Reducing the harms of xylazine: clinical approaches, research deficits, and public health context

Building Multidisciplinary Consensus on Inpatient Xylazine Management through Clinical Protocols

The evolving unregulated drug supply in the United States has led to an unprecedented rise in xylazine-adulterated synthetic opioid use-related morbidity and mortality, of which Pennsylvania shoulders a disproportionate burden. People experiencing these xylazine harms who seek acute medical care require complex clinical management, multidisciplinary coordination, and appropriate linkage to outpatient care. We describe our experience leading a hospital-wide multidisciplinary xylazine workgroup from February to June 2024 to collaboratively develop time-sensitive clinical protocols on inpatient management of patients exposed to xylazine. Workgroup participants were organized into three subgroups: (1) toxicology screening and harm reduction; (2) withdrawal management; and (3) inpatient wound care management and linkage to outpatient wound care. We summarize our implementation process and clinical protocol recommendations of each subgroup and highlight important cross-cutting issues related to the changing drug supply, standardized patient and provider educational tools, care coordination, and next steps.

Psychosocial Impact of Suspected Xylazine-Associated Skin Wounds Among People Using Fentanyl, Philadelphia, 2022 to 2023

BACKGROUND

The United States opioid crisis has been worsened by the emergence of fentanyl adulterated or associated with the veterinary sedative xylazine. Designated by the White House as an "emerging threat to the US" in 2023, xylazine use is associated with severe skin wounds.

METHODS

This research explored beliefs, concerns, and treatment behaviors for skin wounds among 93 participants recruited outside of a Philadelphia, Pennsylvania harm reduction agency who reported past-6-month history of a skin wound via a cross-sectional survey administered August-September 2022 (group 1; n = 33). Following a December 2022 Philadelphia Department of Public Health Report that indicated xylazine was becoming more prevalent in the Philadelphian drug supply, additional data was collected with new participants from February-March 2023 (group 2; n = 60) using the same survey. Participants were ≥18 years old, reported past-year fentanyl use, and spoke English. Our 17-item tool measured skin wound-related beliefs, concerns, treatment behaviors, and treatment sources. An open-response item explored why participants self-treat skin wounds.

RESULTS

Participants averaged 41 years old (SD = 9), slightly more than half were men (n = 54, 58%), 31% (n = 29) were non-White, and most (n = 66, 71%) were unhoused. Overall, 79% of participants self-treated skin wounds. Participants endorsed worry about limb loss (n = 77; 83%), wound shame (n = 76; 82%), and appearance changes (n = 80; 86%). Sixty participants (65%) reported waiting to see wound severity before seeking care. Forty-one participants (44%) delayed wound care because of withdrawal fears.

CONCLUSIONS

People with probable xylazine-associated skin wounds have psychosocial concerns about and self-treat these wounds. Findings may be a harbinger of skin wound harm in other regions of the United States and internationally where xylazine is increasing.

"We can't change that while they're in the hospital": Unveiling the manifestations of infrastructural violence and wound care for people who inject drugs

Healthcare avoidance or delays for wounds and related skin- and soft-tissue infections are often attributed to negative interactions with medical providers. An infrastructural violence framework posits that healthcare infrastructure serves as a material channel for structural violence, maintaining inequities in healthcare experiences and outcomes. Infrastructural violence ensues when infrastructure is designed for some members or groups within a society while perpetuating violence among others. This study draws on the concept to understand how healthcare infrastructure creates and perpetuates inequities within the healthcare system for people who inject drugs for their wound care-related needs. Between January and September 2023, semi-structured interviews were conducted with 12 medical providers in Maryland. An abductive thematic analysis approach was followed. Healthcare infrastructure mediated the relationship between structural factors, such as policies on prescribing privileges of medications for opioid use disorder and subsequent individual health experiences. Medical providers also described how their access to training, protocols, and other resources was insufficient to meet the needs of people who inject drugs presenting to healthcare settings for wound care. A new conceptual grounding provides recommendations on extending beyond medical provider behavior change interventions in healthcare settings to create supportive infrastructure, which includes readily available and accessible policies, protocols, and resources to care for this patient population.

Managing xylazine-involved overdoses in a community harm reduction setting: lessons from Tijuana, Mexico

BACKGROUND

Xylazine is a α2-adrenergic receptor agonist, used for sedation in veterinary contexts. Although it is increasingly found in overdose deaths across North America, the clinical management of xylazine-involved overdoses has not been extensively studied, especially in community-based harm reduction settings. Here we present a clinical series of xylazine-involved overdose and share the clinical approach and lessons learned by a community overdose response team in Tijuana, Mexico amidst the arrival of xylazine.

CASE PRESENTATION

We present three cases describing the clinical management of patients with xylazine-involved overdoses that occurred in close proximity to the Prevencasa community harm reduction clinic. The long period of post-naloxone sedation in xylazine overdoses is a unique clinical feature. The first case is a 61-year-old man with longstanding opioid and methamphetamine use disorder found hypoxic, who received 4.0 mg of intranasal naloxone, and quickly began respirating well. He remained unconscious for 20 min, and upon awakening, experienced withdrawal symptoms, agitation and confusion, and exposed himself to considerable physical danger by entering a local roadway. The second is a 28-year-old man who primarily uses stimulants, who overdosed while trying "China White". His oxygen saturation improved from 81 to 100% with supplemental oxygen and field management, and he did not require naloxone administration. He recovered consciousness after 40 min. The third patient is a 36-year-old male who was found down, saturating at 20%, who received 0.4 mg intramuscular naloxone, was placed in recovery position, and remained unconscious for 12 min before making a complete recovery. The first and third patients provided urine and drug samples that tested positive for xylazine and fentanyl.

CONCLUSIONS

We describe insights about the clinical management of combined xylazine-fentanyl involved overdoses in the field, from a community harm reduction context where xylazine arrived suddenly spurring a large number of overdoses. In response to the long period of post-naloxone sedation inherent to xylazine overdoses, the clinical team learned to center oxygenation-not consciousness-as the key parameter of interest for the titration of naloxone, increase emphasis on field airway management, portable oxygen administration, and scene safety, and employ xylazine testing strips for urine and direct substance analysis to educate the patient population about health risks.

First Detection of Xylazine in Texas Wastewater and Its Association with Fentanyl Use

The United States is dealing with the drug overdose crisis that has intensified over the past decade and compounded by the emergence of new threats particularly xylazine, a veterinary sedative increasingly found in illicit drug supplies. This study investigates the prevalence of xylazine in El Paso, Texas, a U.S.-Mexico border city where its impact remains poorly understood. We employed wastewater analysis to detect xylazine and examine its potential correlation with fentanyl use over a 14-month period (June 2023 to July 2024). Our results show that xylazine was detected in wastewater samples from three of the four treatment plants serving the city. The prevalence of xylazine was heterogeneous, with the highest detection rate of 29% observed in one sewershed. All samples on xylazine-positive days also tested positive for norfentanyl, a fentanyl metabolite, demonstrating the widespread fentanyl consumption. Notably, sewersheds with higher xylazine detection exhibited significantly higher fentanyl loads, suggesting a community-level association between the two substances use. This study provides the first evidence of xylazine in Texas wastewater and highlights the urgent need for enhanced monitoring and targeted public health interventions to mitigate the growing threat of xylazine, particularly in border communities affected by the opioid crisis.

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.

Use of fentanyl test strips by people who inject drugs: Baseline findings from the South Atlantic Fentanyl Test Strip Study (SAFTSS)

BACKGROUND

Research published during the early fentanyl period exposed a growing concern of unwitting fentanyl exposure and a general willingness to use fentanyl test strips (FTS). A paucity of FTS studies over the last several years has restricted our ability to understand FTS use in the late fentanyl era. The South Atlantic FTS Study (SAFTSS) was established to investigate contemporaneous changes in FTS use and drug use behavior among a rural cohort of PWID.

METHODS

Between June 2021 and March 2022, a total of 541 PWID completed an in-person survey. Baseline survey questions included demographics, socioeconomic characteristics, and drugs used. FTS questions covered lifetime use, past 6-months, and past 30-day use and included reasons for using FTS, levels of access, and confidence testing illicit opioids and stimulants. Multivariable analyses examined significant baseline correlates of lifetime and 30-day FTS use.

RESULTS

Overall, more than half (58%; N=315) used FTS in their lifetime. Among lifetime FTS users, almost half (47%) used FTS in the past 6 months and 30% in the past 30 days, with an average of 13 months from last FTS use and the baseline survey. The most common reason for not using FTS was "not having them with me when I use drugs." Less frequent reasons were "I already know it's fentanyl" followed by "FTS take too much time to use." Among past 30-day FTS users, 74% used FTS on heroin, 55% on methamphetamine, and 33% on fentanyl. Consumer confidence using FTS was higher with illicit opioids (66%) but lower for methamphetamine (43%). In both the lifetime and past 30-day models, PWID with FTS use were more likely than non-users to have witnessed an overdose in the past six months (lifetime aOR = 2.85, p<.001; 30-day aOR=2.57, p<.01). Virtually no differences in drug use behaviors were found when comparing past 30-days FTS use to no FTS use. Women (aOR=1.68, p<.05) and non-white PWID (aOR=2.43, p<.05) were more likely than men and white PWID to have used FTS.

CONCLUSIONS

Declines in FTS use are consistent with what syringe services programs have been signaling for years. Needs assessments to gauge interest in FTS before scaling up can help ensure funding better spent on naloxone and syringes is not allocated to idle FTS. Increased FTS among women and racial minorities presents opportunities for tailored interventions. Recognizing trauma associated with witnessing overdoses as a growing component of the opioid epidemic is a critical first step toward addressing the full spectrum of drug-related harm.

A call for compassionate opioid overdose response

High dose and long-acting opioid overdose reversal drugs can precipitate withdrawal in people who are opioid dependent. Products recently brought to market for community use in the United States (US) have drawn international concern because of their increased risk of withdrawal. At the March 18-19, 2024, Compassionate Overdose Response Summit & Naloxone Dosing Meeting, a panel of harm reduction experts issued the following call to action: 1) people who use drugs should be directly involved in decisions regarding the research, development, selection, and distribution of opioid overdose reversal products; 2) regulatory agencies and pharmaceutical manufacturers should carefully consider and communicate the risk and duration of withdrawal associated with higher dose and longer-acting opioid antagonists; 3) take-home naloxone kits should include at least two doses of an intramuscular (IM) product containing 0.4 mg or an intranasal (IN) product containing ≤4 mg; 4) At this time, high dose and long-acting opioid antagonists have no use in acute opioid overdose response; and, 5) overdose response educational materials, instructions on overdose response, and training should emphasize the restoration of breathing, avoiding withdrawal, and compassionate post-overdose support and care. High dose and long-acting opioid overdose reversal drugs were approved without testing for withdrawal and are often aggressively marketed despite decades of evidence from naloxone distribution programs worldwide that the ideal dose of naloxone is one that restores breathing without inducing withdrawal. Government agencies should direct resources to harm reduction programs to make standard dose take-home naloxone products widely available among people who use drugs. Lay bystanders, people who use drugs, their families, and professional first responders can learn and apply a compassionate approach to opioid overdose response.

Xylazine's Impacts on the Community in Philadelphia: Perspectives of People Who Use Opioids and Harm Reduction Workers

BACKGROUND

Xylazine is in 99% of the fentanyl supply in Philadelphia, PA and is on the rise throughout the United States. Perspectives about this emerging crisis among people who use opioids (PWUO) and harm reduction workers are lacking.

METHODS

We conducted focus groups with PWUO and harm reduction workers in Philadelphia, PA. Discussions focused on xylazine's impact on PWUO. Transcripts were coded for thematic analysis.

RESULTS

Themes across focus groups included xylazine withdrawal, wounds, safety concerns, and overdose response implications. Participants emphasized extreme xylazine withdrawal and the difficulty of withdrawal management. Groups explored potential roles of first responders in addressing xylazine-related wounds. PWUO were receptive to receiving help, but many harm reduction workers expressed reservations about partnering with police.

DISCUSSION

Results underscore the impact of xylazine withdrawal on PWUO. Emerging information on withdrawal management should be shared among care providers to identify optimal protocols. Safety-planning with PWUO should be explored, but structural interventions are imperative. While there may be a role for first responders in delivering harm reduction interventions, it is important to recognize historical harms by first responders against PWUO.

Xylazine awareness and attitudes among people who use drugs in Ohio, 2023-2024

BACKGROUND

The prevalence of xylazine, a non-opioid tranquilizer not for human consumption, in illicitly manufactured fentanyl is increasing in the United States. However, little is known about xylazine awareness and attitudes among people who use drugs.

METHODS

A cross-sectional survey of people who use drugs in Ohio was conducted from November 2023 - May 2024 to identify xylazine awareness and attitudes in rural and urban counties across the state. Study participants were recruited from naloxone distribution sites, including health departments, syringe service programs, and community-based organizations.

RESULTS

Among 630 people who use drugs in Ohio, more than one-half (53.5%) were unaware of xylazine being in "street drugs," regardless of urbanicity. Among individuals who were aware of xylazine, most (73.0%) indicated they did not want to use the drug and try to avoid it. In addition, 75.8% of this group felt it was "very" or "extremely" important to know if xylazine was in their drugs.

DISCUSSION

This research found that many people who use drugs in Ohio are unaware of xylazine and its risks. An important finding of this study is that most individuals who had heard of xylazine did not want to use it and were concerned about knowing whether xylazine was in their drugs.

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.

Social determinants of injection drug use-associated bacterial infections and treatment outcomes: systematic review and meta-analysis

Background

Individual injecting practices (e.g., intramuscular injecting, lack of skin cleaning) are known risk factors for injection drug use-associated bacterial and fungal infections; however, social contexts shape individual behaviours and health outcomes. We sought to synthesize studies assessing potential social determinants of injecting-related infections and treatment outcomes.

Methods

We searched five databases for studies published between 1 January 2000 and 18 February 18 2021 (PROSPERO CRD42021231411). We included studies of association (aetiology), assessing social determinants, substance use, and health services exposures influencing development of injecting-related infections and treatment outcomes. We pooled effect estimates via random effects meta-analyses.

Results

We screened 4,841 abstracts and included 107 studies. Several factors were associated with incident or prevalent injecting-related infections: woman/female gender/sex (adjusted odds ratio [aOR] 1.57, 95% confidence interval [CI] 1.36-1.83; n=20 studies), homelessness (aOR 1.29, 95%CI 1.16-1.45; n=13 studies), cocaine use (aOR 1.31, 95%CI 1.02-1.69; n=10 studies), amphetamine use (aOR 1.74, 95%CI 1.39-2.23; n=2 studies), public injecting (aOR 1.40, 95%CI 1.05-1.88; n=2 studies), requiring injecting assistance (aOR 1.78, 95%CI 1.40-2.27; n=8 studies), and use of opioid agonist treatment (aOR 0.92, 95%CI 0.89-0.95; n=9 studies). Studies assessing outcomes during treatment (e.g., premature hospital discharge) or afterward (e.g., rehospitalization; all-cause mortality) typically had smaller sample sizes and imprecise effect estimates.

Conclusions

Injecting-related infections and treatment outcomes may be shaped by multiple social contextual factors. Approaches to prevention and treatment should look beyond individual injecting practices towards addressing the social and material conditions within which people live, acquire and consume drugs, and access health care.

Modeling Changes of Fatal Xylazine-Involved Drug Overdoses in Connecticut Across Time

BACKGROUND

Fatal drug overdoses have involved both xylazine and fentanyl. Xylazine is a non-opioid substance used in veterinary medicine. This study aimed to model changes in fatal xylazine-involved drug overdose deaths from 2019 to 2023 in Connecticut using overdose death data from the Office of the Chief Medical Examiner.

METHODS

Xylazine-involved drug overdose fatality rates were calculated by number of deaths per year per 100,000 population from 2019 to 2023. We used joinpoint regression modeling to evaluate quarterly overdose rates across age, number of drugs, and drug types with a significance level of p < 0.05.

RESULTS

From 2019 to 2023, there were 1116 xylazine-involved fatal overdoses with a cumulative rate of 31.3 deaths per 100,000. Xylazine-involved overdose death rates were significantly higher in Hispanic populations compared to both non-Hispanic White and Black populations (p < 0.05). The joinpoint analyses showed that xylazine-fentanyl mortality rates significantly increased by 0.18 per 100,000 per quarter from 2019 to 2022. Xylazine-fentanyl overdoses involving at least 4 or 5 substances significantly increased. Windham, Hartford, New London, and New Haven counties had the highest xylazine-involved death rates.

CONCLUSION

Xylazine-fentanyl deaths increased from 2019 to 2023, and often involved multiple substances (e.g., cocaine, ethanol, benzodiazepines, and oxycodone). Results show Hispanic populations, those aged 35-49, and 50+ experienced high rates of xylazine-fentanyl overdose deaths. Vulnerable populations in Connecticut for special consideration for future intervention and local resource allocation are recommended.

Harm reduction nursing and the path toward developing best practice: Lessons from caring for people with xylazine-associated wounds in Philadelphia, PA

Xylazine-associated wounds are a distinct, novel clinical entity characterized by co-occurrence with substance use, progressive necrosis of skin, muscle, tendon, and bone, and slow healing. In Philadelphia, the specter of limb loss, stigma, and shame has hung over hospital-based care for xylazine-associated wounds among people who use drugs (PWUD) and kept many people away from engaging in care. Continued engagement in harm reduction wound care nursing, however, offers an opportunity for PWUD to address their wounds and their fears with members of the medical world. In the absence of established best practices, harm reduction's model of risk-reductive care offers a way forward for patients and practitioners alike. Here, "harm reduction" describes an ethic of practical, trauma-informed, patient-centered care. It is this integration of harm reduction into medicine and public health that effectively promotes the safety, survival, and recovery of PWUD across all spectrums of drug use habits and housing stability.

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.

Barriers to, and Facilitators of, Checking Drugs for Adulterants in the Era of Fentanyl and Xylazine: Qualitative Study

BACKGROUND

Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterants such as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increases risks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to a combination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to check drugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many people who use drugs decline to use them.

OBJECTIVE

We sought to better understand why people in the New York City area do or do not check drugs before use. We plan to use study findings to inform the development of technology-based interventions to encourage consistent drug checking.

METHODS

In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructured qualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interview guide examined participants' knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines; using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded, transcribed, and analyzed for emerging themes.

RESULTS

Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for not checking included lacking convenient access to test supplies, or a place to check samples out of the public's view, as well as time considerations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterants because they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sell them adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agency staff.

CONCLUSIONS

New forms of outreach are needed not only to increase people's knowledge of adulterated substances and awareness of the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. This includes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing and volatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefits public health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted community members including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-cost drug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide.

Classics in Chemical Neuroscience: Xylazine

Xylazine (also known as "tranq") is a potent nonopioid veterinary sedative that has recently experienced a surge in use as a drug adulterant, most often combined with illicitly manufactured fentanyl. This combination may heighten the risk of fatal overdose. Xylazine has no known antidote approved for use in humans, and age-adjusted overdose deaths involving xylazine were 35 times higher in 2021 than 2018. In April 2023, the Biden Administration declared xylazine-laced fentanyl an emerging drug threat in the United States. In 2022, the Drug Enforcement Agency (DEA) reported nearly a quarter of seized fentanyl powder contained xylazine. This dramatic increase in prevalence has solidified the status of xylazine as an emerging drug of abuse and an evolving threat to public health. The following narrative review outlines the synthesis, pharmacokinetics, pharmacodynamics, and adverse effects of xylazine, as well as the role it may play in the ongoing opioid epidemic.

Xylazine awareness, desire, use and exposure: Preliminary findings from the Rhode Island community-based drug checking cohort study

Background

Xylazine is an ⍺2 adrenergic receptor agonist and a veterinary sedative that can cause severe health complications yet interventions to detect and treat human exposure remain underdeveloped. Community-based drug checking services (DCS) involve the testing of small amounts of drugs to increase community knowledge of unregulated supplies and decrease harms. This study characterized xylazine awareness, desire, use and exposure among people who use drugs (PWUD) in Rhode Island, US.

Methods

We analyzed data from an ongoing PWUD cohort study. In 2023, 125 PWUD were enrolled and surveyed. Using point-of-care Fourier Transform infrared spectroscopy (FTIR-S), we tested a drug sample from each participant onsite and confirmed the results offsite at a laboratory. Results were conveyed in real-time, along with harm reduction education, referrals to resources and care.

Results

Virtually all participants (99.2 %) wanted to avoid xylazine exposure. Half (51.2 %) knew what xylazine was, and a quarter (26.1 %) suspected previous exposure. Xylazine exposure was primarily surmised through sedating (45.2 %) and ulcerative (29.0 %) effects. Only 8.8 % of participants submitted a sample that they expected to contain xylazine. Xylazine was detected in 14.5 % of samples using FTIR-S and in 21.4 % of samples using a dual laboratory approach of gas chromatography mass spectrometry (GC-MS) and liquid chromatography quadrupole-time-of-flight mass spectrometry (LC-QTOF-MS). Participants thought that these xylazine-positive samples were fentanyl (78.3 %), heroin (13.0 %), or Percocet® (8.7 %).

Conclusion

Implementing point-of-care DCS at harm reduction organizations could be useful in rapidly increasing xylazine awareness and engaging at-risk individuals in prevention, harm reduction, treatment, and rapid care for xylazine-related wounds.

Xylazine is an agonist at kappa opioid receptors and exhibits sex-specific responses to opioid antagonism

Xylazine is in the unregulated drug supply at increasing rates, usually combined with fentanyl, necessitating understanding of its pharmacology. Despite commentary from politicians, and public health officials, it is unknown how xylazine impacts naloxone efficacy, and. few studies have examined it alone. Here, we examine the impact of xylazine alone and in combination with fentanyl on several behaviors in mice. Surprisingly, naloxone precipitates withdrawal from xylazine and fentanyl/xylazine coadministration, with enhanced sensitivity in females. Further, xylazine is a full agonist at kappa opioid receptors, a potential mechanism for its naloxone sensitivity. Finally, we demonstrate surprising effects of xylazine to kappa opioid antagonism, which are relevant for public health considerations. These data address an ongoing health crisis and will help inform critical policy and healthcare decisions.

Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports From Front-Line Health Workers in 7 US States

BACKGROUND

Xylazine, an adrenergic alpha-2 agonist increasingly present in the US drug supply, is associated with severe skin ulcers and other harms. Expert knowledge from front-line harm reduction and healthcare professionals is an essential component of evidence-based practice. The purpose of this study is to describe the progression and treatment of xylazine-associated wounds, other xylazine-related health concerns, and the most urgent research priorities as reported by front-line harm reduction and healthcare professionals serving people who use drugs.

METHODS

A convenience sample of 17 healthcare and harm reduction professionals who serve people who use drugs in the US states of Maryland, Massachusetts, Michigan, Minnesota, North Carolina, Pennsylvania, and Texas participated in semi-structured interviews. Participants were asked about the appearance and progression of xylazine-associated wounds; preferred treatment strategies; other xylazine-related harms experienced by people who use drugs; and the most urgent priorities for xylazine-related research.

FINDINGS

Xylazine-associated wounds were broadly described as small lesions appearing mostly on extremities both at and away from injection sites, often within hours or days of exposure, that quickly developed into large, complex, chronic wounds. Reported risk of secondary infection was generally low but appeared more common among unhoused populations. Most participants preferred conservative treatment strategies that included regular wound care, enzymatic debridement, and hygiene. Xylazine-associated wounds and xylazine withdrawal reportedly act as significant barriers to care, including addiction treatment. Participants reported urgent need for scientific research and evidence-based guidance on the management of xylazine-associated wounds and withdrawal.

CONCLUSIONS

High-quality scientific evidence on risk factors for xylazine-associated wounds and on their biologic mechanisms is needed. Such studies could inform new strategies for the prevention and treatment of these wounds. Efforts to improve the management of xylazine withdrawal and to reduce stigma by incorporating harm reduction professionals into healthcare settings may improve access to and retention in care.

Media framing xylazine as a "zombie drug" is amplifying stigma onto people who use drugs

Amid increasing efforts to understand xylazine-associated harms, examining the potentially catastrophic role of stigma resulting from media outlets framing xylazine as the "zombie drug" is imperative. Zombies are cinematically depicted as soulless, dangerous, and required to be killed off entirely for public safety, making the "zombie" analogy especially grave amid the fatal overdose crisis. Xylazine is called the "zombie drug" due to its heavy sedative effect and associated-severely infected skin ulcers. We surmise that wide-scale media framing of xylazine as the "zombie drug" has increased stigmas onto people who use drugs as their likening to zombies reifies subhuman status. The present commentary highlights many media headlines and quotes that use "zombie" terminology when writing about xylazine, and examine how this expansive media framing amplifies stigmas. Xylazine's proliferation in the illicit drug market will likely increase infected ulcers needing medical attention. People who use drugs are often reluctant to seek medical care due to experiences of medically-institutionalized stigma. Based on the media's extensive depiction of xylazine as the "zombie drug," it is plausible that medical practitioners have been exposed to this stigmatizing framing, which could unknowingly detrimentally impact provision of medical care. Strategies to offset harms of xylazine-associated stigmas are proposed, including that medical practitioners undergo evidence-based training to reduce stigmatizing responses to severe xylazine-associated ulcers as any indication of enacted stigma can be internalized by the person seeking treatment, which in turn can perpetuate harms like sepsis or overdose. Author ethnographic observations of xylazine presence are included, which encompass three distinct urban settings that span North America. Finally, we suggest approaches media outlets could adopt to reflect on how referring to xylazine as the "zombie" drug amplifies stigmas onto people already surviving under structural conditions heightening physical and mental trauma, and use language instead that could aid in lessening these harms.

Xylazine co-occurrence with illicit fentanyl is a growing threat in the Deep South: a retrospective study of decedent data

BACKGROUND

Xylazine is a dangerous veterinary sedative found mainly in illicit fentanyl in the Northeast and Midwest. Its role in the Deep South overdose crisis is not well-characterized.

METHODS

We conducted a retrospective review of autopsy data in Jefferson County, Alabama to identify trends in xylazine prevalence among people who fatally overdosed from June 2019 through June 2023.

RESULTS

165 decedents met inclusion criteria. While the first identified xylazine-associated overdose was in June 2019, xylazine has become consistently prevalent since January 2021. All cases of xylazine-associated fatal overdoses were accompanied by fentanyl, and most (75.4%) involved poly-drug stimulant use. The average age was 42.2, and most decedents were white (58.8%) and male (68.5%). Overall, 18.2% of people were unhoused at the time of death.

DISCUSSION

Xylazine is prevalent in the Deep South. Efforts to promote harm reduction, publicly viewable drug supply trends, and legalization of drug checking and syringe service programs should be prioritized.

Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore

BACKGROUND

Addressing xylazine harms are now a critical harm reduction priority, but relatively little epidemiological information exists to determine prevalence, magnitude, and correlates of xylazine use or related outcomes.

METHODS

We conducted a rapid behavioral survey among people who inject drugs (n = 96) in Baltimore November-December 2022. Using a novel indicator of self-reported presumed xylazine effects, we examined prevalence and sociodemographic correlates of past year presumed xylazine effects and association with overdose and wound-related outcomes. Chi-square and descriptive statistics were used to examine bivariate associations overall and separately for those who reported xylazine by name and by reported fentanyl use frequency.

RESULTS

Almost two-thirds (61.5%) reported experiencing xylazine effects. There were no differences by socio-demographics, but xylazine effects were more commonly reported among those who reported injecting alone (66% vs 38%%, p < 0.007) and daily fentanyl use (47% vs 24% p < 0.003). Those reporting xylazine exposure was three times as likely to report overdose (32% vs 11%, p < 0.03) and twice as likely to have used naloxone (78% vs 46%, p < 0.003). They also more commonly reported knowing someone who died of an overdose (92% vs 76%, p < 0.09) and to report an abscess requiring medical attention (36% vs 19%, p < 0.80). These associations were higher among respondents who specifically named xylazine and those who used fentanyl more frequently, but fentanyl frequency did not fully explain the heightened associations with xylazine effects.

CONCLUSIONS

This study provides insight into the scope of xylazine exposure and associated health concerns among community-based PWID and suggests measures that may be instrumental for urgently needed research.

Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges

Xylazine abuse is emerging globally, while the identification of xylazine lethal cases poses a great challenge in clinical and forensic practice. The non-specific symptoms delay the diagnosis and treatment of xylazine poisoning, the pathological changes and lethal concentration of xylazine in body fluid and organs of fatal xylazine poisoning cases are seldom reported and the other toxins detected in such cases complicate the role of xylazine in the cause of death. Therefore, we carefully reviewed related updated information on xylazine, summarized the knowledge from clinical and forensic perspectives and can thus provide a reference in such cases and throw light on further study in the field of xylazine poisoning.