How Pitt is taking on the next phase of the opioid epidemic

How do you stop the spread of a dangerous substance if you don't have a way to detect it?

When Raagini Jawa, an assistant professor in the Department of Medicine and clinician investigator in the Center for Research on Health Care moved to Pittsburgh in the summer of 2022, she was on the lookout for signs of whether xylazine, an adulterant in illicit fentanyl and heroin, had infiltrated the local drug supply. It had already occurred where she previously lived in Boston.

Jawa found that while many of her new Pittsburgh physician colleagues had heard of xylazine, most were unsure if it was in the local supply and if their patients were exposed.

Unfortunately, there's a lack of accessible community-level surveillance of the illicit drug supply in the U.S., said Jawa, and until January 2023, drug testing equipment like fentanyl and xylazine test strips were considered paraphernalia and were illegal.

"If we limit or criminalize harm reduction modalities, some of which allow for community-level drug testing, you're not going to have real-time surveillance of the rapidly changing drug supply," she said. "The data is lagging in reaching patients who are directly impacted even with the legalization of xylazine testing strips."

Straddling direct care with scientific inquiry has made Jawa a leading voice in xylazine education and treatment. In partnership with the Grayken Center for Addiction Training and Technical Assistance in Boston, she has led the education of thousands of health care providers nationwide on clinical impacts and harm-reduction best practices related to xylazine use.

Though overdose deaths from synthetic opioids dropped in 2023, xylazine adulteration continues, and its impact on overdoses remains to be seen - and Jawa and other Pitt professors and instructional staff are taking the lead in educating the public, physicians and frontline workers on treatment best practices.

Staying ahead of the curve

Xylazine, also commonly called tranq, is a sedative approved by the FDA only for veterinary procedures. When humans take the drug, it can slow down brain function and cause drowsiness and dangerously low blood pressure.

It's also an increasingly prevalent adulterant to illicitly manufactured fentanyl and heroin, amplifying those street drugs' already precipitous risks. Even after being treated with naloxone, the first-line antidote for an opioid overdose, a person may be unresponsive because xylazine is still active in their system.

In April 2023, the Biden administration designated fentanyl adulterated or associated with xylazine as an emerging threat - the first such designation ever in the U.S. Pennsylvania's Gov. Josh Shapiro then temporarily classified xylazine as a schedule III controlled substance.

In 2023, the Pennsylvania Department of Health identified the drug as a contributing factor in 669 deaths in 45 counties, wreaking havoc and heartache across the commonwealth.

Jawa sees the harms of the changing illicit drug supply firsthand: She treats people with opioid use disorder, some of whom have xylazine wounds, in UPMC's Addiction Medicine clinic and as a volunteer provider at Prevention Point Pittsburgh, a nonprofit organization dedicated to providing health empowerment services to people who use drugs.

"People who use drugs are a vulnerable population who have historically been disenfranchised by the medical and public health systems. Often they are left to fend for themselves," Jawa said. "It's important to normalize the fact that this patient population are the experts in the changing drug supply, and their voice and experience is critical to teach health providers and guide public health advocates. When there are changes in the drug supply, we learn about it from the people who are directly exposed to these drugs."

A telltale sign that a person who uses opioids has been exposed to xylazine-adulterated drugs is the appearance of necrotic skin and soft tissue wounds. Those wounds can occur both at and away from injection sites, adding an extra layer of complexity to an already difficult treatment process. For example, if a person injects fentanyl-laced xylazine in their arm, a wound may emerge on their leg or foot.

When people are unable to access low-barrier, non-stigmatizing wound care, those wounds have the potential to progress in severity, sometimes requiring surgeons to remove skin, attach skin grafts or even amputate.

An all-hands-on-deck approach is the only way to hamper the drug's impact, said Jawa.

"We need systems, we need support, we need funding and we need research."

On the front lines

The tide of xylazine-adulterated opioids swept across Pennsylvania seemingly overnight, said Charles Franklin, a senior program implementation specialist for community health initiatives in the Strategies to Coordinate Overdose Prevention Efforts(SCOPE) statewide program, an initiative of the School of Pharmacy's Program Evaluation and Research Unit.

"It used to be that one part of the state would be struggling with a new formulation of substances, and it would eventually make its way across Pennsylvania, but opioid addiction is an evolving, fast-moving disease," he said.

Even before the federal and Pennsylvania state governments made decrees about xylazine's danger, SCOPE adapted its training to the threat of xylazine usage. SCOPE instructors teach continuing education workshops to first responders in Pennsylvania and southern Ohio to reduce the impact of opioid overdoses in their communities, giving instructors a direct line to EMS and firefighters with firsthand, daily experience of the challenges in their community - and observations of the changing landscape of opioid use.

One common misconception is that substance use disorder only shows up in some places.

"It's very easy for individuals to think, 'not in my backyard, we don't have a problem,'" said Rachel Rock, the senior program implementation specialist for community health initiatives in SCOPE. "The reality is that xylazine is throughout the drug supply."

Rural counties don't possess the same resources as urban areas to monitor drug supplies, and that adds value to SCOPE instructors' training; first responders learn about issues facing other counties.

"The reality is xylazine was identified in Philadelphia because Philadelphia coroners started testing for it -the alert came from the medical examiners because they were testing the supply," said Rock.

Over the past three years, close to 3,700 first responders have received SCOPE training.

The program curriculum addresses the complexities inherent in treating individuals with substance use disorder. First responders are trained in trauma-informed care, naloxone administration and motivational interviewing, which leads substance users to explore options to change their behavior and to connect them to potential recovery resources.

After an overdose victim is revived, there is an opportunity to have a conversation in the moment with the drug user about getting help, said Franklin.

"We teach public safety providers how to provide that intervention. The overdose survivor may say, 'I'm really stuck, and I don't know where to go; can you help me?' And that's the place where a first responder responds, 'in a matter of fact, we can, and here's what we can do together."

- Nichole Faina, photography provided by Kristy Rzepecki, program manager for the Program Evaluation and Research Unit

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