"In 2020, correctional administrators reported 36,264 allegations of sexual victimization in prisons, jails, and other adult correctional facilities (figure 1). This included allegations of inmate-on-inmate nonconsensual sexual acts, inmate-on-inmate abusive sexual contact, inmateon-inmate sexual harassment, staff-on-inmate sexual misconduct, and staff-on-inmate sexual harassment.1 Of all the allegations reported in 2020, 2,351 were substantiated after investigation, the lowest number since 2014, when there were 2,350 substantiated incidents.

"These findings from the present study suggest that trenbolone use may be linked to increased verbal aggression among males using AAS, particularly at higher doses. This extends on current literature highlighting the potential effects of AAS on non-physical aggression (Chegeni, Pallesen, et al., 2021), of which trenbolone is a potent example.

"Outside of animal or clinical use, trenbolone has three times the androgen receptor binding affinity of testosterone (Yarrow et al., 2011) and thus is renowned for its ability to rapidly increase lean muscle mass while minimising fat accumulation or promoting fat loss. Nevertheless, these benefits are accompanied by significant risk.

"PWUD demonstrated a predominantly protective approach to xylazine emergence by modifying their drug consumption routes and reducing injection drug use, aiming to mitigate potential harms associated with xylazine adulteration. While often discussed in the context of xylazine here, this echoes a broader literature that reveals an elevated prevalence of smoking among people who previously injected opioids on the West Coast of North America [30–32].

"The emergence of xylazine has led to several unintended consequences for PWUD [People Who Use Drugs] across North America, such as tissue necrosis and heightened sedation, the latter of which has potential implications for elevated risk of overdose and social consequences (such as being robbed or assaulted) [5, 21].

"Originally developed as an anti-hypertensive agent by Farbenfabriken Bayer AG (now Bayer AG) in 1962, xylazine was found to cause severe hypotension and central nervous system depression.7,8 Xylazine was never approved for human use but was instead approved in 1967 as a sedative in large animal anesthesia.7,9 Short

"Xylazine (also known as “tranq, tranq dope, Philly dope, sleep-cut, or zombie drug”) is a non-opioid veterinary tranquilizer that has become a common additive with illicit fentanyl and other opioids.1 When xylazine is injected with fentanyl, the result can be severe soft tissue injury ranging from superficial irritation to deep tissue necrosis and even bony involvement (Fig. 1).

"Around the world, there is no evidence of the need or benefit of higher dose products, particularly from people to whom they would be administered (Saari et al., 2024). People who used opioids, in one qualitative study, preferred lower dose IN products (Neale et al., 2022). In 2024, the Michigan Drug User Health Alliance surveyed 108 people who use drugs about their reversal product preferences. Respondents overwhelmingly preferred standard-dose products to high dose or long-acting products (Michigan Drug User Health Alliance, 2024).

"Studies in two states in the US have found that there is no association between the introduction of fentanyl into the drug supply and naloxone dosing required to reverse opioid overdoses. This conclusion emerged from data collected over four years at a SSP in Pittsburgh, PA, that distributed primarily 0.4 mg IM naloxone to people who use drugs (Bell et al., 2019; Bell & Dasgupta, 2024).

"In 2021, due to the widespread availability of high-potency synthetic opioids like fentanyl, the US FDA approved two high-dose naloxone products, an 8 mg IN spray (Kloxxado) and a 5 mg IM injectable (Zimhi). The only studies reported in the FDA package inserts for both products are pharmacokinetic studies in healthy volunteers, which demonstrated substantially higher naloxone plasma levels than standard doses of naloxone (0.4 mg IM vs. 8 mg IN and 2 mg IM vs. 5 mg IM, respectively).