(Fourth of five parts. Read Part 1 | Read Part 2 | Read Part 3 )
BETHLEHEM, Pa. — Five years after the "emerging threat" designation for illicit drugs was created, it was used for the first time in 2023 to warn the nation of a veterinary tranquilizer, xylazine, being used as a human recreational drug.
A week later, Pennsylvania Gov. Josh Shapiro temporarily classified xylazine a schedule III drug — the illicit use and trafficking of which carries penalties of up to 30 years in prison and $5 million in fines.
He made that action permanent a year later in 2024 by signing House Bill 1661, approved by the state Legislature.
Nine state representatives co-sponsored the bill, including now-U.S. Rep. Ryan Mackenzie. Its prime sponsor was state Rep. Carl Walker Metzgar, R-Somerset County.
In response to an email inquiry from LehighValleyNews.com, Mackenzie described lawmakers' action as "playing catch-up" with the ever-changing illicit drug market.
"We heard how detrimental xylazine can be and thought the law should be updated and reflect that," said Mackenzie, a Republican who represented the 187th House District for 12 years before joining Congress this year.
"Act 17 of 2024, which I co-sponsored, is the result. Over the years, I have engaged with different rehabilitation and treatment centers for input on drug-related legislation.
"I believe it is critically important that we get information from the experts who deal with these issues every day."
'Outdated' treatment model
On the streets, xylazine commonly is called "tranq" and is used as a cutting agent with fentanyl.
But to some on the front lines of the opioid epidemic, Pennsylvania's move to schedule xylazine as a crime has had an adverse reaction — pushing drug suppliers and users to other harmful substances.
Sarah Laurel is among them. She founded and heads Savage Sisters, a nonprofit substance abuse education and outreach center in Philadelphia.
According to Laurel, more can be done to manage the threat — creating a safe supply, mandating xylazine testing statewide and spreading xylazine withdrawal treatment.
"... So keep talking and supporting the treatment avenue, but completely neglecting to acknowledge or even discuss the fact that the treatment model that we have is outdated and does not apply to the poly-chemical substance wave that we are in right now."Sarah Laurel, founder and executive director of Savage Sisters
Harm reductionists like Laurel promote the use of tactics that reduce negative consequences associated with drug usage as opposed to solely promoting abstinence.
Harm reduction approaches typically include those mentioned by Laurel, and other practices like naloxone distribution, syringe services programs, and care kits.
Last August, the Pennsylvania Department of Health distributed 50,000 wound care kits to 200 medical and harm reduction associations across the state.
Among the health risks of xylazine, which is not approved for human use, are severe skin wounds that may not be associated with injection sites.
"I'm super grateful for it, but we're five years into this crisis," Laurel said of the wound care kits. "So keep talking and supporting the treatment avenue, but completely neglecting to acknowledge or even discuss the fact that the treatment model that we have is outdated and does not apply to the poly-chemical substance wave that we are in right now."
Pennsylvania Secretary of Health Dr. Debra Bogen said the wound care kits were intended as a harm reduction tool.
“Our focus remains on harm reduction strategies, reducing stigma associated with substance use and addiction, providing education and training to reduce overdose, and helping people get connected to treatment and other services," Bogen said.
In response to an email inquiry, the state Health Department said continuing harm reduction strategies by the Shapiro administration include drop-in center services, community-based supports and treatment, and "law enforcement tactics to hold accountable the bad actors peddling this poison in our communities."
The moves require collaboration among the state Department of Drug and Alcohol Programs, the Pennsylvania Commission on Crime and Delinquency and the Department of Human Services, according to the Department of Health.
To Laurel, it's a step in the right direction, but not enough.
As the executive director of Savage Sisters, she's seen the effects of what's known as "tranq" — adulterated xylazine and fentanyl — personally and watched it infiltrate Philadelphia's drug market.
And since xylazine became a scheduled drug, she said, she's watched a different veterinary sedative — medetomidine — take over.
Raising awareness
Tracking illicit drugs and shifts in their prevalence is difficult work.
Pennsylvania appears to lack a dedicated organization that requires health care professionals to review public health alerts or advisories, such as those warning of new adulterated substances in the illicit drug market.
The Philadelphia Department of Health disseminates that information via its health information portal to area health care professionals.
It sent one to its "Health Alert Network" last Aug. 1, warning of medetomidine's detection in the illicit drug supply in Philadelphia and Pittsburgh, and stating distribution is "statewide."
Danny Teixeira da Silva, medical director of the Philadelphia Department of Health's Substance Use Division, said the information portal lets professionals review information such as alerts.
But he said to his knowledge, they're not required to.
The alert about medetomidine from the DOH asked those receiving it to share with their staff. It also shared treatment recommendations, background information and a summary about the drug.
Bill Carver, Allentown's public health paramedicine specialist, said he tries to pass along developing information to his team as much as he can.
In Allentown, Carver said the city's health department has been "giving out xylazine and fentanyl test strips for several years." Carver said he is well-versed in the signs and symptoms of xylazine use, often being in direct contact with users in the area.
With experience both in public health and emergency services, Carver said "the education we provide in EMS is to treat the symptoms."
Other avenues by which first responders can obtain updated information about emerging drug trends is through the University of Pittsburgh's Program Evaluation and Research Unit (PERU). A report copyrighted in 2022 detailed the effects of xylazine, community support and awareness, indications of use and trends.
Charles Franklin, a senior program implementation specialist at PERU, said the report came from a grant, as most of PERU's operations are funded.
"We, as first responders, sit in a position of trust in our communities."Charles Franklin, University of Pittsburgh's Program Evaluation and Research Unit
SCOPE Statewide is a first responder training program run by PERU with the aim of reducing opioid overdoses. It teaches first responders how to assist those struggling with substance use disorders.
While SCOPE can assist emergency service personnel, Franklin said a more boots-on-the-ground approach — going directly to EMS professionals in-person — has "really gotten me the most bang for my buck."
Franklin said that, to his knowledge, no entity in the state requires that information such as the xylazine pamphlet be distributed to medical professionals — alerts typically ask for hospitals, EMS councils, federally qualified health centers, local health jurisdictions and professional organizations to "please distribute as appropriate."
But he said it's a career goal of his to one day stand before legislators in Harrisburg who have made that a requirement.
"It would be easy if our government mandated a solution, right?" Franklin said.
For now, he said he works to grow his outreach because, "we, as first responders, sit in a position of trust in our communities."
He said that trust can leverage training or treatment opportunities in communities — such as naloxone vending machines or distributing fentanyl test strips.
Opioid settlement funds
Both Northampton and Lehigh counties have committed and spent a combined total of more than $1.5 million in Pennsylvania Opioid Settlement money from the Pennsylvania Opioid Misuse and Addiction Abatement Trust, or POMAAT, according to a database tracking the funds from the news organization SpotlightPA.
Funds went toward drug disposal pouch disbursal, free Narcan distribution boxes and enhancements to Northampton County recovery centers.
In Allegheny County, Prevention Point Pittsburgh has seen programs such as syringe services benefit its community.
The database shows $325,000 went toward the nonprofit organization's program, but there's yet to be a program like that developed in the Lehigh Valley.
Having access to sterile injection equipment prevents the spread of HIV, Hepatitis C, endocarditis and other blood borne illnesses, said Alice Bell, overdose prevention project coordinator at Prevention Point Pittsburgh.
It's a concept often viewed negatively by the public, according to the Johns Hopkins Bloomberg School of Public Health.
"I think Neil Capretto, who used to be the medical director of Gateway Rehab, used to say, 'People who are opposed to harm reduction, does that mean that you're (in favor of) harm enhancement?'"Alice Bell, overdose prevention project coordinator at Prevention Point Pittsburgh
That school reported in 2018 that, according to results of a study among 1,004 adults, "only 29 percent supported legalizing safe consumption sites in their communities and only 39 percent supported legalizing syringe services programs in their communities."
That's in spite of such strategies having "been found to reduce drug overdoses and HIV transmissions."
Bell doesn't view any of those strategies as radical.
"I think Neil Capretto, who used to be the medical director of Gateway Rehab, used to say, 'People who are opposed to harm reduction, does that mean that you're (in favor of) harm enhancement?'" Bell said.
"There's decades of research that access to sterile injection equipment reduces the spread of blood borne illness, so that it's just good public health."
Local organizations such as Lehigh County Medical Society, Lehigh Valley Health Network, Counseling Solutions of the Lehigh Valley and Northampton County Medical Society are among over 180 organizations that support the expansion of syringe services programs, compiled by the PA Harm Reduction Network.
But those strategies haven't moved toward the Lehigh Valley.
And with legislative focus instead directed toward criminalization of illicit substances like xylazine, Laurel said, "what you see is the criminal drug market is responding with a new drug that is easier to access."
COMING TOMORROW: "The next coming nightmare" arrives. How the synthetic animal tranquilizer medetomidine is rapidly overtaking xylazine on the streets.
