresses the issues of the opioid epidemic, it’s addressed locally by E.M.S., social services and jails. Those are all county functions in North Carolina, so that’s why it made sense for them to get the bulk of the resources,” said Josh Stein, the North Carolina attorney general, who helped negotiate the national opioid settlements.Dressing a skin wound in the Kensington neighborhood of Philadelphia.Matt Rourke/Associated PressEach county is establishing its own priorities. Stanly County, he said, is setting up teams to reach people who have just survived overdoses, hoping to connect them with services. Mecklenburg County has directed some of its funding for post-recovery education and job-training programs.Such uses can help to lift a community stricken by addiction, said Ms. Christensen, whose group monitors opioid settlements for 13 states. “I really subscribe to the idea that overdoses are often ‘deaths of despair’ — that the reason many folks spiral into chaotic drug use has a lot to do with what has happened to them and their lack of opportunities,” she said. “So how can we invest in the community to prevent that from happening generation after generation? That’s why I think community input is so important in this process.”The groups that released the new set of priorities cited examples of promising use of the funds. Michigan’s plans include adding rooms in hospitals so that new mothers can stay with infants born with neonatal abstinence syndrome. Kentucky is giving $1 million to four legal aid groups to represent people with opioid-related cases.“I was blown away by that,” said Shameka Parrish-Wright, executive director of VOCAL-KY, a community group that worked on the priorities documents. Ms. Parrish-Wright, a former candidate for Louisville mayor who had been addicted to drugs, homeless and incarcerated, added: “Those legal entities are really helpful in making sure we deal with paraphernalia charges and evictions. People coming out of treatment are sometimes discriminated against because of those charges and can’t get housing or jobs.”VOCAL-KY has not applied for settlement money but works closely with groups that do. Its members attend meetings held by Kentucky’s opioid task force. “Knowing that Black and brown and poor white communities are dealing with it the worst, we pushed them to have another town hall in those communities,” Ms. Parrish-Wright said.With Big Tobacco’s cautionary tale shadowing these debates, the issue of accountability looms. Who ensures that grantees spend their money appropriately? What sanctions will befall those who color outside the lines of their grants?So far, the answers remain to be seen. Christine Minhee, a lawyer who runs the Opioid Settlement Tracker, which analyzes state approaches to spending the funds, noted that on that question, the voluminous legal agreements could be opaque.“But between the lines, the settlement agreements themselves imply that the political process, rather than the courts, will bear the actual enforcement burden,” she said. “This means that the task of enforcing the spirit of the agreement — making sure that settlements are spent in ways that maximize lives saved — is left to the rest of us.”

As states and counties spend the first wave of billions of dollars from the pharmaceutical industry, public health groups are challenging how some funds are being used.After years of litigation to hold the pharmaceutical industry accountable for the deadly abuse of prescription painkillers, payments from what could amount to more than $50 billion in court settlements have started to flow to states and communities to address the nation’s continuing opioid crisis.But though the payments come with stacks of guidance outlining core strategies for drug prevention and addiction treatment, the first wave of awards is setting off heated debates over the best use of the money, including the role that law enforcement should play in grappling with a public health disaster.States and local governments are designating millions of dollars for overdose reversal drugs, addiction treatment medication, and wound care vans for people with infections from injecting drugs. But law enforcement departments are receiving opioid settlement money for policing resources like new cruisers, overtime pay for narcotics investigators, phone-hacking equipment, body scanners to detect drugs on inmates and restraint devices.“I have a great deal of ambivalence towards the use of the opioid money for that purpose,” said Chester Cedars, chairman of Louisiana’s advisory opioid task force and president of St. Martin Parish. The state’s directives say only “law enforcement expenditures related to the opioid epidemic,” added Mr. Cedars, a retired prosecutor. “That is wide open as to what that exactly means.”On Monday, 133 addiction medicine specialists, legal aid groups, street outreach groups and other organizations released a list of suggested priorities for the funds. Their recommendations include housing for people in recovery and expanding access to syringe exchange programs, personal use testing strips for fentanyl and xylazine, and medication that treats addiction.They expressly stated that no funds “should be spent on law enforcement personnel, overtime or equipment.”“Law enforcement already gets a lot of funding, and I’m sure they would say it’s never enough,” said Tricia Christensen, an author of the proposed priorities, who is the policy director at Community Education Group, which has been tracking opioid settlement money across Appalachia. But the opioid money, she said, “is really unique.”Law enforcement departments have been receiving opioid settlement money for policing resources like new cruisers, overtime pay, phone-hacking equipment, body scanners and restraint devices.Whitney Curtis for The New York Times Groups that monitor opioid settlements use various criteria to estimate the total payout. But even employing the most conservative tabulation, the final amount could well be north of $50 billion when pending lawsuits are resolved, notably the multibillion-dollar Purdue bankruptcy plan, which the Supreme Court temporarily paused last week. At first glance, that looks like a fabulous trove of money. In reality, it will be parceled out over 18 years and is already dwarfed by the behemoth dimensions of the opioid crisis, now dominated by illicit fentanyl and other drugs.The spectacle of states as well as thousands of cities, counties and towns all struggling to determine the most effective uses of these desperately needed funds is raising many questions.Underlying the wrangling is a push for greater transparency in awarding the money and a determination not to repeat the mistakes of the Big Tobacco settlement 25 years ago. State governments have used most of the $246 billion from tobacco companies to plug budget holes and pay for other projects, and reserved relatively little to redress nicotine-related problems.Now, states and local governments have committees to determine appropriate allocation of the opioid money. Sheriffs and police officials comprise less than a fifth of the members on those task forces, according to a recent analysis by KFF Health News, Johns Hopkins University and Shatterproof, a national nonprofit that focuses on addiction.But public sentiment in many communities favors ridding the streets of drug dealers as a means of abating the crisis.When Samuel Sanguedolce, the district attorney of Luzerne County in Pennsylvania, presented his budget to the County Council in November, he made a pitch for some of the county’s settlement money, about $3.4 million so far.“With 10 more detectives, I could arrest those cases around the clock,” he said, referring to drug dealers. “I think this is a good way to use money that resulted from this opioid crisis to assist those detectives without putting it on the taxpayers.”“And I’ve asked not just for detectives,” he continued. “But hiring people, of course, costs money, in the way that they need guns and vests and computers and cars.”In many areas of the country, the lines between law enforcement and health care can be somewhat blurred: Police and sheriffs’ departments are also emergency responders, trained to administer overdose reversal drugs. Louisiana is dedicating 20 percent of its opioid money to parish sheriffs.OnPoint NYC, an overdose prevention center and safe injection site.Seth Wenig/Associated PressSheriff K.P. Gibson of Acadia Parish, who represents sheriffs on Louisiana’s opioid task force, said that he intended to use the $100,000 his department is set to receive for “medical needs” of people in the jail, including various opioid treatments and counseling. The goal, he said, is to help inmates become “productive citizens within our community,” once they are released.Public health officials and addiction treatment specialists are also concerned about another use of the money: grants for faith-based rehab programs that prohibit federally approved medications like Suboxone and methadone, which blunt cravings for opioids.“I would be open to a faith-based cancer program, but not one that doesn’t let you take effective medicines to treat the cancer,” said Dr. Joshua Sharfstein, a professor at Johns Hopkins Bloomberg School of Public Health, which has released its own guidance principles for the settlement funds.Throughout the years of negotiating opioid settlements, lawyers for states, tribes and local governments and those defending drug distributors, manufacturers and pharmacy chains struggled to avoid the pitfalls that emerged from the Big Tobacco litigation.This time, local governments have struck agreements with state attorneys general over the allocation of the money. Legislatures are largely excluded from most of the funds.Johns Hopkins praised Rock County, Wis., as a jurisdiction that strove to get a full picture of local needs for the money: It put together a working group to review evidence-based literature and conducted surveys and meetings to elicit community suggestions.In North Carolina, county governments receive 85 percent of the funds, which have reached nearly $161 million so far. Having signed onto the core principles worked up with the attorney general, the counties have great discretion in spending their allotments.“When you look at who addresses the issues of the opioid epidemic, it’s addressed locally by E.M.S., social services and jails. Those are all county functions in North Carolina, so that’s why it made sense for them to get the bulk of the resources,” said Josh Stein, the North Carolina attorney general, who helped negotiate the national opioid settlements.Dressing a skin wound in the Kensington neighborhood of Philadelphia.Matt Rourke/Associated PressEach county is establishing its own priorities. Stanly County, he said, is setting up teams to reach people who have just survived overdoses, hoping to connect them with services. Mecklenburg County has directed some of its funding for post-recovery education and job-training programs.Such uses can help to lift a community stricken by addiction, said Ms. Christensen, whose group monitors opioid settlements for 13 states. “I really subscribe to the idea that overdoses are often ‘deaths of despair’ — that the reason many folks spiral into chaotic drug use has a lot to do with what has happened to them and their lack of opportunities,” she said. “So how can we invest in the community to prevent that from happening generation after generation? That’s why I think community input is so important in this process.”The groups that released the new set of priorities cited examples of promising use of the funds. Michigan’s plans include adding rooms in hospitals so that new mothers can stay with infants born with neonatal abstinence syndrome. Kentucky is giving $1 million to four legal aid groups to represent people with opioid-related cases.“I was blown away by that,” said Shameka Parrish-Wright, executive director of VOCAL-KY, a community group that worked on the priorities documents. Ms. Parrish-Wright, a former candidate for Louisville mayor who had been addicted to drugs, homeless and incarcerated, added: “Those legal entities are really helpful in making sure we deal with paraphernalia charges and evictions. People coming out of treatment are sometimes discriminated against because of those charges and can’t get housing or jobs.”VOCAL-KY has not applied for settlement money but works closely with groups that do. Its members attend meetings held by Kentucky’s opioid task force. “Knowing that Black and brown and poor white communities are dealing with it the worst, we pushed them to have another town hall in those communities,” Ms. Parrish-Wright said.With Big Tobacco’s cautionary tale shadowing these debates, the issue of accountability looms. Who ensures that grantees spend their money appropriately? What sanctions will befall those who color outside the lines of their grants?So far, the answers remain to be seen. Christine Minhee, a lawyer who runs the Opioid Settlement Tracker, which analyzes state approaches to spending the funds, noted that on that question, the voluminous legal agreements could be opaque.“But between the lines, the settlement agreements themselves imply that the political process, rather than the courts, will bear the actual enforcement burden,” she said. “This means that the task of enforcing the spirit of the agreement — making sure that settlements are spent in ways that maximize lives saved — is left to the rest of us.”

Critics say a fierce law-and-order approach could undermine public health goals and advances in addiction treatment.Three teenage girls were found slumped in a car in the parking lot of a rural Tennessee high school last month, hours before graduation ceremonies. Two were dead from fentanyl overdoses. The third, a 17-year-old, was rushed to the hospital in critical condition. Two days later, she was charged with the girls’ murders.Listen to This ArticleFor more audio journalism and storytelling,

The decision gives the Purdue Pharma owners long-sought protection, but it will release billions of dollars from their fortune to states and communities to help cope with the costs of addiction.Members of the Sackler family, the billionaire owners of Purdue Pharma, will receive full immunity from all civil legal claims — current and future — over their role in the company’s prescription opioids business, a federal appeals court panel ruled on Tuesday.The ruling gives the family the sweeping protection that it has been demanding for years, in exchange for payment of up to $6 billion of the family’s fortune to help address the ongoing ravages of the opioid crisis.That money, plus the company’s initial outlay of $500 million, can now begin to be dispensed to states and communities for addiction treatment and prevention programs, needs that soared during an epidemic that has grown far beyond abuse of Purdue’s signature prescription painkiller drug, OxyContin.Unless it is successfully appealed to the Supreme Court — an unlikely prospect, legal experts said — the new ruling will close the door on Purdue’s hotly contended bankruptcy restructuring, which began nearly four years ago. The bankruptcy is at the core of a plan intended to resolve thousands of opioid cases against the company nationwide, plus roughly 400 against individual Sackler family members.According to the plan, Purdue would be restructured into a new entity called Knoa Pharma that will manufacture medications for addiction reversal and treatment as well as continue to produce other drugs, including OxyContin. It will be overseen by a public board. Over time, Knoa Pharma is expected to contribute at least many hundreds of millions dollars more to plaintiffs.Some close observers of the Purdue case applauded the ruling, calling it a pragmatic reading that could now loosen up billions of dollars for states, local governments, tribes and individuals who sued Purdue for its early and aggressive role in marketing OxyContin as a nonaddictive pain treatment.“It’s time to put this bankruptcy behind us. Victims have been waiting for too long to recover,” said Ryan Hampton, an advocate for opioid victims who served as the co-chairman of the Purdue creditor’s committee.He added: “The system is far from perfect, but the true injustice will be if this victims’ settlement is held up any longer.”But others said the Sacklers had received a significant pass. “Bankruptcy was not meant to be an alternative justice system for powerful corporations and their superrich owners. But that is the effect and perception when courts read the law to provide extraordinary protections well beyond what Congress authorized,” said Melissa B. Jacoby, a law professor at the University of North Carolina at Chapel Hill.A bankruptcy filing typically puts a temporary halt on a company’s creditors, including on lawsuits. The major issue in this case was that even though Purdue had filed for bankruptcy, the Sacklers, as individuals, had not. As a result, plaintiffs who fought the plan contended, the Sacklers should not receive the benefit of their company’s liability protection.The Sacklers stepped down from Purdue’s board of directors in 2018 and have had no direct involvement in the company since then.Judge Eunice C. Lee of the United States Court of Appeals for the Second Circuit, who wrote Tuesday’s opinion for a three-judge panel, found that the bankruptcy code permits corporate owners who haven’t filed for personal bankruptcy to receive liability protection under certain circumstances.“Bankruptcy is inherently a creature of competing interests, compromises, and less than perfect outcomes,” she wrote. “Because of these defining characteristics, total satisfaction of all that is owed — whether in money or in justice — rarely occurs.”Quoting from a bankruptcy ruling in a 2019 case that did not involve Purdue, Judge Lee also stressed that the releases granted to the Sacklers “ ‘are not a merit badge that somebody gets in return for making a positive contribution to a restructuring,’ nor are they ‘a participation trophy’ or a ‘gold star for doing a good job.’ ”The Sacklers’ liability protection does not extend to criminal prosecutions, should any ever be filed.Purdue filed for bankruptcy in September 2019, as the rising opioid cases against the company turned into a torrent.Tuesday’s ruling came more than a year after oral arguments before the Second Circuit panel. As months passed, thousands of litigants expressed growing frustration that the case remained unresolved, with promised payments held in abeyance even as the opioid epidemic itself, now marked by fentanyl use, continued to surge.The ruling was a win for Purdue, which appealed a decision by a federal district judge, who overturned a settlement that had originally been approved by a bankruptcy court judge in 2021. But most of the parties that had appealed the 2021 plan eventually wound up dropping their objections, after the Sacklers increased their payout offer by roughly $1.73 billion.The only objectors who remain include several Canadian municipalities, a few individuals and the U.S. Trustee, a Justice Department program that is the watchdog of the bankruptcy system. Ms. Jacoby, the North Carolina law professor, said that because the last objecting states had agreed to the Purdue plan, the U.S. Trustee’s argument for pursuing the case would not be robust.The U.S. Trustee declined to comment on Tuesday’s ruling.In a statement after the ruling was issued, Purdue called the decision “a victory for Purdue’s creditors, including the states, local governments and victims who overwhelmingly support the plan of reorganization.”“Our focus going forward is to deliver billions of dollars of value for victim compensation, opioid crisis abatement and overdose rescue medicines,” the statement continued. “Our creditors understand the plan is the best option to help those who need it most, the most fair and expeditious way to resolve the litigation and the only way to deliver billions of dollars in value specifically to fund opioid crisis abatement efforts.”The families of the two founding brothers of Purdue, Dr. Mortimer Sackler and Dr. Raymond Sackler, both deceased, said in a joint statement: “The Sackler families believe the long-awaited implementation of this resolution is critical to providing substantial resources for people and communities in need. We are pleased with the Court’s decision to allow the agreement to move forward and look forward to it taking effect as soon as possible.”

Drug dealers are mixing xylazine, an animal tranquilizer relied on by veterinarians, into fentanyl, with deadly results. But controlling it is tricky.Penny, a 3-year-old sorrel mare with a white blaze, had been slobbering her feed and fighting her bit, signs of a likely toothache. An exam confirmed that she needed two wolf teeth extracted and the sharp edges of some molars ground down, procedures that required propping her jaws open with a speculum.To protect Penny from pain, and protect himself from the kick of a horse who outweighed him tenfold, Boyd Spratling, Penny’s veterinarian, gave her a shot of xylazine, a common animal tranquilizer. Within moments, her long neck drooped and her eyelids fluttered at half-mast. Forty-five minutes later, dental surgery done, Penny sauntered out of the clinic in rural Nevada and into her trailer.To Dr. Spratling, xylazine is a vital analgesic and sedative, which he also occasionally uses in cattle, for procedures like C-sections in cows and penile injury repairs in bulls. It’s a staple for zoo veterinarians, too. But in the last few years, the drug has also turned into something else: a cheap, addictive adulterant to illicit fentanyl that is contributing to the rise in overdose deaths around the country. The xylazine-fentanyl combo, known in the drug trade as “tranq dope,” is a life-threatening mix that depresses breathing, heart rate and blood pressure, and can cause blackened, chemical burn-like flesh wounds that can lead to amputation.In a xylazine alert in March, the Drug Enforcement Administration said that in 2022, it had detected the drug in nearly a quarter of the confiscated fentanyl samples in 48 states.Last week, the White House’s Office of National Drug Control Policy designated the drug mix as an “emerging drug threat,” a classification that requires the office to devise a governmentwide intervention plan. But addressing the threat is proving to be a tricky balancing act involving stakeholders in areas as disparate as addiction medicine, commercial livestock and law enforcement. The challenge is to walk a careful line by managing a drug that is essential for veterinarians but is fueling a public health crisis.Law enforcement agents are pressing for xylazine to be listed as a controlled substance, which would criminalize distribution for human use. Currently, the police can’t arrest a person for sales or distribution of xylazine. Their resources to track down its production are modest. A controlled-substance designation would make a crucial difference, law enforcement officials said.But veterinarians fear that if that happened, their access to the medicine would be heavily regulated. They would have to maintain separate logbooks for federal inspection. More worrisome: Production of a classified drug would require additional quality control and security measures so costly that a manufacturer could raise the drug’s price or just stop making it altogether.“When we first starting seeing on the news that xylazine was being mixed with fentanyl, we were horrified,” said Dr. Spratling, who keeps his xylazine in a double-locked container.But, he added, “let’s not shoot from the hip because then the people who really pay the price, regulatory-wise, are the ones who have been using it in a responsible manner all along.”Some addiction medicine specialists and harm reduction groups have different worries. They fear that new tough restrictions could set off a domino effect of the sort that contributed to the fentanyl crisis, including criminal charges against people with substance use disorders.Dr. Spratling gave a dose of xylazine to a horse before setting to work to clean out a puncture wound.Kim Raff for The New York TimesAuthorizing a drug to be listed as a federal controlled substance can be done either by Congress or jointly by the Food and Drug Administration and the D.E.A.A state can also list the drug. On Tuesday, Gov. Josh Shapiro of Pennsylvania, where the Philadelphia neighborhood of Kensington is ground zero for tranq dope, announced that his administration was doing so.A spokesman for the governor, Manuel Bonder, said Mr. Shapiro had decided to move ahead with the designation “rather than wait for any future possibilities in D.C.”Xylazine was approved by the F.D.A. for veterinary procedures in 1972. Since then, it has been used for procedures on sheep, deer, elk and even cats and dogs, as well as on horses and cattle. Earlier trials in humans had been shut down because the drug led to respiratory depression, so manufacturers never sought approval for human use. Until now, there has been insufficient incentive to research its impact on people. Its causal relationship to the flesh wounds that can result from its use is not understood. And unlike the protocols for opioids, those for reversing tranq dope withdrawal or managing rehabilitation have not been standardized.Last month, a bipartisan bill introduced in both chambers of Congress by members from rural states — including Nevada, Iowa, New Hampshire, California, Florida, Texas and Colorado — offered a compromise. Rather than listing xylazine as a controlled substance, the bill proposes that a person who employs it for “illicit” purposes — sales or distribution for human use — would face the same penalties as if it were listed as a Schedule III drug, including fines up to $500,000 and a first-offense sentence of up to 10 years in prison.Controlled substances are classified according to medical need and potential for abuse and addiction. Schedule III includes buprenorphine, the medication used to treat opioid use disorder. By comparison, Schedule I includes heroin and L.S.D. Schedule II includes oxycodone and fentanyl, which can be prescribed for pain.Legislators said this path represented a hard-fought middle ground for bipartisan buy-in and, they hope, a fast track to passage.“We need to make sure that we make it illegal for human use because of the devastating impact we see, but I also know, working with cattlemen and the ranchers in my state, that they need to be able to treat their horses and large animals with this drug,” said Sen. Catherine Cortez Masto, a Nevada Democrat, who introduced the bill with Sen. Chuck Grassley, an Iowa Republican, and Sen. Maggie Hassan, a New Hampshire Democrat.Their bill has been endorsed by veterinary, rancher and police associations. If enacted, it would require manufacturers to enhance xylazine record-keeping and send tracking reports to a D.E.A. database. Law enforcement agents could pursue dealers.But it exempts the legal use of xylazine for “administration to nonhuman species.” With that carve out, veterinarians would not face the restrictions of a controlled substance.Outreach workers attended to a man who they believed had just injected tranq dope, in the Kensington section of Philadelphia.Hilary Swift for The New York TimesTypically, domestic, veterinary-grade xylazine comes as liquid in a vial while bulk xylazine shows up as a cheaper powder, possibly imported. The F.D.A. already announced it was ramping up surveillance of imported xylazine.Beau Kilmer, the co-director of the RAND Drug Policy Research Center, said, “It’s important to know where xylazine is being mixed. The D.E.A. reports finding empty xylazine bottles at U.S. stash houses, so some mixing is happening here, but does mixing in the U.S. account for the majority or minority of cases?” But at this stage, he said, it was unclear what impact scheduling would actually have on human consumption and health.Many harm reduction groups and drug policy experts question the long-term efficacy of scheduling xylazine.The recent history of efforts to tighten controls on prescription painkillers highlights some of their concerns. As federal and state agencies imposed strict controls on prescription opioids, drug dealers and people who use drugs shifted to using illegal opioids — heroin, counterfeit pills and illicit fentanyl. Many people arrested as sellers are themselves dependent on those drugs.Maritza Perez Medina, the federal affairs director of the Drug Policy Alliance, a nonprofit harm reduction organization, said she worried that criminalizing xylazine would not substantially address its problems. “Simply put: Crackdowns put us in a game of whack-a-mole. When we try to eradicate one drug, a new one comes up.”Xylazine began appearing sporadically as an addictive substitute for heroin in the 2000s: In 2011, a study observed that people in farming areas of Puerto Rico were injecting horse anesthesia and developing serious lesions.Around 2006, the drug was found in Kensington, the Philadelphia neighborhood, which has a substantial Puerto Rican population. Its use there began escalating around 2018, after which it spread throughout the Northeast, following the path of fentanyl.Addiction medicine experts said their chief concern was abating the health dangers created by xylazine. They urged that newly introduced xylazine test strips, which people can use to check the drugs they buy, be as widely distributed as fentanyl test strips.But Dr. Joseph D’Orazio, the head of medical toxicology and addiction medicine at Temple University Hospital in Philadelphia, which has treated hundreds of patients for the effects of tranq dope, says that street drugs are mixed with so many different additives that even test strips fall short of what is needed to save lives.He said the immediate focus should be on developing better treatments to manage acute withdrawal from xylazine. “So many patients avoid or abandon treatment because our current medications are not adequate to combat the dose of fentanyl and xylazine found on the street.”For his part, Dr. Spratling remains aghast at the wildfire that xylazine has become. “I’ve been using xylazine for 45 years, and I’ve never seen the skin ulcerations and lesions on a horse that people are getting. It’s terrible. I’m dumbfounded,” he said.Penny, the young mare, not only sprang back from her xylazine shot but also quickly recovered from her dental surgery. Her spirits and mouth healed, she performed well a few weeks ago at a local county stock horse competition.But Dr. Spratling, who uses xylazine at least a half-dozen times a week for procedures, is uneasy. He said that if the government were to regulate the drug for him and his colleagues, many veterinarians would have a simple response. “They’ll just stop using it,” he said.Kim Raff for The New York Times

Officials said the formal designation was a sign of the grave danger posed by xylazine, which can cause horrific wounds and, when mixed with fentanyl, increase the likelihood of overdose.The White House on Wednesday designated a common animal tranquilizer that is increasingly mixed into street fentanyl as an “emerging drug threat,” a formal move that requires the administration to create strategies to enhance law enforcement efforts, health interventions and data collection to combat it.This is the first time that the White House’s Office of National Drug Control Policy has ever identified a substance for that designation, a mark of the gravity of the danger that it considers to be posed by the drug, xylazine.Xylazine was approved for veterinary procedures, primarily in cattle and horses, 50 years ago but has never been sanctioned for medical use in humans. Known popularly as tranq or tranq dope, it is a powerful and addictive sedative that slows breathing and heart rate, increases the risk of fatal overdose and often produces severe skin ulcers and abscesses that have led to amputations. “Many communities are not even aware of the threat in their backyard,” Dr. Rahul Gupta, the head of the drug control office, who is often referred to as the national drug czar, said in a briefing with reporters.According to a 2018 directive from Congress that established the emerging threat designation, the administration must now lay out plans within 90 days to coordinate a national response to xylazine. That could include creating protocols for treatment, withdrawal and wound care therapies, expanding testing for the drug’s presence and scheduling it as a controlled substance, which would give federal law enforcement agents authority to pursue its illicit use.Dr. Gupta said that xylazine withdrawal could lead to symptoms so intense — such as migraines, double vision and body-rattling anxiety — “that persons may leave medical treatment, including drug treatment, against medical advice.”But it is sought out by dealers and drug users because it is relatively cheap, with its own addictive properties, whether consumed on its own or mixed with opioids or even amphetamines. Like fentanyl, xylazine first appeared as an adulterant in the illicit drug supply in the Northeast, predominantly in Philadelphia, and then rapidly spread west and south. Citing data compiled by the Drug Enforcement Administration and the Department of Justice, Dr. Gupta noted that in the two-year period from 2020 through 2021, detection of xylazine in forensic labs grew 112 percent in the West and 193 percent in the South.Currently, the supplies of xylazine are thought to come from China and possibly Mexico, India and Russia, but they could also be coming from some domestic manufacturers who sell to veterinarians.Wednesday’s announcement follows a crescendo of recent alerts from local health authorities and warnings from other federal agencies. In a xylazine alert in March, the D.E.A. said it had detected the drug in 23 percent of confiscatedfentanyl samples in 48 states in 2022. Last November, the Food and Drug Administration, which approved xylazine decades ago for veterinary procedures, issued a nationwide warning to health care providers, and in February, it announced it would monitor imported xylazine for illegal diversion.Xylazine differs from fentanyl in major ways, which contributed to administration’s decision to declare it an emerging threat. Unlike fentanyl, heroin or the prescription painkiller oxycodone, xylazine is not an opioid. That means conventional methods for reversing an opioid overdose, like naloxone injections or nasal sprays, may not succeed in fully reviving a person who has used it.Xylazine withdrawal symptoms must be managed differently from those of an opioid, and rehabilitation protocols are not yet established. And unlike opioids or, for that matter, amphetamines, xylazine is not listed as a controlled substance, which would make it subject to greater law enforcement scrutiny.Dr. Rahul Gupta, the Biden administration’s drug czar. Designating xylazine as an emerging drug threat gives the administration further powers for drug detection and deterrence and for designing strategies to manage withdrawal and rehabilitation.Sophie Park for The New York TimesWednesday’s White House announcement had long been awaited by many community outreach groups and clinics, anxious for direction on how to combat xylazine. Dr. Joseph D’Orazio, chief of medical toxicology and addiction medicine at Temple University Hospital in Philadelphia, which has had perhaps the country’s largest influx of patients afflicted by xylazine, said that research about how the drug works in humans would be critical.“We still don’t know what causes the wounds, just a lot of conjecture,” he said. “Once that’s understood, maybe we can work up strategies on how to avoid the wounds or treat them better. And we need to understand the withdrawal so we can figure out how to treat it better.”Dr. Gupta noted that managing xylazine’s licit and illicit uses would be challenging. It is frequently used as a sedative and an analgesic in large-animal medicine, as veterinarians suture wounds, grind down sharpened molars and treated infected hooves. Preserving the drug’s status and access for veterinarians while shutting down supplies to dealers is a topic already under deep discussion.And Dr. Gupta was candid about the fact that getting a better grip on xylazine, while urgent, would be only a step in long, painful journey. His office is also pressing this effort, he said, in part to look ahead “to what potentially comes after xylazine, as an additive to fentanyl, in order to get in front of the next additive in the drug supply.”

Esta versión de la naloxona, el fármaco que bloquea el efecto de los opiáceos en el cerebro, puede salvar vidas. Este es el modo de usarlo correctamente.Narcan, un atomizador nasal que puede revertir rápidamente una sobredosis de opioides, ha recibido la aprobación federal para ser vendido sin receta médica en Estados Unidos. A finales del verano, debería estar ampliamente disponible, no solo en las farmacias, sino también en tiendas de conveniencia, grandes cadenas y, posiblemente, a través de minoristas en línea.Si se utiliza a tiempo, Narcan, una versión del fármaco naloxona, que bloquea el efecto de los opiáceos en el cerebro, puede salvar la vida de alguien que tome opiáceos, como oxicodona, heroína o fentanilo.Piensa en Narcan o en cualquier atomizador nasal de naloxona como en un extintor de incendios, dijo Corey Davis, director del Proyecto Legal de Reducción de Daños de la Red para la Ley de Salud Pública. “Con suerte nunca lo necesitarás”, dijo. “Pero en algún momento puede que la cocina se incendie y no tengas tiempo de correr a la tienda por extintores”.Aquí encontrarás una guía para usar Narcan de forma correcta:¿Cómo sé si alguien tiene una sobredosis?Su respiración puede ser lenta, con gorgoteos o detenerse por completo. Sus pupilas pueden estrecharse hasta tener el tamaño de la punta de un alfiler, y sus labios o uñas pueden volverse azules o morados. La piel puede estar húmeda al tacto. Incluso sacudiéndolos y gritándoles, no los puedes despertar.¿Qué contiene la caja de Narcan?Una caja contiene dos dispositivos de atomizador nasal del tamaño de la palma de la mano, cada uno con cuatro miligramos de naloxona.¿Debo probar primero el atomizador para asegurarme de que funciona?No. Si aprietas el atomizador liberarás la dosis y la desperdiciarás.¿Cómo debo usarlo?Inclina suavemente hacia atrás la cabeza de la persona. Introduce la punta del atomizador en una fosa nasal hasta que ambos dedos estén contra la nariz. Empuja el atomizador para liberar la dosis completa.¿No debería llamar primero al 911?Llama al 911 después de utilizar el atomizador. Se trata de una emergencia, pero al avisar a un operador puedes perder minutos valiosos.¿Qué hago después de aplicar el atomizador y llamar al 911?Asegúrate de que las vías respiratorias de la persona están protegidas y despejadas. Coloca a la persona de lado, apoyando sus manos bajo su cabeza. Dóblale las rodillas para evitar que caiga boca abajo o boca arriba.Quédate con la persona unas horas o hasta que llegue el personal de emergencias.Los paquetes tienen dos dosis. ¿Debo emplear la segunda?Por lo general, una dosis es suficiente. Pero si la persona no ha empezado a despertarse al cabo de dos o tres minutos, aplica la segunda dosis en la otra fosa nasal, sobre todo si sabes que podría haber consumido un opioide más fuerte, como el fentanilo.¿Será perjudicial el atomizador si resulta que la persona no tenía una sobredosis de opioides?No. A menos que alguien sea alérgico a la naloxona, lo cual es poco frecuente, lo más seguro es utilizar el atomizador.¿Tiene efectos secundarios?El Narcan puede provocar síntomas de abstinencia, como vómitos. Hay que mantener abiertas las vías respiratorias para evitar el ahogamiento.Otros síntomas de abstinencia son: diarrea, dolores corporales, aumento del ritmo cardíaco, fiebre, piel de gallina, sudoración e irritabilidad. Recuerda que, aunque la abstinencia de opiáceos sea terrible, estás salvando una vida.¿Quién debe llevar consigo naloxona?Según informes de los Centros para el Control y la Prevención de Enfermedades, en 2021, en el 46 por ciento de las sobredosis mortales de opiáceos había transeúntes presentes. Si hubieran llevado naloxona y supieran cómo usarla, se podrían haber salvado vidas.Si conoces a personas que consumen drogas, aunque sea de forma ocasional, o si tú mismo consumes opiáceos, no hay ningún inconveniente en llevar Narcan. Si trabajas en una empresa que tiene un botiquín de primeros auxilios a mano, ¿por qué no guardar en él un aerosol de naloxona? Padres de adolescentes o adultos jóvenes, ¿qué tal una caja en su botiquín? ¿En las residencias universitarias? ¿En la enfermería del colegio? ¿En las bibliotecas?Piensa en el atomizador como si fuera un EpiPen para las alergias, un inhalador para el asma o, de hecho, un extintor de incendios.Jan Hoffman escribe sobre salud conductual y legislación sanitaria. Sus reportajes incluyen temas tan variados como los opioides, las tribus, los derechos reproductivos, la salud mental de los adolescentes y las dudas sobre las vacunas. @JanHoffmanNYT