In Philadelphia, getting people into addiction treatment was hard enough. Then xylazine changed everything

Every weekday, a massive RV rolls down Kensington’s narrow streets, delivering addiction care and medical supplies to triage the latest danger in Philadelphia’s drug crisis.

When it parks on Kensington Avenue, the team inside from Girard Behavioral Wellness Center, one of the city’s oldest addiction treatment organizations, steps out to try to encourage people with addiction into treatment.

Nowadays, the first question nurse Elaina Rodriguez asks of patients who approach her is whether or not they have any wounds.

It’s a sign of the spread of the animal tranquilizer xylazine through Philadelphia’s drug supply — and it’s made the Girard team’s already difficult job that much harder.

Xylazine, or tranq, has intensified the dangers of an overdose epidemic that killed 1,276 people in Philadelphia in 2021, the last year for which full data are available.

It’s normally combined with fentanyl, the powerful synthetic opioid which took the place of heroin in the mid-2010s. The fallout has been devastating: Xylazine makes a fentanyl overdose harder to treat, sends patients into painful withdrawal and causes gaping wounds on the people who use it. Officials believe it was added to fentanyl to produce a longer-lasting high, and for years people buying illicit drugs had no way to detect its presence.

Two months ago, Girard opened a clinic dedicated to treat patients who need higher-level medical care for their wounds — who are often turned away from other rehab clinics that don’t have the capacity to treat xylazine wounds. So far, about two dozen patients have come through.

Some are too serious even for the clinic to treat. Rodriguez scrolled through photos she’d sent to doctors recently, stopping at a picture of a wound the size of a baseball on a man’s knee. The flesh was blackened — necrotizing. The infection had worn down to the bone. The team on the RV told him he had to visit an emergency room.

“It’s my first experience working outside of a hospital setting, in the community, and every day is a challenge,” Rodriguez said.

On a recent morning, Will Rodriguez, the outreach and engagement coordinator at Girard (and no relation to nurse Elaina Rodriguez), swept up needle wrappers and trash from the stretch of sidewalk outside the bus. He set up a folding table with snacks, water, pamphlets about Girard’s treatment programs, and boxes of naloxone, the opioid-overdose reversing drug.

Girard’s street outreach operation is designed to streamline entry into treatment. In Philadelphia, patients can wait hours at ERs or crisis response centers for medical assessment before they’re sent to an inpatient bed. The team on the RV aims to get the process done in an hour or so.

Rodriguez knows the area well: More than two decades ago, he was selling heroin here — and eventually became addicted himself. But the product he sold and sniffed was radically different from what he’s trying to save his clients from now.

“If I were out here using now,” he said, “I don’t think I would have survived.”

Midway through the morning, a young woman bleeding from a quarter-size wound on her shoulder walked up to the RV. “Do you guys have a Band-Aid?” she asked.

Her name was Megan; she was from Northeast Philadelphia; and she’d been living on the streets of Kensington for two years. (She declined to give her last name because of the stigma associated with active addiction.)

Though she uses tranq, she’d been lucky to avoid getting the sores she’d seen on friends. But when she did cut or scrape herself, the wound was much slower to heal. The one on her shoulder had reopened after she bumped into a car door.

Elaina Rodriguez washed Megan’s shoulder with antiseptic and carefully placed a bandage over it. It’s the kind of wound she can treat on her own, at the van. She handed Megan a few more bandages to take with her, and watched as she set off down the avenue.

“Maybe she’ll come back next week,” Will Rodriguez said. “Maybe she’ll think, ‘hey, people were kind to me here.’ ”

Over the last two months, outreach workers for the wound care clinic have been trying to get the word out to potential patients: Xylazine causes wounds. Then those wounds become painful. Patients may seek to treat the pain with more fentanyl. Many will avoid hospitals because they’re worried they’ll be treated poorly — and because doctors are still learning how to treat xylazine withdrawal, said Monika Van Sant, the physician who runs the clinic.

“People will end up with [a bone infection], or an amputation, and then the problem becomes, where do you put patients that have no limbs? A lot of facilities won’t take them. The shelters don’t want them,” she said. “The system is broken.”

Ramsey, a man in his 20s who declined to give his last name, said he’d been on the wound unit for about a week, receiving treatment for a wound on his thigh. His drug of choice was cocaine; he had first tried it at 15. On the street in Kensington recently, he had injected what he thought was cocaine into his leg. But he missed the vein, putting himself at risk for a skin infection.

The cocaine, he learned, also contained fentanyl and xylazine, and the small needle prick festered into a wound that stretched up his calf. “I tried to treat it myself, but I didn’t have anything to cover it, my clothes would stick to it,” he said. Eventually, he called an outreach worker and was referred to the Girard clinic.

Sober since he arrived on the unit, Ramsey said his wound had been healing and that he was looking forward to going to a recovery home when he was cleared to leave.

Even without xylazine wounds, Rodriguez and his team can sometimes struggle to find a placement for patients who need a higher level of addiction treatment, like inpatient care. One afternoon at the van, he waited for hours for two men who had promised they’d show up to get taken to an inpatient facility.

“Hallelujah!” he shouted when he finally spotted them walking up the sidewalk.

They spent an hour on the bus doing intake interviews and setting up treatment beds. There was one available for the first man, but not the second, who needed a different level of care. He’d have to wait until the next morning, Rodriguez told him.

At this, the man’s friend rose from his seat in the van. “He came here with me,” he said. “He’s not from here. He doesn’t know nothing — he came here because of me. I can’t just leave him.”

It’s the kind of conversation Rodriguez has to navigate frequently. Sometimes patients have a wound too severe for Girard to handle, or insurance that the clinic doesn’t take.

The team managed to get in touch with a shelter for the man for the night, and bundled his friend into a car bound for Girard.

The next morning, the team was back on Kensington Avenue in the RV. Sometimes, Rodriguez wonders what effect his efforts are having, watching the same scenes of despair play out day after day.

But the man he’d turned away yesterday was waiting for them on the avenue. This time, a bed was ready.