Many people living on the streets in Philadelphia's Kensington neighborhood — the largest open-air drug market on the East Coast — are in full-blown addiction, openly snorting, smoking or injecting illicit drugs, hunched over crates or on stoops. Syringes litter sidewalks, and the stench of urine fouls the air.
The neighborhood's afflictions date to the early 1970s, when industry left and the drug trade took hold. With each new wave of drugs, the situation grows grimmer. Now, with the arrival of xylazine, a veterinary tranquilizer, new complications are burdening an already overtaxed system.
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"It's all hands on deck," said Dave Malloy, a longtime Philadelphia social worker who does mobile outreach in Kensington and around the city.
Dealers are using xylazine, which is uncontrolled by the federal government and cheap, to cut fentanyl, a synthetic opioid up to 50 times stronger than heroin. The street name for xylazine is "tranq," and fentanyl cut with xylazine is "tranq dope." Mixed with the narcotic, xylazine amplifies and extends the high of fentanyl or heroin.
But it also has dire health effects: It leaves users with unhealing necrotic ulcers, because xylazine restricts blood flow through skin tissue. Also, since xylazine is a sedative rather than a narcotic, overdoses of tranq dope do not respond as well to the usual antidote — naloxone — which reverses the effects of only the latter.
Xylazine has been spreading across the country for at least a decade, according to the Drug Enforcement Administration, starting in the Northeast and then moving south and west. Plus, it has proven to be easy for offshore bad actors to manufacture, sell and ship in large quantities, eventually getting it into the U.S., where it often circulates by express delivery.
First detected in Philadelphia in 2006, xylazine was found in 90% of street opioid samples in the city by 2021. That year, 44% of all unintentional fentanyl-related overdose deaths involved xylazine, city statistics show. Since testing procedures during postmortems vary widely from state to state, no comprehensive data for xylazine-positive overdose deaths nationally exists, according to the DEA.
Here in Kensington, the results are on display. Emaciated users walk the streets with necrotic wounds on their legs, arms and hands, sometimes reaching the bone.
Efforts to treat these ulcers are complicated by the narrowing of blood vessels that xylazine causes as well as dehydration and the unhygienic living conditions that many users experience while living homeless, said Silvana Mazzella, associate executive officer of the public health nonprofit Prevention Point Philadelphia, a group that provides services known as harm reduction.
Stephanie Klipp, a nurse who does wound care and is active in harm reduction efforts in Kensington, said she has seen people "literally living with what's left of their limbs — with what obviously should be amputated."
Fatal overdoses are rising because of xylazine's resistance to naloxone. When breathing is suppressed by a sedative, the treatment is CPR and transfer to a hospital to be put on a ventilator. "We have to keep people alive long enough to treat them, and that looks different every day here," Klipp said.
If a patient reaches the hospital, the focus becomes managing acute withdrawal from tranq dope, which is dicey. Little to no research exists on how xylazine acts in humans.
Melanie Beddis lived with her addiction on and off the streets in Kensington for about five years. She remembers the cycle of detoxing from heroin cold turkey. It was awful, but usually, after about three days of aches, chills and vomiting, she could "hold down food and possibly sleep." Tranq dope upped that ante, said Beddis, now director of programs for Savage Sisters Recovery, which offers housing, outreach and harm reduction in Kensington.
She recalled that when she tried to kick this mix in jail, she couldn't eat or sleep for about three weeks.
There is no clear formula for what works to aid detoxing from opiates mixed with xylazine.
"We do need a recipe that's effective," said Dr. Jeanmarie Perrone, founding director of the Penn Medicine Center for Addiction Medicine and Policy.
Perrone said she treats opioid withdrawal first, and then, if a patient is still uncomfortable, she often uses clonidine, a blood pressure medication that also lessens anxiety. Other doctors have tried gabapentin, an anticonvulsant medication sometimes used for anxiety.
Methadone, a medication for opioid use disorder, which blunts the effects of opioids and can be used for pain management, seems to help people in tranq dope withdrawal, too.
In the hospital, after stabilizing a patient, caring for xylazine wounds may take priority. This can range from cleaning, or debridement, to antibiotic treatment — sometimes intravenously for periods as long as weeks — to amputation.
Philadelphia recently announced it is launching mobile wound care as part of its spending plan for opioid settlement funds, hopeful that this will help the xylazine problem.
The best wound care that specialists on the street can do is clean and bandage ulcers, provide supplies, advise people not to inject into wounds, and recommend treatment in medical settings, said Klipp. But many people are lost in the cycle of addiction and don't follow through.
While heroin has a six- to eight-hour window before the user needs another hit, tranq dope wanes in just three or four, Malloy estimated. "It's the main driver why people don't get the proper medical care," he said. "They can't sit long enough in the ER."
Also, while the resulting ulcers are typically severely painful, doctors are reluctant to give users strong pain meds. "A lot of docs see that as med-seeking rather than what people are going through," Beddis said.
In the meantime, Jerry Daley, executive director of the local chapter of a grant program run by the Office of National Drug Control Policy, said health officials and law enforcement need to start cracking down on the xylazine supply chain and driving home the message that rogue companies that make xylazine are "literally profiting off of people's life and limb."
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