Drug use practices and wound care experiences in the age of xylazine adulteration.

INTRODUCTION: Exposure to xylazine has been associated with wounds distinct from typical injection-related skin and soft tissue infections. We sought to understand drug use and wound care practices, and treatment experiences of people who use drugs (PWUD) in a high-prevalence area of xylazine adulteration. METHODS: In August 2023, we surveyed adult PWUD reporting at least one past-year drug use-related wound across three Massachusetts syringe service programs. Using a representative illustration, participants indicated if they had experienced a xylazine wound in the past 90 days. We compared demographic, drug use factors, wound care, and medical treatment experiences among those with and without xylazine wounds. We also conducted additional content analysis of open-ended responses. RESULTS: Of the 171 respondents, 87 % (n=148) had a xylazine wound in the past 90 days. There were no statistically significant demographic differences between those with and without xylazine wounds. Among those primarily injecting (n=155), subcutaneous injection was nearly ten times more likely among people with xylazine wounds. For those with xylazine wounds (n=148), many engaged in heterogeneous wound self-treatment practices, and when seeking medical care, 74 % experienced healthcare stigma and 58 % had inadequate pain and withdrawal management. CONCLUSION: People with self-identified xylazine wounds were more likely to engage in subcutaneous injection and faced several barriers seeking medical wound treatment. Programs serving people exposed to xylazine should work to support safer injection practices, including alternatives to injecting and improving access to high-quality, effective wound care. Further study is warranted to understand the causes, promoters, and prevention of xylazine-related wounds.

Implications of xylazine exposure in pregnancy: a narrative review.

The rise in pregnancy-related overdose deaths has been driven by the use of high-potency illicitly-manufactured synthetic opioids including fentanyl. Xylazine, a veterinary sedative, is increasingly noted as a common adulterant in the United States illicit opioid supply. Exposure to the xylazine-fentanyl combination has been associated with severe harms including sedation, necrotic wounds, and symptoms of xylazine withdrawal. Due to limited data that directly addresses the risks of xylazine exposure during human pregnancy, we conducted a narrative review to summarize the available evidence about the clinical implications of xylazine exposure in pregnancy drawing from evidence from animal models, the general adult population, and the authors' clinical experiences. Because xylazine exposure presents unique risks to pregnant persons, management of xylazine exposure and related clinical sequelae in pregnant persons warrants nuanced clinical management. Further, additional research is critically needed to develop best practice guidelines related to the management of co-occurring xylazine-opioid exposure during pregnancy including harm reduction strategies to reduce exposure risk during pregnancy.

Wound Care Capacity of the Addiction Workforce in the Setting of Xylazine.

OBJECTIVES: As xylazine increasingly adulterates the unregulated opioid supply, people who use drugs (PWUD) are more likely to experience sequalae from xylazine. Given xylazine exposure is consistently associated with development of wounds which can heal with medically directed wound care, we sought to understand the level of preparedness and ability of front-line addiction professionals who interact with PWUD to provide wound care treatment. METHODS: We administered a 26-item online survey assessing participant and organizational characteristics, level of wound care training, ability to test for xylazine and treat xylazine-associated wounds, and funding and billing characteristics to a national sample of addiction professionals using a listserv of over 11,000 individuals. RESULTS: We had a response rate of 12.8% in which 1,280 met eligibility criteria and completed the survey, with the majority (23.7%) being nurses. While nearly all participants had cared for patients who had experienced any xylazine-associated harms, less than half (43.6%) had cared for patients with xylazine wounds and 43.4% had any training or certification in wound care, including 26.9% of physicians. Although 75.9% of participants had access to wound care supplies, just 19.5% provided wound care services onsite. CONCLUSIONS: Most addiction professionals, especially physicians, lack wound care training and do not provide onsite treatment for drug-associated wounds at the organizational level. There is a critical need to bridge this gap in knowledge and build capacity to provide evidence-based wound care services to PWUD in areas impacted by xylazine adulteration.

Xylazine and Adulterants in the Evolving Drug Supply: Urgent Call for Responsive Education Models.

Novel adulterants and synthetic substances are rapidly infiltrating the US drug supply causing new clinical harms. There is an urgent need for responsive education and training to address these evolving harms and mitigate new risks. Since 2020, xylazine, a veterinary tranquilizer, has become increasingly common in the illicit opioid supply, especially alongside fentanyl. Training and technical assistance (TTA) programs employing an adaptive model can quickly disseminate emerging information and provide the tools to respond effectively. We describe our TTA program's experience developing and delivering virtual instructor-led xylazine training to a diverse group of addiction care professionals. The training objectives included the following: (1) introducing epidemiologic trends, pharmacology, and existing literature related to xylazine; (2) reviewing xylazine-associated harms and management; and (3) discussing harm reduction strategies related to xylazine use. We conducted 14 training sessions between October 2022 and July 2023, which were attended by over 2000 individuals across 49 states. We review our experience developing innovative training content and managing flexible training logistics and highlight our lessons learned, including targeting multidisciplinary professionals, leveraging online synchronous delivery methods, and a need for sustainable funding for TTA programs.

Implementing harm reduction kits in an office-based addiction treatment program.

BACKGROUND: The rising rates of drug use-related complications call for a paradigm shift in the care for people who use drugs. While addiction treatment and harm reduction have historically been siloed in the US, co-location of these services in office-based addiction treatment (OBAT) settings offers a more realistic and patient-centered approach. We describe a quality improvement program on integrating harm reduction kits into an urban OBAT clinic. METHODS: After engaging appropriate stakeholders and delivering clinician and staff trainings on safer use best practices, we developed a clinical workflow for universal offering and distribution of pre-packaged kits coupled with patient-facing educational handouts. We assessed: (1) kit uptake with kit number and types distributed; and (2) implementation outcomes of feasibility, acceptability, appropriateness, and patient perceptions. RESULTS: One-month post-implementation, 28% (40/141) of completed in-person visits had at least one kit request, and a total of 121 kits were distributed. Staff and clinicians found the program to be highly feasible, acceptable, and appropriate, and patient perceptions were positive. CONCLUSIONS: Incorporating kits in OBAT settings is an important step toward increasing patient access and utilization of life-saving services. Our program uncovered a significant unmet need among our patients, suggesting that kit integration within addiction treatment can improve the standard of care for people who use drugs.