After two years of sobriety, Allie Gramlich began using drugs again in April. This time around, Philadelphia’s street opioid supply was infiltrated with tranq or tranq dope, a mixture of fentanyl mixed and the animal tranquilizer xylazine. The high was non-existent, she said, replaced by hours of unconsciousness followed by intense withdrawal—and when she wanted to come off it only a couple months later, the detox was even worse. 

“It was honestly the most traumatizing experience I’ve ever had in my life.” 

When Gramlich, 28, had previously detoxed off heroin and fentanyl, she said she was sick for about a week. But with tranq, she said her dopesickness—which included constant vomiting, intense heart palpitations, chills, and a complete lack of energy—lasted 21 days. She was given drugs like methadone and clonidine, which is used to treat anxiety, to help ease the withdrawal, but she said “there was no comfort at all the entire time.” 

“They have no idea what they’re in for. They have no idea how to treat it.”

“These detox centers, these rehabs, they have no idea what they’re in for. They have no idea how to treat it. Some of them don’t even know what xylazine is.” 

Gramlich went to an inpatient treatment program run by Recovery Centers of America, which she described as “one of the nicer rehabs.” Still, she said, she wasn’t tested for xylazine, and no one she came across was familiar enough with xylazine to discuss it with her. She said she didn’t start feeling normal again until a week after she left rehab and went into a sober living house. 

“I would encourage anyone to go to detox, but like my heart would break for them knowing what they were for,” she said. “Some of these people have been using this shit for years and if it was that bad for me I cannot even imagine… how bad it would be.” 

Recovery Centers of America did not respond to VICE News’ request for comment. 

While Philadelphia is an epicenter for xylazine in the U.S., data exclusively shared with VICE News shows the drug has spread to at least 39 states. But doctors, governments, and the rehab industry are struggling to cope with its noxious effects. It knocks users out for hours at time; causes more severe overdoses, as xylazine doesn’t respond to naloxone; and has been linked to severe skin ulcers, wounds, and amputations, as VICE News previously reported. On top of that, many drug users aren’t even aware that they’re taking it, and because there’s no quick turnaround test for xylazine in rehabs and hospitals, they won’t necessarily find out—and neither will the people taking care of them. Because there are no best practices for detoxing off tranq, many users who want to quit are fearful that they won’t have access to medication that will take the edge off of their excruciating withdrawal. In a recent post about xylazine, one rehab said, “Tranq just might mean never coming back—ever.” 

“Most people, when you talk to them, they’re like, ‘I’m not going to rehab.’ It’s just too painful,” said Sarah Laurel, founder of Savage Sisters, a harm reduction group in Philadelphia. “They’re not going to sit there and be miserable and uncomfortable for two weeks.” 

Xylazine is a veterinary sedative that is not FDA-approved for human consumption, but it’s not federally scheduled, making it easy to purchase online. It was detected in Puerto Rico’s drug supply in the early 2000s but has since made its way to the northeast United States, where it appears to be most prevalent in drug deaths in Pennsylvania.  

Most commonly found in bags of drugs sold as fentanyl and heroin, xylazine was found in 90 percent of dope samples tested in Philadelphia in 2021, according to the city. It went from being found in less than 2 percent of the city’s fatal opioid overdoses from 2010 to 2015 to 34 percent in 2021.  

And now it’s spreading to the rest of the country. NMS Labs, the largest private forensic toxicology lab in the country, looked at 260,000 samples screened for xylazine between January 2019 and June 2022. The results, provided to VICE News, found that positive samples—taken from suspected impaired driving cases and autopsies in the U.S. and Canada—increased five-fold during that time. In January 2019, samples from 41 states showed xylazine present in eight states and Puerto Rico—by June 2022, samples from all 50 states showed xylazine in 39 of them as well as Washington, D.C., and Puerto Rico. 

Aegis Sciences Corporation, one of the few labs that does urine and oral fluid testing for xylazine from samples taken from rehabs, told VICE News it has found the tranquilizer in 30 states in 2022, though Josh Schrecker, the lab’s director of clinical affairs, said it’s likely there are drugs in every state that have been adulterated with the animal sedative. 

But it’s hard to get a true sense of how many people are using xylazine. While the Centers for Disease Control and Prevention’s overdose stats track synthetic opioids like fentanyl, they don’t yet include xylazine-related deaths. The data we do have is piecemeal, coming from local health departments, coroner’s offices, and drug checking services. 

“[Xylazine] is becoming more and more prevalent in fatality, so if there is no way for a user to even test and determine if it’s in their supply and for medical professionals to also not know upfront what they’re treating—it’s a problem,” said Dr. Phillip Moore, chief medical officer of Gaudenzia, a non-profit that has multiple recovery centers in the northeast. 

Rehabs can be another source of data for drug use, but most don’t screen for xylazine. Because it’s a relatively new contaminant in the drug supply, xylazine isn’t included on typical drug screens in rehabs, which test for up to a dozen of the most commonly used illicit substances, like cocaine, opioids, and benzodiazepines. Those immunoassay tests use urine to provide quick results but toxicology experts told VICE News there is no immunoassay test for xylazine in the U.S. (A Canadian company has just reportedly come out with test strips.) That means facilities that want to test their patients for tranq have to send their results out to a specialized lab, such as Aegis, which is slower and more expensive. Aegis said its tests typically take 72 hours, which isn’t as useful to a facility providing acute care to someone who is in withdrawal. 

VICE News reached out to 10 rehab facilities in and around Philadelphia to ask if they send out samples to a lab for xylazine testing or have specific xylazine-related protocols. Of the four that responded, none regularly sent out client’s samples to have them tested for xylazine. Their reasons for not doing so included the tests not coming back quickly enough to be relevant to a person’s care and insurance not covering the tests. All four said they were aware that xylazine was in the drug supply and that if their clients were using bags of fentanyl, there was a high likelihood they were also using xylazine. All of the facilities who responded also said they treated tranq users based on first-hand experiences and trial and error, because best practices don’t exist. 

The FDA issued an alert about xylazine on Nov. 8, noting that “health care professionals should provide supportive measures and consider screening for xylazine using appropriate tests.” The agency also said people who stop using xylazine abruptly can experience severe withdrawal but “no medications have an FDA-approved indication to manage xylazine withdrawal in symptomatic individuals.” 

In some ways, xylazine is following the same path as fentanyl, which rehabs didn’t regularly test for until a few years ago. That meant people seeking treatment weren’t always given opioids for their withdrawal because they didn’t test positive for drugs, sources in the rehab industry told VICE News. In the meantime, fentanyl rapidly infiltrated the drug supply and overdoses spiked, leaving addictions experts and harm reductionists scrambling. While North America still doesn’t have a handle on the fentanyl crisis, strong adulterants like xylazine are making the situation a lot worse.    

“They’re still experiencing tremulousness, anxiety, problems sleeping, restlessness, sweats.”

Moore said Gaudenzia sometimes sends out samples for xylazine testing when a client is going through detox and showing resistance to medication-assisted treatment (MAT)—drugs like methadone or buprenorphine, which are the gold standard for treating opioid addiction. (Research shows that people who don’t receive MAT are much more likely to start using drugs again.) 

“When you start MAT you have that instant relief,” he said. But xylazine doesn’t hit the opioid receptors, so opioid treatments don’t provide the same feeling. 

“They’re still experiencing tremulousness, anxiety, problems sleeping, restlessness, sweats.” 

He said he’s had some success with giving clients clonidine, which comes from the imidazoline class of drugs; imidazolines work on receptors in the sympathetic nervous system, which are also impacted by xylazine.

Dr. Joseph D’Orazio, director of medical toxicology and addiction medicine at Philadelphia’s Temple University Hospital, said it can be hard to tell which withdrawal symptoms are coming from fentanyl and which are coming from xylazine, but he said for tranq users, even when the opioid withdrawal symptoms have cleared up, there is often still severe anxiety.

D’Orazio, who has been treating patients who use tranq for years, said part of the problem is that street doses of fentanyl have gone up “tremendously,” making opioid withdrawal harder to manage.

“It’s just so difficult to match street doses when you’re in an inpatient drug rehab, a detox, (or) a hospital. Patients are still in withdrawal despite maximal effort,” he said. 

One of the more grim markers of tranq are the wounds and skin ulcers that users develop—sometimes at the sites of injections but also in other parts of the body. There’s no concrete scientific explanation as to what’s causing the wounds, but Moore said xylazine may cause blood vessels to narrow and constrict, which can increase the time it takes the body to heal. 

According to the city of Philadelphia, emergency department visits for skin and soft tissue injuries more than quadrupled between the first quarter of 2019 and the end of 2021. 

At Temple, D’Orazio said tranq users can be treated for wounds and withdrawal simultaneously. But many inpatient rehab facilities can’t treat the types of wounds that are common to tranq users, putting up another block to those people getting treatment. They’re also getting turned away from sober living houses and even shelters because of their open wounds, he added. 

“If we cannot place somebody in a drug rehab, a nursing home, a skilled nursing facility, recovery house, the shelter is the last place that we’ll send them to,” he said. “You cannot go to a shelter with an open wound. And so really, people are forced back onto the street and they have wounds, which is really unfortunate because we have already identified that these are people that have the worst disease and need the most help.” 

D’Orazio said the city needs to provide low-barrier wound care to people using tranq, which could include having wound care specialists visit inpatient rehabs and recovery homes. 

The city’s department of behavioral health and intellectual disabilities services, which oversees rehabs, did not respond to a request for comment. 

D’Orazio said his takeaways come from his experience working with patients, but that there aren’t objective studies that have looked at xylazine withdrawal. Part of the problem, he said, goes back to the lack of testing. 

“We need to build the impetus to do the research to look at and identify the withdrawal syndrome, to determine the cause of wounds, to determine the best pathway for treatment of xylazine withdrawal,” he said, adding he believes those steps are a few years away. 

But getting clinical trials approved for xylazine would be an uphill battle, because it’s not approved for use in humans. 

Schrecker, of Aegis, said part of the reason it’s hard to commit resources to developing immunoassay tests for novel drugs is it’s not clear how long they’ll be in the drug supply. There has been a push by some lawmakers to schedule xylazine at a state-level, though nothing federally yet.  

“A lot of times those things are driven by whether a drug becomes federally scheduled. That’s where we start to see things make a pretty quick exit out of the market.” 

For advocates like Laurel, who has seen many people she knows die after using tranq, waiting for the medical establishment to catch up has been frustrating. 

Laurel has been on a “crazy kick” trying to get rehabs to test for xylazine. She’s been handing out business cards to drug users around Pennsylvania that say “test me for xylazine,” in the hopes that more medical practitioners will learn about it.  

At a recent event a couple hours outside of Philadelphia, she said a mother came up to her and showed her photos of her daughter, who has been living in an encampment. 

“She was like, ‘Her boyfriend’s poisoning her. Look what’s happening to her skin.’ And I was like, ‘That’s not what’s happening. This is a different type of drug.’” 

Laurel’s advice to harm reduction groups in other parts of the U.S. that are being hit with xylazine is to incorporate oxygen tanks and rescue breathing into overdose reversal; ramp up on-the-street wound care; and teach people how to inject drugs safely and more hygienically.  

She’s not hopeful that xylazine will disappear from the drug supply anytime soon. 

“It is much easier to access for drug dealers, because it’s less expensive, because there’s actually no restrictions on this substance. Why in God’s name would anyone ever stop using this substance?” 

Follow Manisha Krishnan on Twitter.