The Southern Tier Aids Program (STAP) staff keep a “bad batch board” hanging on the wall at their syringe exchange location in Johnson City.
People coming by the location to get clean syringes can write on the board if they have had a bad or unusual experience with a drug.
“I think people are concerned," said John Barry, executive director of STAP. "It's why they're coming in and sharing with us, the stuff was this color and this consistency and it had this effect.”
In part, people are concerned about xylazine, a veterinary anesthetic showing up in the drug supply all over the Northeast. Since 2021, 91% of drug samples tested in Philadelphia contained xylazine. It has also been found in the opioid supply in New York City and throughout the rest of the state.
Public health officials are grappling with how to respond to the spread of xylazine. But harm reduction providers, like those at STAP, say it is just the latest in a rapidly evolving drug market.
Xylazine, also called “tranq,” can cause open sores and painful, sometimes black wounds on the skin. Skin wounds can show up anywhere on the body, not just at injection sites.
The drug can also cause intense withdrawal symptoms and a knockout high that puts people using it at serious risk. It is not an opioid, so the opioid overdose-reversing drug naloxone doesn't reverse its effects.
People don’t know they’re using xylazine because it is cut into opioidslike fentanyl, along with many other drugs, such as benzodiazepines, other sedatives, and dilutants meant to bulk up the product.
Barry said xylazine is just one of many synthetic drugs added to opioids to make them smaller, stronger, and easier to smuggle. He calls that the “iron law of prohibition.” The harder law enforcement cracks down on a drug, the more dangerous it gets.
“When alcohol was illegal in this country, people were shipping whiskey from Canada, not cases of beer,” Barry said. “So, the more law enforcement you bring into the equation, the more dangerous, the more concentrated and the more poisonous you are going to make the drugs.”
Barry said with such an increasingly dangerous drug supply, the focus should be on preventing more death. He argues for efforts like “safe supply”, in which providers prescribe medical-grade heroin and other opioids to people who have not been helped by drugs like buprenorphine or methadone.
Jessica Irvine, STAP’s harm reduction coordinator, said the bad batch board is a useful community resource, but it’s not always enough. She said while people may suspect that xylazine or other substances are in their drugs, they can’t easily test them.
“We’ll hear that people are having to use a lot of Narcan when reversing an overdose. And I’m always curious to know if xylazine was in the substance,” Irvine said.
Soon, STAP will be able to test drugs in real-time using a spectrometer. With just a tiny sample or the residue of a drug, the machine can determine the substances it has been cut with. Unlike testing strips, it can also tell people how much of each substance there is.
OnPoint NYC, the first overdose prevention center, or “safe injection site” in the country, uses similar technology and has checked hundreds of drug samples since 2021.
Working with the state as part of a pilot program, STAP has received two machines. Some of the staff will learn how to test people’s drugs. They will check their results for the first 100 or 150 samples, by sending them to a street drug analysis lab at the University of North Carolina.
“It's not heroin anymore”
Fernando Montero is a medical anthropologist at Columbia University. He has studied the effects of synthetic drugs like xylazine, fentanyl, and methamphetamine on the drug market in Philadelphia for years.
“It's not heroin anymore," Montero said. "For the most part, people in the Northeast are now consuming a little bit of fentanyl and a lot of xylazine.”
He said between 1991 and 2013, the heroin supply in the Northeast was very consistent. If you were buying street opioids, you usually got heroin. But when fentanyl showed up, it replaced heroin. He said that has caused ripple effects.
“From the point of view of a person who uses drugs, who uses opiates every day, fentanyl is a worse drug in many respects than heroin. And the most important way in which it is worse is that it lasts so much less,” Montero said.
That means people get sick much faster and have to use more often to stave off withdrawal. Montero said that’s opened the door to other drugs, like xylazine. When combined with fentanyl, xylazine extends its effects.
“It mimics heroin. And that's what makes it appealing to consumers. Then again, it also introduces all these new problems, right?” Montero said.
He added there is still a lot of misunderstanding about the dynamics of the drug supply, and that makes it more difficult for the health system to catch up.
“A lot of the inability of public health, and of harm reduction, to respond to these huge changes in the supply in real-time, has to do with a general lack of knowledge regarding how drug markets work,” Montero said.
He said to get ahead of those changes, providers need to talk to people who use and sell drugs, because they’re usually the first to know about a new substance in the supply.
“Six months from now, what's going to be the new thing?”
In the parking lot of the Southern Tier Aids Program in Johnson City, Dean O’Gorman and Kurt Kleefeld have parked their mobile harm reduction van for the moment.
They hand out supplies like syringes and wound care kits, and they connect people to resources. In the van, they can drive across 11 counties to reach people, so they have seen the spread of new synthetics in the supply.
“Being mobile in different areas, we could see where it would start in Broome, or Syracuse, and merge into Cortland, and spread out to Norwich or Elmira,” O’Gorman said. “And you could see the color change, basically, with what's going on with the drug.”
That gave them the chance to warn people in advance. But Kleefeld said it is often hard to keep up with the changing drug supply.
“A Canadian company just came out with a xylazine test strip. Great, that's awesome,” Kleefeld said. “And in the back of my mind I think, six months from now, what's gonna be the new thing that's out that we don't have the technology to help people with?’”
In the meantime, the STAP team still has tools that work. O’Gorman is adamant that people should continue to use Narcan, and he's frustrated by language implying that xylazine is "Narcan-resistant".
"Xylazine is a tranquilizer. It's not an opioid. It's not resistant. It's not even made to work with [Narcan], but it is mixed with the fentanyl," O'Gorman said. "Fentanyl will cause the respiratory depression; the tranq will not. So always, always give Narcan."
And no matter how the drug supply continues to change, people will still need clean syringes and connections to health care and housing.