PITTSBURGH — Megan Norris, who lives outside Pittsburgh, has battled severe heroin and fentanyl addiction for more than a decade.
When she relapsed during her pregnancy earlier this year, Norris knew the opioids she was buying on the street likely contained something new and toxic: xylazine
"It was the beginning of my pregnancy," Norris said. "Xylazine is so addictive, so physically addictive, you just can't stop. It's like the flu times a hundred. I was throwing up a lot. I was just in a rotating pit of hell. So I was using."
Drug overdoses are already a leading cause of death for pregnant women in the U.S. Research shows as many as 1 in 20 women use addictive substances at some point during their pregnancies. A study by the National Institutes of Health found "substance use during pregnancy is prevalent." Opioid use by pregnant women had already quadrupled before fentanyl hit, according to the Centers for Disease Control and Prevention.
Now, public health experts warn that xylazine poses a fast-growing threat to women, their fetuses and newborns.
"Almost 100% of our drug supply is fentanyl and 80% to 90% of that fentanyl is adulterated with xylazine," said Dr. Elizabeth Krans, a physician and researcher at UPMC Magee-Womens Hospital in Pittsburgh.
Krans is one of the country's leading experts on pregnancy and drug addiction. She said the impact of xylazine is like nothing she's seen before. "Patients coming in with really intense wounds that add a layer of pain and discomfort," she said.
Xylazine is a potent animal tranquilizer normally used by veterinarians. For reasons that aren't completely clear, drug gangs began mixing it into street fentanyl a couple years ago. The chemical is toxic in humans, causing skin lesions and wounds that heal slowly, if at all.
"It starts to necrotize your skin and they just don't heal," said Norris, age 33, who has been grappling with xylazine wounds during her pregnancy. "One tiny little needle mark and it turns into that big hole."
Norris said she felt deep shame and experienced severe stigma because of her drug use.
She said that sense of guilt grew when it was confirmed her fetus had been exposed to xylazine. "It's scary to not know what's going to happen to my baby or what the effects are long-term," she said.
It might seem simple for pregnant women to simply stop using street drugs. Studies show many women do try desperately to enter recovery when they become pregnant.
"People think it's easy to just kind of not use anymore and it's just not like that," Norris said.
Indeed, researchers say xylazine appears to be even more addictive than fentanyl or heroin, street drugs which are already notoriously difficult to escape.
Medical experts say fentanyl is already so powerful that even without xylazine in the mix, it's advisable for pregnant women to seek medical care before stopping drug use. Xylazine also appears to complicate use of medications like methadone and buprenorphine that are proven to ease opioid cravings.
"They're scared, they're terrified"
Dr. Ilana Hull, a doctor at the University of Pittsburgh, said it's clear most women experiencing the kind of severe addiction that exposes them to fentanyl and xylazine do care deeply about their fetuses and newborns, but they often feel trapped and overwhelmed.
"Our patients know that this is out there," Hull said. "They're scared, they're terrified and they are very worried about the potential impacts on their pregnancies, their deliveries, and their infants."
She said one challenge for pregnant women who want medical help is that they often face legal risk. Drug use is a crime. Seeking care and admitting to the use of substances like fentanyl and xylazine often cost women custody of their children.
Hull co-authored one of the first studies of xylazine's impact on pregnant women, a report she described as a "wake-up call."
"We don't know really much about exposure of xylazine in humans, so this is really a call to action to focus attention [and research] on this," Hull said.
In one study, 74% of babies tested positive for xylazine
What is clear is that far more pregnant women experiencing addiction are being exposed to xylazine.
A new study conducted by Washington University in St. Louis found the rate of xylazine-positive tests in opioid-addicted patients cared for in one of the city's maternity wards surged from zero percent in December 2022 to 100% by July 2023.
"These results underscore the critical need to further study the impact of xylazine on obstetric outcomes," concluded lead author Dr. Cassandra Trammel.
In an interview with NPR, she said it has now been shown conclusively that the toxic chemical is transferring from mothers to newborns.
"73% of those babies were ultimately testing positive for xylazine themselves after delivery," Trammel said.
There is no research or data showing how the chemical might be affecting women's reproductive systems, their fetuses or newborns. One bit of good news is that, so far, the growing number of babies born with xylazine in their systems haven't experienced the kind of lesions or flesh wounds seen in adults.
Hull's study noted that the best available data currently is drawn from past studies into the impacts of xylazine on unborn farm animals when used by veterinarians.
Possible harmful effects include reduced blood flow and oxygenation to the fetus which "raises concerns during critical stage of development."
The National Institutes of Health is currently funding xylazine research, but according to Hull physicians caring for pregnant women exposed to the chemical are being forced to improvise, with little scientific data.
"It is very frustrating and makes it hard to treat people," Hull said. "It seems like we're always playing catch-up."
Indeed, most doctors and scientists interviewed for this story said they fear the street drug supply will continue to evolve in ways that pose new dangers to pregnant women. Already, drugs being sold on the streets are laced with a stew of synthetic opioids, powerful tranquilizers, and industrial chemicals.
"We're desperately trying to keep up," said Dr. Krans at Magee-Womens Hospital. "We're just behind."
For now, a key strategy is to identify as many pregnant women as possible experiencing fentanyl-xylazine addiction and transition them to medications and counseling. But according to Krans, far too many women aren't getting that kind of high-quality medical care.
"We have these medications [proven to help] but we also have these systems in place that are preventing patients from getting to those medications," she said, pointing to lack of affordable healthcare, stigma and legal risks faced by many women who use drugs.
Megan Norris did finally get treatment. When she spoke to NPR she had been off fentanyl and xylazine for months, taking a prescribed dose of methadone. Tests showed her fetus appeared to be healthy and she was trying to be hopeful:
"They were worried about her heart, her heart wasn't growing properly at first," Norris said. "She's fine now, she's just going to be small."
After her interview with NPR, Norris gave birth to a daughter. She and her little girl are doing well. Norris said she hopes more moms and their babies will get the same kind of quality care that helped her and her child.
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