When the staff at Prevention Point Pittsburgh drive their syringe service van into a neighborhood, they take with them a whiteboard.
“People come to us, they see the bags board hanging up, behind where I’m standing, asking them for their supplies,” said Gabby Warner, Prevention Point’s harm reduction services coordinator. “Some people might want me to bring it down so they can take a picture of it with their cell phone to share with their friends.”
The bag board lists the names of stamp bags — used by dealers to label heroin, fentanyl or other drugs commonly referred to as “dope” — associated with an overdose or unanticipated side effects.
While recently preparing the van for a week of distributions, Warner added new warnings to the list. Nearly all were for the veterinary tranquilizer xylazine.
According to Warner, Prevention Point Pittsburgh’s clients have reported signs of the sedative more than ever before. Often combined with fentanyl, people who use what’s known as “tranq dope” say the mixture lengthens the duration of the opioid’s effects.
On its own, xylazine can slow a person’s breathing, heart rate and blood pressure to critical levels. But because xylazine is not an opioid, the overdose reversal drug naloxone — commonly sold as Narcan — can’t reverse its effects.
“Naloxone does not work for xylazine, where it does work for fentanyl,” Warner said. “So, that makes things really scary for people who are using drugs right now.”
Xylazine was detected in 37 of Pennsylvania's 67 counties in 2021, according to preliminary overdose death records. It’s a meteoric rise from 2017, when the drug was detected only in Philadelphia County.
But when someone comes to them with suspicions that xylazine is in their supply, Prevention Point Pittsburgh staff cannot provide any confirmation.
Warner holds up a package of fentanyl test strips.
“This can tell you that there’s fentanyl in your opiates, but it doesn't tell you how much is in there, doesn't tell you if there are other drugs in there,” Warner said. “I think that's the real issue.”
With contaminants on the rise, testing products have a shorter window of opportunity
In November 2022, former Gov. Tom Wolf signed into law legislation decriminalizing fentanyl test strips, as well as products that test for other substances.
The measure will apply to xylazine test strips, if and when they are made available to the public. Researchers have developed a testing agent that can identify the contaminant and are partnering with harm reduction organizations to test them out in cities across the U.S., although the strips are not yet commercially available.
Melanie Beddis, program director at Savage Sisters Recovery in Philadelphia, said that lack of availability has forced people to rely on word of mouth.
“Each bag of dope doesn't come with nutritional information on the back of it,” Beddis said. “If we were able to test the drugs ourselves, then you [would] actually know what you're putting into your body.”
Beddis, now 20 months sober, first started noticing the kind of dark, easily-infected wounds that often result from xylazine use on her skin long before she or any of her physicians knew the drug by name.
Xylazine was occasionally detected in fatal overdoses in Philadelphia as early as 2006. By 2020, it was present in more than a quarter of all overdose deaths in the city.
“I just would go to urgent care or try to get an antibiotic and doctors would just say, ‘Oh, maybe you have MRSA.’ [They] didn't really know what was happening,” she recalled. “And before I knew it, my body was dependent on it.”
Laboratory drug-checking conducted by the city’s health department found that between May and September of last year, fentanyl and xylazine were present in 91% of samples.
Beddis said, because of that, much of the population Savage Sisters serves had already developed a dependence on both substances by the time the organization began handing out fentanyl test strips several years ago. (The product was legalized by municipal directives in Philadelphia and Pittsburgh prior to the state measure.)
Data on xylazine’s prevalence elsewhere in Pennsylvania, however, remains limited. In a statement, officials with the state’s Department of Drug and Alcohol Programs said the agency is “continually monitoring established and emerging drug trends, particularly in the illicit drug supply, which includes xylazine.”
That includes data from state and federal law enforcement on drug seizure trends, emergency departments and prevention and treatment programs, as well as research findings. The agency said it also has regular conversations with local drug and alcohol authorities since the drug supply is always changing and varies from place to place.
In Allegheny County, where fentanyl was present in 86% of all fatal overdoses last year, the county medical examiner’s office said it does not yet view xylazine as significant to the final cause or manner of death.
Beddis said that could mean now is the short window during which xylazine test strips could make a difference.
“There's still a chance that if we had a xylazine test strip, people that are really into their addiction now and are trying to avoid xylazine, it would at least give them the opportunity,” she said. “But because of the lack of testing materials, nobody's getting that opportunity.”
In other states, real-time drug checking is available
Still, even once xylazine test strips are available for widespread distribution, the drug isn’t even close to being the only harmful substance contaminating the street-level opioid supply.
“If you look at labs that test for substances, it's dozens, hundreds of substances per sample,” said James Latronica, a Pittsburgh-based physician and member of the Pennsylvania Society of Addiction Medicine.
“They're benzodiazepines and other sedatives,” he continued. “And it's far worse than what most people understand.”
Latronica said testing that can detect a broad range of contaminants is needed most and pointed to now decades-old models in Europe.
More recently, New York launched three city-funded drug-checking sites. There, people can bring their drugs to outreach workers trained to operate high-tech machines that reveal exactly what’s inside.
Similarly, the Chicago Recovery Alliance has seen a surge in demand for its real-time drug-checking program, available at its six outreach vans that travel to different neighborhoods in the city.
At Thomas Jefferson University, in Philadelphia, assistant professor Megan Reed has a Fourier-transform infrared spectrometer, or FTIR, ready to do the same as soon as funding is secured.
Nicknamed ‘Sally’, the machine is about the size of a breadbox.
“It has a diamond on it, and you put a very small sample of a drug — less than half a grain of rice — onto the diamond,” Reed explained.
Infrared beams run through the sample, sending back what Reed called a chemical fingerprint. That’s then compared to fingerprints of other chemicals, like sugars or heroin.
“Pretty much everything that's out there, and you're able to interpret what's in the sample,” Reed said.
That way, people who use drugs can know exactly what’s in there, and from there make an informed decision about whether, and how much, to use.
But operating FTIRs requires extensive training, and the devices are expensive: Reed’s cost just under $39,000. When asked about possible public funding to help local drug and alcohol authorities and harm reduction organizations purchase these devices, officials with DDAP said only that the department will “continue to monitor the use and implementation of evidence-based practices in harm reduction strategies.”
Many advocates have also raised questions about where these devices might be located, if deployed in Pennsylvania. While Reed’s machine is portable, other models are not and, if purchased, would require a building to house them.
That must be a place where people feel safe to bring their drugs, said Warner with Prevention Point Pittsburgh.
“Even if testing is legal here, where are people going to go to where they trust people and bring a bag of what they believe is heroin?”
But that, Warner said, could be a tall order in Pennsylvania, where syringe service programs aren’t even legal, though local governments in Pittsburgh and Philadelphia have authorized them.
DDAP previously told WESA it supported local efforts to promote public health, “including the decision to operate safe syringe service[s] programs.” But multiple bills in the General Assembly to permit these programs statewide have died in committee.
Rep. Sara Innamorato, who represents part of Allegheny County, plans to reintroduce the measure this legislative session. She said the bill gained ground during the effort to decriminalize test strips, and now has a better shot.
“I think we saw — when we were laser-focused on the decriminalization of fentanyl test strips and other testing materials — that was able to move across the finish line in a pretty non-controversial way,” said Innamorto. “But there was a lot of work on the back end to get people there and to get folks to neutral.”
But stigma continues to be the biggest hurdle in garnering support, Innamorato said.
“People view syringe service programs as enabling drug use. The reality is that people use drugs, and we know that, if they are trying to hide their drug use or don't have access to clean needles or testing strips, then they're putting themselves in harm's way,” she said. “Much more so than if they had access to a syringe service program.”
With Pennsylvania ranking eighth in drug overdose mortality nationwide and roughly 5,343 drug overdose deaths in 2021, Latronica said the legislature can’t afford to delay a vote.
“We're already behind,” he said. “If we want any chance at stemming this tide of what is functionally an ongoing and unabated mass casualty event, these interventions need to be rolled out as quickly as possible.”
