PHILADELPHIA — Three days a week, dozens of people in active addiction stream through Sarah Laurel's tiny storefront on Kensington Avenue — looking for a place to sit, a hot shower or a snack from Laurel's outreach organization, Savage Sisters.
More often than not, they're also seeking help for serious wounds from injecting drugs laced with an animal tranquilizer called xylazine.
"Tranq," as it's known on the street, is wreaking havoc among people who use opioids in Philadelphia. Not approved for human use, it's nonetheless become a hallmark of the city's already volatile drug supply. It's most often used to cut fentanyl, the powerful synthetic opioid that has replaced most of the city's heroin. Health officials believe xylazine was initially added to fentanyl to give users a longer-lasting high.
But the side effects — playing out on the streets of Kensington, in rowhouses in South Philadelphia, on the Savage Sisters' exam table — have been devastating. Because tranq is not an opioid, people who use opioids laced with it are at risk for overdoses that are harder to treat with naloxone, the opioid overdose-reversing drug.
They report severe wounds and painful withdrawal that doesn't respond to traditional opioid withdrawal treatment. They tell Laurel that the fear of withdrawal keeps them from entering drug treatment, even as they risk infection and death from xylazine wounds, because many providers aren't adequately treating xylazine withdrawal symptoms.
"I've never seen human beings remain in these kinds of conditions," Laurel said. "They have open, gaping wounds, they can't walk, and they tell me, 'If I go to the hospital, I'm going to get sick.' They're so terrified of the detox."
There's little known about xylazine
Philadelphia officials are scrambling to address the problem, announcing recently that they will use some money from a massive settlement in a lawsuit against opioid manufacturers to expand wound care. Last fall, the city health department issued guidelines to physicians on how to treat withdrawal from xylazine, and Laurel and other advocates say it's crucial that health-care providers adapt.
"There's so much fear of withdrawal," said Stephanie Klipp, a harm reduction nurse with Unity Recovery, a recovery support organization in Pennsylvania and Texas. "The system is not well educated on how to treat these wounds."
There's little research on xylazine, but it's believed that its effect on blood pressure and the vascular system can cause wounds to open easily and heal slowly. Injection-site wounds are common, but some injection drug users report wounds on parts of the body they've never injected into; even drug users who snort or smoke their drugs speak of developing similar wounds.
At Laurel's storefront in Kensington on a recent afternoon, Nick Gallagher, 43, eased his arm out from under a sweatshirt to show outreach workers a long, jagged wound on his left shoulder. It was red, puffy and painful. "It's actually healed a lot," he said. "It used to be four fingers wide."
Gallagher has been injecting drugs for years and last spring developed an infected abscess where he had injected into a biceps. He underwent surgery to halt the spread of infection, but the massive wound remained, never quite closing. "I know tranq made it slower to heal," he said.
In the back of the storefront, a man who said his name is C.J., but declined to give his last name, sat on an exam table as Jen Shinefeld, a field epidemiologist with the city health department, wrapped gauze and a bandage around a wound on his hand. "It's healing so nicely," she told C.J. encouragingly.
C.J. smokes tranq dope, but developed an abscess on his arm earlier this year, and said he notices now that everyday cuts and scrapes stay open longer. "It takes like a month for a normal wound to heal, and they get bigger just on their own," he said.
Limited treatment options
Laurel is also concerned about the lack of widespread treatment for xylazine withdrawal and what that means for people who want to get off the drug. She's asked local addiction treatment organizations to look for and treat xylazine withdrawal among patients who come to them seeking treatment for opioid withdrawal. But many don't know what to look for — or what to do if they recognize xylazine withdrawal, she said.
Philip Moore, chief medical officer for the nonprofit treatment provider Gaudenzia, is among the physicians who have become familiar with xylazine withdrawal over the last year. He has had patients who report using heroin or fentanyl but who then begin to experience withdrawal symptoms that don't abate after treatments for opioid withdrawal. (Xylazine has sedative properties, but is not an opioid.)
"We'll start treating for opioid withdrawal, and they should be getting better — but we'll see chills, sweating, restlessness, anxiety, agitation," he said. "They're very, very unpleasant symptoms. That's what triggers us that we're dealing with a more complicated withdrawal, that there's more xylazine in the mix."
There are no FDA-approved treatments specifically for xylazine withdrawal, but Moore and other physicians are developing protocols to help ease patients' symptoms. He's prescribed clonidine and lofexidine, both medications for high blood pressure, to get patients through withdrawal, as well as sedatives such as phenobarbitol or Valium.
"The challenge is educating other physicians, nurses, nurse practitioners, and the community," he said. "If we don't recognize xylazine withdrawal, patients are really uncomfortable and they'll leave treatment because they don't feel like they're getting better."
Gaudenzia operates facilities that can care for people with serious wounds, but not every treatment center has the medical capabilities to do so. That's another treatment deterrent, advocates say: Often, even a person suffering from a serious wound who is ready for treatment struggles to get accepted at a treatment center.
Outreach workers around the city say the tranq dope problem, while most visible in Kensington, is not limited to that neighborhood. In South Philadelphia, Destinie Campanella, Unity Recovery's harm reduction program director, hands out sterile syringes, smoking kits, and hygiene supplies weekly at Broad Street and Snyder Avenue. Some of the population she serves is homeless, but many are using in their homes in the neighborhood — and suffering from similar wounds.
"There is a significant need here, not just for harm reduction supplies, but wound care," she said.
On a recent afternoon, Campanella and a team of outreach workers handed out syringes and naloxone, the opioid-overdose reversing drug. A young woman in her 20s asked the team if they could look at a lesion she'd recently developed. Klipp grabbed a first-aid kit and drew her aside.
Klipp is in recovery herself and used to treat wounds at Pittsburgh's syringe exchange. She's lived in Philadelphia for five months and has been shocked at xylazine's spread here. Wider access to wound care — whether on the street or in hospitals — is crucial to keep patients alive, she said.
She tries to build trust with patients and to help them into treatment. Sometimes, it takes weeks before someone is comfortable enough to show her a wound.
"There's so much trauma and shame. Stigma is the killer. It drives people to not want to access care," she said. "And we can be doing a lot more as a city. I'm new here — but I know what I see."
