A few days after Gabriel Rosario missed his vein with the hypodermic needle, he knew something had gone terribly wrong.

It was spring 2018, and Rosario, then 29, was living in a Kensington heroin encampment. After surviving Hurricane Maria in his native Puerto Rico, he came to Philadelphia to stay with family — and landed at the heart of America’s urban opioid crisis. Already in addiction, Rosario continued to spiral until he ended up on the streets.

The veins in his arms collapsed from dozens of injections. Desperate to avoid the intense pain of withdrawal, he paid other drug users to inject him in the neck. One day, unable to find someone lucid enough to help, Rosario tried to inject heroin and cocaine into a vein in his foot. But he missed, and poked his skin with the needle instead.

In the days after, “my foot swelled up like an elephant’s,” he said. The tiny wound from the needle’s prick had become infected, and bacteria were spreading into his bloodstream.

Rosario’s story is an increasingly common one in Philadelphia. Infections stemming from intravenous drug use are on the rise here — from the kinds of bacterial infections that Rosario suffered, to endocarditis. This infection of the the inner lining of the heart chambers and valves occurs when bacteria in the blood attach to the heart. Viruses like HIV, hepatitis C, and hepatitis A are also on the rise among people who use drugs.

But as overdose deaths have soared, advocates say that infections and other chronic health issues faced by people who use drugs don’t get much public attention — even though they can become deadly if they’re left untreated.

“Overdoses and infections are two sides of the same coin,” said Ben Cocchiaro, a physician who works at Prevention Point, the Kensington-based public health organization for people with addiction.

‘It’s a cycle’

Changes in Philadelphia’s drug market that are driving some of the highest overdose rates in the country could also be behind the rise in infections.

Fentanyl, the powerful synthetic opioid that has replaced much of Philadelphia’s heroin supply and causes most of the city’s overdose deaths, has a shorter “half-life” than heroin. That means it sends drug users into withdrawal faster. People in opioid addiction who were used to injecting a few times a day have found themselves injecting every few hours to stave off the pain, nausea, craving, and cramps of withdrawal.

Even with syringe exchanges handing out free needles, sometimes desperate people who can’t find a new needle reuse an old one, risking infection.

» READ MORE: Philadelphia officials, including Mayor Kenney, visit supervised injection sites in Canada

Living rough exacerbates the infection risk, because people don’t have reliable access to bathrooms, showers, or clean clothes. Rosario believes his living conditions worsened his infection. But, when you’re dope-sick, he said, staying out of withdrawal is the only priority.

“People are injecting more often, they need more syringes, and they don’t necessarily have enough, and because of that they’re reusing syringes, which increases their risk," said Lia Pizzicato, a substance-use epidemiologist for the city health department. “And then because they’re injecting so much, it’s difficult to find a vein, and they’re more likely to miss. It’s a cycle.”

For the last two years, more drug users have been contracting infections like group A streptococcus, a bacterium that can live harmlessly in the throat and sometimes on the skin, but becomes a dangerous invader when it begins to spread through the body.

From 2011 to 2016, Philadelphia saw between 41 and 61 invasive group A strep cases every year among people aged 12 to 65. In 2017, that number spiked to 73 cases, followed by 107 in 2018. Last year, half of all invasive group A cases in the city occurred in people who used drugs.

Endocarditis is also rising among people who use drugs in Philadelphia, from 74 hospitalizations in 2015 to 111 in 2016 to 165 in 2017. Left untreated, the condition can damage the heart valves and lead to life-threatening complications such as heart failure and stroke.

‘When the doctor comes in in a hazmat suit’

West of the city, at Crozer-Chester Hospital in Chester, emergency department physician Rick Pescatore sees people in addiction turn up with everything from abscesses to endocarditis to fungal infections. He finds himself in what once was an unimaginable role for a physician: counseling patients on safer injection practices, which includes sending them home with alcohol swabs and sterile saline flushes.

“The public has little to no knowledge of the acute infection risks of IV drug use,” he said. “The overwhelming majority of my patients [in addiction] with abscesses think it’s a spider bite.”

That’s why opening supervised injection sites — where people can use drugs under medical supervision and access treatment — isn’t simply about preventing fatal overdoses, he said. It’s also about preventing infections.

“When the doctor comes in in a hazmat suit, you feel people are grossed out by you.”

Gabriel Rosario

Rosario didn’t know much about infections. But when the pain in his foot had become too much to bear, he knew he had to go to the hospital, much as he tried to avoid it.

Stigma weighs heavily on people in addiction, even when they need care the most. A 2018 study in the Journal of Drug and Alcohol Dependence that surveyed 145 heroin users in Boston and Sacramento, Calif., found that two-thirds had suffered a skin infection, and more than a third waited for two or more weeks before seeking treatment. More than half left the hospital against medical advice — many said they feared going into withdrawal if they were stuck there without access to opioids, and even more worried about being judged or mistreated.

“When the doctor comes in in a hazmat suit, you feel people are grossed out by you,” Rosario said. “It’s so embarrassing.” Especially so for him, he said, because he had to go twice.

Weeks after leaving the hospital for his first infection treatment — which included surgery — he was readmitted and had a second surgery on his foot. A sympathetic surgeon at Jeanes Hospital warned him he could lose his leg, or die, if he didn’t fully heal. That’s when he decided to seek treatment for his addiction, too.

» READ MORE: Nearly 3 in 10 Philadelphians know someone who has died from opioid use

But even then, finding help was difficult. With his infection healing, but still unsteady on his feet, he went to Access Point, the 24-hour center in Spring Garden that connects patients with addiction treatment. Staff there are supposed to find clients a spot in a treatment facility within a day.

For Rosario, it took several days. One inpatient treatment facility after another refused to take him in because his foot wound put him at risk of falling, making him an added liability, he said. Staffers at Access Point begged him to stick around, he said: They knew that the longer he was denied treatment, the worse his cravings for heroin might get, and the higher the risk he would return to the streets and overdose.

Rosario stayed, and eventually was admitted to a facility.

He’s been in recovery for more than a year with the help of methadone and is beginning to reconnect with the family he became estranged from during his addiction. He has a new apartment in North Philadelphia and recently completed training to become a community health worker, treating trauma in others.

“I have strong support. People I can lean on," he said. “There’s light at the end of the tunnel.”

He knows how lucky he is to have survived, and he’s happy to be on the other side — with an enormous scar on his foot serving as a permanent reminder of the fate he so narrowly escaped.