Addiction takes a toll on life and limb

The woman came to Samir Mehta’s clinic with a wound in her leg. The infection ran so deep and had destroyed so much soft tissue that Mehta thought he was dealing with an aggressive form of cancer.

As the Penn Medicine orthopedic surgeon was removing infected flesh around the patient’s tibia — a process called debridement – the bone began to crumble at his touch, he said, like “rotting wood that falls apart in your hands.”

He decided the only option was to amputate.

It was 2022, and doctors around the Philadelphia region were facing the same decision as hundreds of drug users arrived at hospitals with similarly grave wounds. The harm was unlike anything they’d seen before: blackened hands and fingers, lesions that hollowed out arms and legs to the bone, maggots swimming in rotten flesh.

This new chapter opened in the opioid crisis about five years ago, with Philadelphia becoming ground zero for “tranq,” the street name for xylazine, an animal tranquilizer that quickly overtook the city’s illicit street drugs. Understudied and never approved for human use, tranq doesn’t kill instantly like the powerful synthetic opioid fentanyl.

But the toll is clearly devastating: The severity of the skin wounds associated with tranq is costing people their limbs. Amputations among people addicted to opioids have doubled in five years in Philadelphia, The Inquirer found, in an extensive analysis of medical billing data and over six months of interviews with medical professionals, patients, and tranq users.

At least 450 people with documented opioid use disorders had amputations between 2020 and 2023, the analysis found. And that is likely an undercount.

The healthcare system does not yet have a specific code that would enable it to track xylazine wounds treated at hospitals. Looking at amputations, combined with factors indicating drug use, offers public health officials a way to begin to assess tranq’s impact.

The amputation spike extends beyond Pennsylvania. Based on their own survey of medical billing data, New Jersey state health officials said the number of amputations among patients with a substance use disorder increased by about 60% between 2019 and 2023, compared with about 8% among patients without a documented drug problem.

Beyond indicating tranq’s harm, the rise in amputations is also a mark of the slow public health response to the latest threat in the drug epidemic, and shows the limits of available medical treatment.

Philadelphia health officials only last year published their first extensive wound treatment recommendations for healthcare providers and petitioned the federal government to create a diagnostic code to better track xylazine wounds. Meanwhile, an even more potent sedative called medetomidine — whose effects doctors know even less about — has begun replacing xylazine in the street drug supply.

The city acknowledged there is no standard for when to amputate. A spokesperson for the Philadelphia Department of Public Health said there is “growing consensus” among doctors, but practices still vary widely among hospitals.

» READ MORE: A doctor's persistence pays off for one patient.

And increasingly, doctors and patients are asking difficult questions: Have all the amputations been necessary? Some wounds are so severe that amputation is a matter of life or death. But could others have been avoided?

Some drug users say the fear of an amputation has a perverse consequence — they avoid seeking wound treatment at hospitals.

Meanwhile, doctors are starting to gather evidence that basic wound care and limiting drug use can lead to better outcomes: Limbs, even with dangerous levels of damage, can heal.

Two years ago, a wound on Alexandria Elizabeth Carsello’s left arm deteriorated so badly that the limb was hanging on to her torso by a quarter-inch piece of flesh.

Losing a limb wasn’t enough to help her break the cycle of addiction. Withdrawing from drugs was so painful that she went back to using opioids and developed more tranq wounds. When doctors considered amputating her left leg, the 31-year-old refused.

She requested a “do not resuscitate” order be placed in her medical file, telling her doctors not to amputate even in the event of a potentially deadly infection.

“It was just hell, but if anything happened, they could just let me go,” Carsello said.

Then something unexpected happened: After a decade in addiction, Carsello stopped using drugs during a hospital visit in December. She is now receiving regular wound care. The leg that doctors suggested severing has begun to heal, the once-blackened skin regaining a reddish hue with healthy blood flow.

“If I had listened to them,” Carsello said, ”I never would have known that my leg was actually OK.”

Xylazine was approved for veterinary use in the 1960s, but it didn’t become prevalent as a street drug until about 2018. Available to purchase online for as cheap as $6 a kilogram, the sedative offered a convenient filler for opioid traffickers amid a growing crackdown on illicit fentanyl.

Fentanyl was also a short-lived high, and tranq extended it. By 2021, drug testing showed nine out of 10 “dope” bags sold in Philadelphia contained xylazine.

At the onset, wounds associated with tranq use are not life-threatening. But frontline medical treatment was limited — and mainly done by volunteer groups that handed out antiseptic and gauze on the streets of Kensington, the epicenter of the city’s opioid crisis.

Meanwhile, the number of people seeking medical treatment has soared. About 3,400 people with both opioid use disorder and deep skin infections were hospitalized in 2023 — a 194% increase over 2016, The Inquirer’s analysis found.

At Temple University Hospital, the worst cases were brought to Lisa Rae, medical director of the burn unit and an expert in treating serious skin injuries.

Temple has done more amputations on opioid users than any other city hospital, The Inquirer found. By training, surgeons are cautious with any wound of this gravity, said Rae, and amputation is recommended when risk of infection is high.

“You want to be safe at first,” Rae said.

In November, at their first-ever conference to discuss treating patients with xylazine wounds, Rae and other Philadelphia-area doctors shared grim stories:

A man who had both hands amputated, but was not ready to enter addiction treatment, and had his mother help him inject drugs.

A woman who had a successful reconstructive surgery on her arm, but who relapsed three months later and lost the limb.

A man who left a hospital against medical advice with a serious wound on his arm, then returned two years later with the arm missing below the shoulder. It had fallen off on its own six months earlier, he told surgeons.

Alexandria Carsello struggled with depression in her teenage years, but never drank alcohol or smoked a cigarette. After a breakup with her high school sweetheart in 2015, the then-21-year-old went to Kensington with a coworker from McDonald’s to get dope.

“I was always depressed,” she said. “But I didn’t know about withdrawal. I didn’t know what Kensington was.”

The fentanyl was so powerful that within a week she knew she was hooked.

Then came xylazine. Sores and scabs began to appear on her arms and legs, growing into deep hollows and lesions. Not all users develop wounds from the drug. But others like Carsello can develop several at the same time.

Medical treatment on the street was scarce, said Carsello, by then without a home. No one taught her how to properly care for her skin — or what to expect if she didn’t get proper treatment.

Even after she moved into an apartment in 2018 through Pathways to Housing, a Philadelphia program that offers housing to people with addiction with no requirements for sobriety, she avoided medical care.

Her biggest fear was going into withdrawal in a hospital.

She described the deprivation from the tranq-and-fentanyl cocktail as terrifying — a constellation of symptoms like intense pain, agitation, vomiting, and anxiety.

Every day, she drove over the bridge to New Jersey to panhandle for money. After almost collapsing in the Wawa parking lot in Cherry Hill, she was forced to seek urgent medical care. She fell into a yearslong cycle of using until a crisis forced her to go to the hospital.

During one emergency hospital visit in 2022, doctors warned her that she was at risk of an amputation.

“When I say my arm was coming off by a teeny tiny thread of skin, I mean it was maybe a quarter inch,” she said. “It was so thin.”

After the amputation, she kept using drugs. “I wasn’t ready to stop.”

Within a year, wounds on both her legs grew worse and put her at risk for a severe infection. At one point, Carsello asked if she had another option. She knew doctors often help burn patients by removing healthy skin from another part of the body and grafting it on top of the injured area.

» READ MORE: How we measured tranq's toll

But most surgeons hesitate to perform skin grafts until a patient is sober, as continued injection at that site can cause the skin graft to fail.

Carsello broke the cycle of her addiction unexpectedly. She was admitted to the hospital in December and fell into a coma. It lasted a week, long enough for the withdrawal from drugs to weaken. She finally agreed to start treatment for addiction.

The coma, she said, saved her life.

Efforts to treat tranq wounds can vary wildly, doctors said, depending on the state of a patient’s wound and the hospital the patient chooses.

In 2023, data showed about half the patients The Inquirer identified as likely having tranq wounds left the hospital against medical advice. Doctors say many leave because they fear going through drug withdrawal.

In New Jersey, between 2016 and 2023, nearly a quarter of patients being treated for drug-related infections left the hospital against medical advice, compared with less than 2% among patients without recorded substance use disorders, the state’s health office found in its analysis of hospital admissions.

While the medical establishment long ago set standard medications for treating opioid withdrawal, there is no such consensus on what medication to offer to stave off withdrawal pain from xylazine. Providers are prescribing everything from antinausea to antianxiety medication.

Then there is the treatment itself.

In patients with the most serious wounds, physicians use skin grafts, transplanted bones, and metal rods to stabilize a limb, with antibiotics to help a patient’s battered immune system fight off infections.

But how long a patient must be sober can vary based on the surgeon.

Some won’t provide operations until three to six months of sobriety. At Penn, one patient received a skin graft and full arm reconstruction after just a month or two of sobriety, and when doctors inquired about it, they were told the patient’s family were Penn donors, according to a doctor who spoke on condition of anonymity to frankly discuss the lack of standards.

A Penn spokesperson would not comment on that case. With no specific sobriety policy, the health system said it leaves decisions about the timing of reconstruction to its doctors.

Research is still limited on xylazine wounds to date, and physicians still do not fully agree on their scientific cause.

Frontline doctors like Rae at Temple are doing their own research into treatment options to avoid amputations.

Conducting a case study among patients, Rae and her team began to observe that the wounds themselves were not making patients sick. Some injection drug users could live with the lesions for months or years, so long as they kept them clean.

“It is a different entity,” Rae said of xylazine’s harm. “And we need to figure out how best to treat it in a very complex patient population.”

At Temple, Rae now applies a unique “synthetic skin” that is more resistant to infection. The sponge-like dermal layer will not trap bacteria like a skin graft, making it optimal for people who aren’t able to stop using and are not otherwise eligible for a graft.

Joseph D’Orazio, an addiction medicine specialist at Cooper University Hospital, has also backed away from immediately recommending amputations for patients because, with adequate care, xylazine wounds can heal.

“If they get off the street and they’re not malnourished and they’re getting good care, they can heal really well,” D’Orazio said.

His approach may have spared Joseph Kunz a life-changing foot amputation.

Kunz arrived at Cooper last summer having already lost fingers and toes to xylazine wounds. The 47-year-old from Woodbury Heights, Gloucester County, had an infected wound on his foot and lesions stretching down his legs.

“Some [nurses and doctors] make you feel less than human,” said Kunz, who had avoided the hospital as long as possible, fearing withdrawal and an amputation.

Eight months later, however, his wounds have healed. He credits D’Orazio’s thoughtful approach for steering him into recovery.

In clinics that treat patients with the most serious xylazine wounds, like Mehta’s orthopedic practice at Penn Medicine, saving a limb requires a grueling course of surgeries and hospital stays that can last up to eight weeks. “By the time they show up in our facility,” he said, ”there’s very little to no hope for salvaging the limb.”

Many patients lack the support needed to undergo months of limb reconstruction. Many do not have a home to be discharged to and cannot reliably access addiction treatment.

Complications from surgery are also common: Over 54% of patients in Cooper’s hand surgery division required postsurgical care. Temple reported a 77% complication rate after hand surgery for tranq-related wounds.

“These are catastrophic injuries to manage,” Mehta said. “The resources we’re employing and the number of clinicians treating these patients is not trivial. And even then, I don’t feel like we’re really moving the needle.”

Addiction rehabs will often refuse to take patients with tranq wounds, given the complexity of their medical needs; nursing homes that could handle complex wound care will often refuse to take patients with a history of addiction.

There are as few as 70 addiction treatment beds citywide that can accept patients with severe flesh wounds, according to recent testimony in City Council.

The cost of rehabilitation can also be unaffordable.

Carsello, for example, has now been waiting over a year for a prosthetic limb. Now four months into sobriety, she found that her government-funded Medicaid insurance only covered a basic prosthetic limb. She’s now trying to crowd source money for a mechanical prosthetic that would give her more range of activity.

“Getting a functional bionic prosthetic arm is going to change my life,” she wrote on her GoFundMe page in March.

She dreams of going to nursing school, buying a house with a garden, and volunteering to help others battling addiction. But daily routines after the loss of her arm remain a challenge.

“I can’t zip up my jacket,” she said. “It’s hard to cut vegetables and cook homemade food.”

Even with a prosthetic limb, patients like her will require ongoing medical appointments, check-ins, and replacements when her prosthetic wears out.

Mehta said, “It’s a lifetime of limbs you may need.”