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Jawa R, Ismail S, Shang M, Murray S, Murray-Krezan C, Zheng Y, Mackin S, Washington K, Alvarez P, Dillon J, McMurtrie G, Stein M, Walley A, Liebschutz JM. Drug use practices and wound care experiences in the age of xylazine adulteration. Drug Alcohol Depend 2024; 263:112390. [PMID: 39173221 DOI: 10.1016/j.drugalcdep.2024.112390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 07/12/2024] [Accepted: 08/03/2024] [Indexed: 08/24/2024]
Abstract
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.
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Affiliation(s)
- Raagini Jawa
- Center for Research on Healthcare, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Ave, 2nd floor, Pittsburgh, PA 15213, USA.
| | - Samia Ismail
- Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Margaret Shang
- Center for Research on Healthcare, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Ave, 2nd floor, Pittsburgh, PA 15213, USA
| | - Stephen Murray
- Clinical Addiction Research and Education Unit, General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA
| | - Cristina Murray-Krezan
- Center for Research on Healthcare, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Ave, 2nd floor, Pittsburgh, PA 15213, USA
| | - Yihao Zheng
- Center for Research on Healthcare, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Ave, 2nd floor, Pittsburgh, PA 15213, USA
| | - Sarah Mackin
- AHOPE, Boston Public Health Commission, 774 Albany St, 1st Floor, Boston, MA 02118, USA
| | - Kenny Washington
- AHOPE, Boston Public Health Commission, 774 Albany St, 1st Floor, Boston, MA 02118, USA
| | - Pedro Alvarez
- Tapestry, 1985 Main Street, Suite G, Springfield, MA 01103, USA
| | - Jaime Dillon
- Life Connection Center, 192 Appleton St, Lowell, MA 01852, USA
| | - Gary McMurtrie
- Center for Research on Healthcare, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Ave, 2nd floor, Pittsburgh, PA 15213, USA
| | - Michael Stein
- Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Alexander Walley
- Clinical Addiction Research and Education Unit, General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA
| | - Jane M Liebschutz
- Center for Research on Healthcare, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Ave, 2nd floor, Pittsburgh, PA 15213, USA
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Russell E, Hawk M, Neale J, Bennett A, Davis C, Hill LG, Winograd R, Kestner L, Lieberman A, Bell A, Santamour T, Murray S, Schneider KE, Walley AY, Jones TS. A call for compassionate opioid overdose response. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 133:104587. [PMID: 39299143 DOI: 10.1016/j.drugpo.2024.104587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 08/27/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024]
Abstract
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.
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Affiliation(s)
- Erin Russell
- Health Management Associates, 2501 Woodlake Cir Suite 100, Okemos, MI 48864, USA.
| | - Mary Hawk
- University of Pittsburgh School of Public Health, Behavioral and Community Health Sciences, 130 DeSoto Street 6127 Public Health, Pittsburgh, PA 15261, USA.
| | - Joanne Neale
- King's College London, 4 Windsor Walk IoPPN, Denmark Hill, London SE5 8AB, United Kingdom.
| | - Alex Bennett
- New York University, School of Global Public Health, 708 Broadway, NY, NY 10003, USA.
| | - Corey Davis
- Network for Public Health Law, 7101 York Ave S. #270, Edina, MN 55435, USA.
| | - Lucas G Hill
- The University of Texas at Austin, 2409 University Ave, A1910, PHR 2.222, Austin, TX 78712, USA.
| | - Rachel Winograd
- University of Missouri, St. Louis, 43 Benton Ct, St. Louis, MO 63121, USA.
| | - Lauren Kestner
- Center for Prevention Services' Queen City Harm Reduction, 811 Eastway Dr., Charlotte, NC 28205, USA.
| | - Amy Lieberman
- Network for Public Health Law, 7101 York Ave S. #270, Edina, MN 55435, USA.
| | - Alice Bell
- Prevention Point Pittsburgh, 460 Melwood Ave, Suite 100, Pittsburgh, PA 15213, USA.
| | - Tim Santamour
- Florida Harm Reduction Collective, 4601 3rd Ave N., Saint Petersburg, FL 33713, USA.
| | - Stephen Murray
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02119, USA.
| | - Kristin E Schneider
- Johns Hopkins Bloomberg School of Public Health, 1812 Ashland Ave, Office 333, Baltimore, MD 21030, USA.
| | - Alexander Y Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, 801 Massachusetts Ave, Boston, MA, 02119, USA.
| | - T Stephen Jones
- T. Stephen Jones Public Health Consulting, 123 Black Birch Trail, Florence MA 01062, USA.
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Tilhou A, Baldwin M, Alves J. No Time to Wait: Leveraging Primary Care to Treat Stimulant Use Disorder. Am J Prev Med 2024; 67:464-469. [PMID: 38762205 PMCID: PMC11338722 DOI: 10.1016/j.amepre.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Alyssa Tilhou
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Marielle Baldwin
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| | - Justin Alves
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
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Harvey LH, Green TC, Park JN, Rich JD. U.S. policy responses to xylazine: Thinking bigger. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 130:104517. [PMID: 39003892 DOI: 10.1016/j.drugpo.2024.104517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Leah H Harvey
- Alpert School of Medicine at Brown University; The Miriam and Rhode Island Hospitals, 164 Summit Ave, Providence, RI, 02906, United States
| | - Traci C Green
- Alpert School of Medicine at Brown University; The Miriam and Rhode Island Hospitals, 164 Summit Ave, Providence, RI, 02906, United States
| | - Ju Nyeong Park
- Alpert School of Medicine at Brown University; The Miriam and Rhode Island Hospitals, 164 Summit Ave, Providence, RI, 02906, United States
| | - Josiah D Rich
- Alpert School of Medicine at Brown University; The Miriam and Rhode Island Hospitals, 164 Summit Ave, Providence, RI, 02906, United States
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Tomson C, Neuschatz R, Teixeira da Silva D. Harm reduction nursing and the path toward developing best practice: Lessons from caring for people with xylazine-associated wounds in Philadelphia, PA. Nurs Outlook 2024; 72:102248. [PMID: 39067108 DOI: 10.1016/j.outlook.2024.102248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/06/2024] [Accepted: 07/07/2024] [Indexed: 07/30/2024]
Abstract
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.
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Affiliation(s)
- Catherine Tomson
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, Philadelphia, PA.
| | - Rachel Neuschatz
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, Philadelphia, PA
| | - Daniel Teixeira da Silva
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, Philadelphia, PA
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Jawa R, Blakemore S, Murray S, Ventura AS, Hristova T, Wilder A, Shang M, Johnson T, LaBelle C. Wound Care Capacity of the Addiction Workforce in the Setting of Xylazine. J Addict Med 2024:01271255-990000000-00348. [PMID: 39051898 DOI: 10.1097/adm.0000000000001352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
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.
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Affiliation(s)
- Raagini Jawa
- From the Center for Research on Healthcare, University of Pittsburgh School of Medicine, Pittsburgh, PA (RJ, MS); Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, MA (RJ, SB, SM, ASV, TH, AW, CLB); and Boston Health Care for the Homeless Program, Boston, MA (TJ)
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Aronson ID, Ardouin-Guerrier MA, Baus JE, Bennett AS. Barriers to, and Facilitators of, Checking Drugs for Adulterants in the Era of Fentanyl and Xylazine: Qualitative Study. JMIR Form Res 2024; 8:e56755. [PMID: 38959505 PMCID: PMC11255526 DOI: 10.2196/56755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/30/2024] [Accepted: 05/15/2024] [Indexed: 07/05/2024] Open
Abstract
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.
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Affiliation(s)
- Ian David Aronson
- School of Global Public Health, New York University, New York, NY, United States
- Center for Technology-based Education and Community Health, NDRI-USA, New York, NY, United States
| | - Mary-Andrée Ardouin-Guerrier
- School of Global Public Health, New York University, New York, NY, United States
- Center for Technology-based Education and Community Health, NDRI-USA, New York, NY, United States
| | - Juan Esteban Baus
- School of Global Public Health, New York University, New York, NY, United States
| | - Alex S Bennett
- School of Global Public Health, New York University, New York, NY, United States
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8
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Salani DA, Valdes B, Weidlich C, Zdanowicz MM. The New Street Adulterant Drug: What Clinicians Need to Know About Xylazine (Tranq). J Emerg Nurs 2024:S0099-1767(24)00135-1. [PMID: 38958620 DOI: 10.1016/j.jen.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/10/2024] [Accepted: 06/03/2024] [Indexed: 07/04/2024]
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Hoffman GR, Giduturi C, Cordaro NJ, Yoshida CT, Schoffstall AM, Stabio ME, Zuckerman MD. Classics in Chemical Neuroscience: Xylazine. ACS Chem Neurosci 2024; 15:2091-2098. [PMID: 38747710 DOI: 10.1021/acschemneuro.4c00172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
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.
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Affiliation(s)
- Gavin R Hoffman
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
- Department of Chemistry and Biochemistry, University of Colorado Colorado Springs, Colorado Springs, Colorado 80918, United States
| | - Chetan Giduturi
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Nicholas J Cordaro
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Cassidy T Yoshida
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Allen M Schoffstall
- Department of Chemistry and Biochemistry, University of Colorado Colorado Springs, Colorado Springs, Colorado 80918, United States
| | - Maureen E Stabio
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Matthew D Zuckerman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
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Park JN, Serafinski R, Ujeneza M, McKenzie M, Tardif J, Krotulski AJ, Badea A, Grossman ER, Green TC. Xylazine awareness, desire, use and exposure: Preliminary findings from the Rhode Island community-based drug checking cohort study. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 11:100247. [PMID: 38974777 PMCID: PMC11225690 DOI: 10.1016/j.dadr.2024.100247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/23/2024] [Accepted: 05/30/2024] [Indexed: 07/09/2024]
Abstract
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.
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Affiliation(s)
- Ju Nyeong Park
- Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School, Brown University, Providence, RI, United States
| | | | - Merci Ujeneza
- Rhode Island Hospital, Providence, RI, United States
| | | | | | - Alex J. Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Horsham, PA, United States
| | - Adina Badea
- Rhode Island Hospital, Providence, RI, United States
| | | | - Traci C. Green
- Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School, Brown University, Providence, RI, United States
- Heller School for Social Policy and Management, Brandeis University, United States
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Bedard ML, Huang XP, Murray JG, Nowlan AC, Conley SY, Mott SE, Loyack SJ, Cline CA, Clodfelter CG, Dasgupta N, Krumm B, Roth BL, McElligott ZA. Xylazine is an agonist at kappa opioid receptors and exhibits sex-specific responses to opioid antagonism. ADDICTION NEUROSCIENCE 2024; 11:100155. [PMID: 39086495 PMCID: PMC11290297 DOI: 10.1016/j.addicn.2024.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Madigan L. Bedard
- Department of Pharmacology, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Xi-Ping Huang
- Department of Pharmacology, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- National Institute of Mental Health Psychoactive Drug Screening Program, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Jackson G. Murray
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Alexandra C. Nowlan
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Sara Y. Conley
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- Program in Neuroscience, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Sarah E. Mott
- Department of Pharmacology, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Samuel J. Loyack
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Calista A. Cline
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Caroline G. Clodfelter
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Nabarun Dasgupta
- Injury Prevention Research Center, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Brian Krumm
- Department of Pharmacology, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
| | - Bryan L. Roth
- Department of Pharmacology, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- National Institute of Mental Health Psychoactive Drug Screening Program, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- Division of Chemical Biology and Medicinal Chemistry, University of North Carolina at Chapel Hill Eshelman School of Pharmacy; Chapel Hill, 27599, USA
| | - Zoe A. McElligott
- Department of Pharmacology, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- Bowles Center for Alcohol Studies, The University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
- Department of Psychiatry, University of North Carolina at Chapel Hill; Chapel Hill, 27599, USA
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12
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Carroll JJ. Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports From Front-Line Health Workers in 7 US States. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:222-231. [PMID: 38258791 DOI: 10.1177/29767342231214472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, NC State University, Raleigh, NC, USA
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Bowles JM, Copulsky EC, Reed MK. Media framing xylazine as a "zombie drug" is amplifying stigma onto people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 125:104338. [PMID: 38364357 DOI: 10.1016/j.drugpo.2024.104338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Jeanette M Bowles
- British Columbia Centre on Substance Use: Vancouver, BC, Canada; University of British Columbia Department of Medicine: Vancouver, BC, Canada.
| | | | - Megan K Reed
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
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Bradford W, Figgatt M, Scott KS, Marshall S, Eaton EF, Dye DW. Xylazine co-occurrence with illicit fentanyl is a growing threat in the Deep South: a retrospective study of decedent data. Harm Reduct J 2024; 21:46. [PMID: 38378660 PMCID: PMC10880285 DOI: 10.1186/s12954-024-00959-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
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.
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Affiliation(s)
- William Bradford
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Diabetes Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA.
| | - Mary Figgatt
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Diabetes Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA
| | - Karen S Scott
- Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, USA
- Department of Pathology, University of Alabama at Birmingham, Birmingham, USA
| | - Stacy Marshall
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Ellen F Eaton
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Diabetes Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA
| | - Daniel W Dye
- Jefferson County Coroner/Medical Examiner's Office, Birmingham, USA
- Department of Pathology, University of Alabama at Birmingham, Birmingham, USA
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German D, Genberg B, Sugarman O, Saloner B, Sawyer A, Glick JL, Gribbin M, Flynn C. Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore. Harm Reduct J 2024; 21:18. [PMID: 38254198 PMCID: PMC10804796 DOI: 10.1186/s12954-024-00940-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
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.
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Affiliation(s)
- Danielle German
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | - Becky Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Olivia Sugarman
- Department of Health, Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Brendon Saloner
- Department of Health, Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anne Sawyer
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Jennifer L Glick
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore, MD, 21205, USA
| | | | - Colin Flynn
- Maryland Department of Health, Baltimore, MD, USA
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Mai T, Zhang Y, Zhao S. Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges. TOXICS 2023; 11:1012. [PMID: 38133413 PMCID: PMC10748319 DOI: 10.3390/toxics11121012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
- Tingting Mai
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
| | - Youyou Zhang
- Department of Geriatric Neurology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China;
| | - Shuquan Zhao
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
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Zagorski CM, Hosey RA, Moraff C, Ferguson A, Figgatt M, Aronowitz S, Stahl NE, Hill LG, McElligott Z, Dasgupta N. Correction: Reducing the harms of xylazine: clinical approaches, research deficits, and public health context. Harm Reduct J 2023; 20:170. [PMID: 38012764 PMCID: PMC10683201 DOI: 10.1186/s12954-023-00903-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Claire M Zagorski
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 3.208J, Austin, TX, 78712, USA.
| | - Rebecca A Hosey
- HIV Prevention Research Division, Department of Psychiatry, School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4000, Philadelphia, PA, 19104, USA
| | | | - Aaron Ferguson
- National Survivors Union, 1116 Grove St, Greensboro, NC, 27403, USA
| | - Mary Figgatt
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Shoshana Aronowitz
- University of Pennsylvania School of Nursing, Fagin Hall, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Natalie E Stahl
- Greater Lawrence Family Health Center, 34 Haverhill Street, Lawrence, MA, 01841, USA
| | - Lucas G Hill
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 3.208J, Austin, TX, 78712, USA
| | - Zoe McElligott
- Department of Pharmacology, Bowles Center for Alcohol Studies, University of North Carolina, CB#7178, 104 Manning Road, Chapel Hill, NC, 2759, USA
| | - Nabarun Dasgupta
- University of North Carolina, 725 MLK Jr. Blvd., CB 7505, Chapel Hill, NC, 27599, USA
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