(Third of five parts. Read Part 1 HERE| Read Part 2 HERE)
BETHLEHEM, Pa. — The immediate response to drug overdoses used to be to administer naloxone.
It still is — just sometimes not as effective.
In what Sarah Laurel of Savage Sisters — a nonprofit providing trauma-informed recovery housing, harm reduction services and education in Pennsylvania — describes as a "poly-chemical substance wave," naloxone is no longer the cure-all.
Health care professionals such as Dr. Rachael Westover, medical director of toxicology at St. Luke's University Health Network, still recommend using the opioid-reversal drug to address any percentage of opioid used in a drug mixture.
"Narcan is kind of a big thing for us in our group, in general," Westover said. (Narcan is the brand name for a device that delivers naloxone.)
"Even patients will be like, 'I don't want that,' and I say 'Take it for someone else. Give it to your family member. Give it to a friend.'
"Because I've had people that have come in after an overdose and said, 'Well, thankfully I had Narcan on me.'"
Laurel, Savage Sister's founder and executive director, has responded first-hand to overdoses — typically from heavily adulterated substances — on the streets of Philadelphia's Kensington neighborhood.
“I've never seen anything like this in my life."Sarah Laurel, founder and executive director of Savage Sisters
And she said administering oxygen is what's bringing people back.
“I've never seen anything like this in my life,” Laurel said in a 2023 interview, referring to the effects and spread of the animal tranquilizer xylazine, also known as "tranq."
“And I was a homeless heroin addict consuming substances. I've seen a lot of terrible things, and I have never seen this many individuals in this kind of desperate state in a first-world country.”
Warnings of inadequacy
Savage Sisters is a nonprofit that provides trauma-informed recovery housing, harm reduction services and education in Pennsylvania, and has been at the forefront of combatting the xylazine epidemic in Philadelphia.
The team has watched the drug grow in usage, combined with opioids such as fentanyl, over the past several years.
It first was recorded in the city in 2006, but overdoses with xylazine detection appear to date to 2010, according to a chart in a March 2022 health alert from the Philadelphia Department of Health.
Even two years ago, the health alert warned that "Providers may find that naloxone will be ineffective for some patients as xylazine intoxication is not reversed by naloxone."
Naloxone is used to reverse opioid-related overdoses by attaching to opioid receptors and reversing and blocking the effects of other opioids, according to the National Institute on Drug Abuse.
But it doesn't work on xylazine, because xylazine isn't an opioid — it's an animal tranquilizer approved for veterinary use.
Often used in combination with fentanyl, xylazine can result in decreased breathing and heart rate.
'Respiratory support is crucial'
Health alerts suggest responders use "supportive care" such as airway management, in the case of xylazine overdose.
Laurel said her team has found that's the key to reviving users.
She recalled in a previous interview that during “the first two years of responding to 'tranq' dope overdoses, we were on our knees doing rescue breathing for 16 to 18 minutes. People were not responsive. They were not coming out of these overdoses.”
A year later, with another veterinary sedative, medetomidine, now in the supply, they still use the same tactics, she said.
"Obviously, we administer naloxone," Laurel said. "We always encourage everyone to administer naloxone, because there is still a very small part that is fentanyl.
"However, respiratory support is crucial when dealing with this mixture."
And now, Laurel said her team has seen individuals experience another overdose within an hour after coming back from one, a result she believes is because of medetomidine's increased potency.
She said she's heard estimates that it's 50 to 200 times as strong as xylazine.
And, chances are, the drug could make its way to the Lehigh Valley.
'They don't know either'
Xylazine first was recorded in overdose deaths in Northampton County in 2020 and Lehigh County in 2023.
Christopher Moraff, founder of PA Groundhogs and Narcomedia, organizations that both work toward tracking drug usage throughout the state, said he knows suppliers close to Philadelphia oftentimes travel to the city for drugs.
"There's a strong likelihood that there is tranq dope in the Lehigh Valley."Christopher Moraff, founder of PA Groundhogs and Narcomedia
"A lot of people as far out as Allentown, I know, come down and cop here" in Philadelphia, Moraff said.
"So whatever they were getting, there's a strong likelihood that there is 'tranq' dope in the Lehigh Valley."
Westover said she's heard patients say they do exactly that — travel to Philadelphia and bring their supply back to the Valley.
When patients come in, Westover said, they sometimes don't realize what they're taking. A patient could say they're only using xylazine or "tranq," but cocaine might show up in their urine.
"It's kind of hard to keep up with the exact substances that patients are using, but they don't know either," Westover said.
Health professionals, organizations and harm reduction specialists still call the medetomidine mixture "tranq dope" or "tranq," which is what users also call xylazine.
Laurel said it's because medetomidine still is found with the original xylazine and fentanyl combination — and Philadelphia DOH health alerts say the same.
The Philadelphia DOH also recommends administering naloxone as the first step when responding to an overdose, even if it might have involved xylazine or medetomidine.
"As with xylazine, medetomidine may cause prolonged sedation which emphasizes the role of administering rescue breaths, placing an individual in the rescue position, and monitoring the individual after administration of naloxone," the May 13, 2024, health alert says.
"Monitoring should be focused on breathing and ensuring that individuals who experience an overdose are able to protect their airway, which may be compromised in the setting of prolonged sedation.
"Once individuals are breathing on their own and taking a minimum of one breath every six seconds, they no longer require more naloxone."
The alert also says that atipamezole or yohimbine may reverse the effects of xylazine and medetomidine, but that neither forms of medicine have been approved for human use.
"Administration of atipamezole or yohimbine to someone regularly using illicit drugs in Philadelphia may lead to harmful and abrupt alpha-2 agonist withdrawal symptoms, such as hypertension, tachycardia, and agitation," the alert says.
"Thus, atipamezole nor yohimbine should not be used to reverse adverse effects of medetomidine."
Anyone responding to an overdose should also call 911, the alert says.
Where to get naloxone
Narcan is for sale over the counter at pharmacies throughout the state.
It can also be bought online at Amazon for $44.97.
The opioid-reversal treatment also is available in-store and online at CVS, Target, RiteAid and Walgreens for around $44.99, and Walmart for $44.97.
All listed retailers show Narcan as Flexible Spending Account (FSA) and Health Savings Account (HSA) eligible.
It's also available for free through other resources.
NEXT Distro, a partnership between NEXT Harm Reduction and Prevention Point Pittsburgh offers mail-based naloxone services to Pennsylvania residents. To request and qualify for naloxone distribution, the webpage asks visitors to watch a video, respond to a questionnaire and provide enrollment information.
Northampton County used its opioid settlement funds to create its "Fake is Real" campaign, which aims to raise awareness about the dangers of fake fentanyl.
The county "commemorated" those campaign efforts in January 2024, announcing it would install nine Narcan distribution boxes throughout the county.
They are:
- Rotunda of the Government Center (669 Washington St., Easton)
- Entrance of the Human Services Building (2801 Emrick Blvd., Bethlehem)
- Entrance of Gracedale Nursing Home (2 Gracedale Ave., Upper Nazareth Township)
- Entrance of the Domestic Relations Building (126 S. Union St., Easton)
- Entrance of the Juvenile Justice Center (650 Ferry St., Easton)
- Entrance of the Criminal Administration Building (105 S. Union St., Easton)
- Entrance of the County Prison & Inside Intake Department (666 Walnut St., Easton)
- Entrance of the Palmer Recovery Center (2906 William Penn Highway, Palmer Township)
- Entrance of the Hope Center (429 E. Broad St., Bethlehem)
The Narcan inside those distribution boxes is free and includes two single-dose nasal spray devices and instructions on the back of the box.
Bill Carver, Public Health Paramedicine Specialist at the Allentown Health Bureau said the organization distributes naloxone as well and is "a few weeks away" from installing vending machines that would include the opioid antagonist inside, among other harm reduction supplies.
Most recently, the bureau installed two naloxone distribution boxes on traffic light posts through a partnership with Lehigh County Drug and Alcohol Services.
The pole boxes are at:
- Ninth and Linden streets (Southwest corner)
- Seventh and Chew streets.
While some celebrated the move, Lisa Baas said she knows all too well the opioid overdose reversal medication has a limit to its use.
Her daughter, Heather Noonan, died of a drug overdose with a significant level of xylazine in her system. She recalled collecting her daughter's belongings from Lehigh Valley Hospital-Muhlenberg and seeing Narcan in Noonan's purse.
While the treatment spray could have reversed the other opioids in Noonan's system, it wouldn't — nor could it — reverse the effects of 19.5 nanograms per milliliter of xylazine in her blood.
Testimony from Robert A. Middleberg of NMS Labs shared that "it appears that concentrations <10 ng/mL are found in non-fatal cases."
In Commonwealth v. Christopher Ferrante, toxicology testimony reported that Ferrante delivered drugs to former state wrestling champion Michael "Mikey" Racciato with a "presence and concentration of fentanyl and xylazine" that were "the significant toxicological contributors" to his death.
Racciato had 20 ng/mL of xylazine in his system — well above the potential "non-fatal" concentration — and Noonan had just .5 ng/mL less.
When Baas saw the City of Allentown's Facebook post announcing the public placement of naloxone distribution boxes, she immediately thought back to her daughter.
"Like, that's great and all, but remember xylazine," Baas said.
A year after her daughter's death and learning about xylazine, Baas wants others to know about it, too.
"It's a great move," Baas wrote in a Facebook comment. "But watch out because ... these days the Fentanyl type drugs can be mixed with Xylazine, which has no antidote. Naloxone will not work.
"Beware. Get help."
COMING TOMORROW: As the federal and state governments have taken steps to address the prevalence of xylazine, illicit drug suppliers and users are introducing new synthetic drugs to the market.
