The “Walmart of Heroin” is how the New York Times described Philadelphia’s Kensington neighborhood—in a much-criticized October 2018 story that Fairness and Accuracy in Reporting condemned as “trauma tourism.” But Philly may soon, depending on the ruling of the judge currently considering a federal case, become home to the first-ever sanctioned safe consumption site (SCS) in the United States.
However, two years of disastrous policy here—beginning with the forced closure in August 2017 of “El Campamento,” a large encampment of transient and homeless people that effectively operated as an unsanctioned SCS—have turned a serious-but-manageable situation into a crisis of harms related to synthetic drugs.
Since June, researchers have identified more than a dozen Novel Psychoactive Substances (NPS), as they’re collectively known, in packages seized by law enforcement or in human bodily fluids, analyzed following deaths. These include a new analogue of LSD (1P-LSD), and a handful of new substituted cathinones (colloquially known as “bath salts”).
Fortunately, and with the exception of new synthetic opioid analogues, death rates involving NPS—at least, to the extent we know about them—have been relatively low. But death is not the only medical emergency or form of human suffering, as anyone who has witnessed a severe reaction to synthetic cannabinoids can attest. And policy-driven lack of knowledge about NPS fuels this suffering.
The national dialogue on drug use in recent years has largely—and rightly—focused on overdose prevention. By that measure, in some cases newly emerging drugs are of relatively little concern.
One of the most recent NPS to emerge, for example, an opioid named piperidylthiambutene, is relatively weak—roughly on par with morphine. But that doesn’t mean it can’t be dangerous if taken in unknown doses, or combined with other drugs—which is more likely if people are consuming it without knowing what it is. It also has anticholinergic properties, meaning it can cause dizziness, sedation or, in rare cases, hallucinations.
A member of the thiambutene family of synthetic opioids, piperidylthiambutene is structurally distinct from fentanyl or its analogues, and from other familiar synthetic opioids. That means first responders, coroners and crime labs would likely miss it if they weren’t specifically looking for it. And given that it is not currently scheduled under the Controlled Substances Act, there’s little reason they would be.
By the time a new drug is identified, it is likely to have already contributed to deaths and other harms.
Public health officials’ reactive approach to the dozens of new synthetics appearing in US drug markets over the past several years, means that by the time a new drug is identified, it is likely to have already contributed to deaths and other harms.
Lack of information also lends itself to wild media claims—such as a report out of Pittsburgh in April of a new, “naloxone-resistant” fentanyl analogue. The thing is, although the potency of opioids varies greatly, there’s no such thing as a naloxone-resistant opioid. If a person overdoses on an opioid and naloxone doesn’t seem to be working, it just means they need more of the overdose-reversal drug.
The hugely diverse array of NPS, including some substances that have been around for longer, now trump fentanyl as the most common topic of conversation for the public health and harm reduction community in Kensington.
Xylazine and Synthetic Cannabinoids
Xylazine, for instance—the animal tranquilizer that has been used recreationally for decades in Puerto Rico and more recently as a cutting agent for heroin in cities including Philadelphia—is increasingly associated with an unusually high number of necrotic skin lesions on IV drug users. A vasoconstrictor, the drug has always had that potential, but why would it suddenly start happening more often now?
“I think they just put a bunch of fentanyl and cut on a plate, pour on the tranq and put it in the microwave.”
A lesion on a Kensington resident’s arm, believed to be related to injecting xylazine. Photo by Christopher Moraff.
I asked one local corner dealer (a “trapper” in Philly parlance) if she knew anything about how the drug, which comes in liquid form, is typically prepared. “I seen them, and I think they just put a bunch of fentanyl and cut on a plate, pour on the tranq and put it in the microwave until it’s cooked,” she said.
Perhaps this practice increases risks; without dedicated research, we can’t be sure.
During an off-the-record September 18 meeting that I attended with several prominent Philadelphia public health and harm reduction experts, the dominant subject was how to incorporate NPS into the framework of harm reduction.
The wide variety of drugs demands tailored responses. Last year, when Philadelphia had two surges of poisonings in quick succession from heroin bags adulterated with synthetic cannabinoids, the harm reduction community sprang into action. The main protocol, hammered home across harm reduction and drug-using communities, was use naloxone.
But naloxone won’t diminish the hallucinations and mental anguish many report after unwittingly taking synthetic cannabinoids. In some cases, where the person was not actually overdosing, naloxone may even have exacerbated negative experiences by removing opioid-induced euphoria, leaving people with nothing to “take the edge off” the synthetic cannabinoids.
People in the harm reduction community say that acute agitation and even violence presented in many of these cases. Harm reductionists paid attention to this suffering, and there is now discussion about titrating naloxone doses to fit individual needs, rather than potentially delivering more naloxone than necessary and precipitating painful withdrawal.
Drug Checking and Visible Failures
Meanwhile, there has been some push to employ low-cost mass spectronomy in SCS, as this marketing flyer from BaySpec illustrates. I’m not familiar with that company, but learned last year that not all portable mass-spec machines are created equally. A Smith Detection HazMat Elite I had access to, for instance, was great at telling whether or not a specific compound was in a powder or not, but lacked the granularity needed to provide a truly useful assessment.
If Safehouse opens, people will be able to inject drugs in a supervised setting. But they’ll still be forced to navigate a chaotic illicit market in chaos to acquire those drugs. Short of ending prohibition, only a massive lab testing program of samples, combined with efficient means to disseminate information, could mitigate this. SCS will benefit by training staff to recognize drug-induced emergencies in which opioids are not the primary factor and respond accordingly.
Despite the acceptance of harm reduction principles in some areas of government, politics still back the “War on Drugs”—with the typical strategy of taking out the generals, leaving foot soldiers and NCOs to fight over the scraps.
The remnants of the structured, hierarchical and multigenerational organizations running heroin enterprises in majority-Latinx areas of West Kensington—the only place in Philly where I know for sure it’s still possible to buy heroin that isn’t cut with fentanyl—are now so skittish that sources tell me they now often only serve established customers.
A couple miles to the east, the secluded side streets adjacent to a bridge briefly served as a haven, known as “Emerald City,” for some former residents of the shuttered “El Campamento.” The last time I saw Emerald City populated, in January, two women were tending to a young man’s minor head wound. Lookouts shouted the ubiquitous cry “Da Bien!” (“It’s ok!”) as customers came and went.
Philadelphia could be seen as America’s Museum of Failed Drug Policy.
Today those streets are blocked by police barricades. Emerald City’s former occupants (who, it should be noted, had obeyed police orders against camping there) are now gathering farther east, out into Port Richmond, than I have ever seen drugs being openly sold and used. New crews set up shop almost daily. And the visibly different behaviors of people who have injected drugs, together with knowledge of the fast-growing range of NPS present, make it impossible to say exactly what people are on.
Philadelphia could be seen as America’s Museum of Failed Drug Policy. Its open-air markets, stamp-branded heroin and contained area where most drugs are sold make it easy to witness in real-time the ground-level impacts of policies and policing.
When they’re not actively removing drug user-led harm reduction efforts, police responses to the uncertainty of NPS have been all over the place. They’ve ranged from vacillating, to handing out trespassing or panhandling citations like candy to homeless people who don’t stand a chance of paying the fine, to turning a blind eye to people publicly injecting on some of North Philadelphia’s main arterial thoroughfares.
Amid the visible evidence of what’s happening, it’s no wonder that most law enforcement officials I’ve spoken with—from beat cop to supervisory level—have told me off the record that they support SCS.
The standard caveat: “I could never say that publicly.”
If Kensington’s proposed SCS, operated by the nonprofit group Safehouse, prevails in federal court, Philly will become something very different: a new model for US cities to emulate.
But make no mistake, Safehouse will not just be an overdose prevention site in the conventional sense. It will also be a means of gathering critical information that can be used to protect people’s health, preventing well-intentioned but contraindicated responses to medical emergencies. Because what’s in the drugs people use there will be a mystery every time a client does a shot.
Top photograph of drug samples for testing by Christopher Moraff.