Theme: Epidemiology & Public Health Research Year: 2025
Background:
Xylazine-adulterated fentanyl is associated with sedation, skin wounds, withdrawal, and can complicate medication for opioid use disorder (MOUD) induction. There is a need to understand the clinical management of xylazine-associated health harms to people who use drugs (PWUD).
Methods:
From February-April 2025, twelve healthcare providers (physicians [n=7]; nurse practitioners [n=2]; physician associate [n=1]; nurse[n=1]) with expertise in managing xylazine-associated health harms completed a 45-minute semi-structured interview. Interviews assessed organizational capacity for xylazine toxicology screening and clinical management of xylazine-associated health harms. Rapid qualitative analysis was used to analyze transcripts.
Results:
Xylazine exposure is typically presumed based on clinical assessment, as toxicology testing is rare. Providers emphasized the importance of respiratory support in xylazine-involved overdose and recommended titratable naloxone to avoid precipitated withdrawal from high-dose or repeated naloxone dosages. Xylazine-associated wounds often begin as pimples/blisters that coalesce into large wounds with eschar that can require considerable follow-up care. Wound-related stigma can prevent PWUD from seeking wound care, worsening wound chronicity, infection risk, and reinforcing drug use. Wound care management often requires multidisciplinary care coordination with providers who infrequently care for PWUD, resulting in stigma-charged conversations about patients. Providers described xylazine-adulterated fentanyl withdrawal as complex, resembling opioid withdrawal but with pronounced patient anxiety and agitation. Some providers described protracted withdrawal among patients with chronic xylazine use. Clonidine is a first-choice therapy that should be added to xylazine withdrawal order sets in combination with common opioid withdrawal comfort medications. Low-dose buprenorphine induction is an important component of withdrawal management; MOUD induction plans should be tailored to patients’ symptoms.
Conclusion:
Findings demonstrate the complexities of care coordination and management of xylazine-associated health harms. The high level of care coordination needed for xylazine-exposed PWUD is a result of the unpredictable drug supply and will become more challenging as new adulterants (e.g., medetomidine) emerge.
Disclosure of Interest Statement:
This research was supported by the National Institute on Drug Abuse (NIDA), grant F31DA061593. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIDA. The funder was not involved in the collection, analysis, or interpretation of study data.
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