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

Abstract

Objectives Xylazine has emerged as a consistent part of the unregulated drug supply in recent months. We discuss major domains of xylazine’s harm, current knowledge deficits, clinical and harm reduction strategies for minimizing harm, and xylazine’s public health and policy context. As an interdisciplinary team from across the USA, we have pooled our knowledge to provide an overview of xylazine’s current and emerging contexts. Methods To inform this essay, the pertinent literature was reviewed, clinical knowledge and protocols were shared by multiple clinicians with direct expertise, and policy and public health context were added by expert authors. Results We describe xylazine’s major harm domains—acute poisoning, extended sedation, and wounds, along with anemia and hyperglycemia, which have been reported anecdotally but lack as clear of a connection to xylazine. Current successful practices for xylazine wound care are detailed. Understanding xylazine’s epidemiology will also require greater investment in drug checking and surveillance. Finally, approaches to community-based wound care are discussed, along with an orientation to the larger policy and public health context. Conclusions Addressing the harms of xylazine requires interdisciplinary participation, investment in community-based harm reduction strategies, and improved drug supply surveillance. The relatively unique context of xylazine demands buy-in from public health professionals, harm reduction professionals, clinicians, basic science researchers, policymakers and more.

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

“…The meaningful inclusion of substance use and harm reduction experts with lived and living experience of xylazine-adulterated drug supplies will be essential for meeting these goals. 30,32 One potentially important finding is the degree to which living environment may impact the progression and healing of xylazine-associated wounds. Interviewees serving unhoused persons emphasized the difficulties that homelessness posed for maintaining regular, hygienic wound care.…”

“…These findings align with general descriptions of xylazine-associated wounds provided by harm reduction researchers with living experience of substance use and their colleagues. 30 Interviewees emphasized that, with appropriate care and lots of patience, these wounds will heal.…”

“…The meaningful inclusion of substance use and harm reduction experts with lived and living experience of xylazine-adulterated drug supplies will be essential for meeting these goals. 30,32…”

Classics in Chemical Neuroscience: Xylazine

“…76 These often occur in places other than the injection site. 10 A possible mechanism for these wounds has been postulated in that xylazine, by constricting local vasculature through interaction with α receptors, leads to reduced tissue perfusion and therefore poor wound healing and predisposition to bacterial overgrowth. 77 It is worthy to note, however, that xylazine is regularly administered to animals via intramuscular or subcutaneous injection without resulting in soft tissue infections, ulceration, or necrosis.…”

“…6 In the early 2020s, xylazine became more prevalent in illicit drug supplies in the United States, being associated with numerous overdose deaths and appearing to be associated with necrotic wounds. 9,10 Nationally, age-adjusted rates of drug overdose deaths involving xylazine increased by 35 times from 2018 to 2021. 11 Reporting has varied state-to-state, but in Philadelphia in 2019, xylazine was detected in 31% of fatal heroin and/or fentanyl overdose cases (up from only 2% between 2010 and 2015).…”