(100) Xylazine Wound Care Among PWUD Accessing Massachusetts Syringe Service Programs

Background &

Introduction: Xylazine, a veterinary sedative increasingly adulterating the illicit opioid supply in the Northeast U.S. since 2019, has been associated with unique skin ulcerations that take a long time to heal, are distinct from the typical spectrum of injection drug use-related skin and soft tissue infections (SSTIs) and wounds, and anecdotally occur irrespective of route of substance use. Despite SSTIs being one of the leading causes of morbidity and mortality among people who use drugs (PWUD), PWUD often defer treatment or delay seeking care in traditional medical settings in favor of self-treatment due to barriers including healthcare-associated stigma and inadequate pain and withdrawal management. Given that xylazine poses the potential for new complexities to SSTI and wound management, we sought to understand wound care practices and treatment-seeking behaviors and experiences from PWUD in a high-prevalence area of xylazine adulteration.

Methods: A sample of 175 adults (>=18) who sought services from three Massachusetts syringe service programs (SSPs) and who reported at least one drug use-related wound in the past year were recruited to complete an anonymous, online 33-item multiple-choice and open-ended response survey. Surveys were created by co-authors and reviewed by content experts and four frontline harm reduction staff for face validity.

The survey assessed demographics, drug use behaviors using an adapted Addiction Severity Index, self-reported exposure to xylazine and development of any SSTI in the past 90 days, past experiences seeking medical care for wounds, and wound self-treatment practices. The survey defined characteristics of xylazine wounds with visual aids as part of the questionnaire. Open ended questions invited participants to provide additional insight regarding their experience with xylazine and wounds. We collected data over four weeks in August 2023, and participants received a $25 gift card for survey completion. We conducted descriptive analyses with frequencies and proportions reported for categorical variables and stratified results if participants had self-reported xylazine wounds. We analyzed open-ended responses using inductive content analysis.

Results: 171 PWUD completed the entire survey, of which 63% were male, 63% white, and 67% non-Hispanic. The most frequently reported age category was 36 to 45 years (42%), and the majority reported experiencing homelessness (73%), and using heroin or fentanyl at least a few times a week (93%) at the time of the study. Among all participants , 148 (87%) had a suspected xylazine wound of varying severity in the past 90 days. Among those with a suspected xylazine wound, participants had experienced several barriers when seeking medical care including long wait times (53%) and inadequate pain (44%) and withdrawal (54%) management. Some felt that their healthcare provider did not know how to treat their wounds (27%), with one respondent saying, “I did have a nasty one [wound] on my arm that I was in the hospital for 2.5 months for. You could see the tendons in the wound. It was weird for even the healthcare providers, they said ‘Wow.’” Another common barrier faced by respondents was provider stigma (65%), in which one specified that when seeking wound care, “Nurses accuse me of lying about not injecting because I have a wound.”

Furthermore, among participants with self-reported xylazine wounds, self-treatment practices varied widely. 35% reported taking non-prescribed antibiotics for suspected wound infection. Participants reported using various agents to clean wounds including water (71%), alcohol (56%), and hydrogen peroxide (41%), and dressings including band-aids (66%) or gauze (66%), with 18% leaving their wounds uncovered.

Conclusions &

Discussion: We found that among a sample of PWUD attending Massachusetts-based SSPs many reported wounds consistent with xylazine exposure. They faced several barriers when seeking medical care, consistent with prior literature. A significant portion reported using caustic agents to treat their wounds, which may delay healing. Xylazine wounds require continuity of medically guided wound care to facilitate healing. Decreasing stigma, adequately treating pain, and managing withdrawal may mitigate wound care barriers and encourage more PWUD with xylazine wounds to seek medical care in the initial stages of wound development, thus decreasing downstream morbidity and mortality. Furthermore, our findings support the urgent need to standardize education for PWUD on harm reduction and self-treatment strategies to support appropriate self-management of their wounds.

References:
Friedman, J., Montero, F., Bourgois, P., Wahbi, R., Dye, D., Goodman-Meza, D., Shover, C., 2022. Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis. Drug Alcohol Depend. 233.

Ozga, J.E., Syvertsen, J.L., Zweifler, J.A., Pollini, R.A., 2022. A community-based study of abscess self-treatment and barriers to medical care among people who inject drugs in the United States. Health Soc Care Community. 30, 1798-1808.

Ruiz-Colón, K., Chavez-Arias, C., Díaz-Alcalá, J.E., Martinez, M.A., 2014. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int. 240, 1-8.

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