'Tranq': perceptions of xylazine and harm reduction practices among people receiving treatment for substance use disorders.

Background: Xylazine, commonly known as 'Tranq,' is a veterinary tranquilizer that is increasingly found in the recreational opioid supply, complicating the user experience. Xylazine-adulterated fentanyl is associated with a withdrawal syndrome that may not respond to usual treatment, and the opioid overdose reversal agent naloxone does not reverse the effect of xylazine.1 While it remains unclear whether xylazine directly increases overdose deaths, its presence in the drug supply likely elevates overall harm and morbidity. Moreover, due to unintended contact, xylazine poses an often unaccounted for danger to people who use drugs, and there is limited understanding of risk perception among people subject to xylazine exposure. The existing research indicates variations in the extent that individuals desire to use or avoid substances that contain xylazine.2, 3 This study aimed to evaluate how people who use drugs perceive their susceptibility to and severity of exposure to xylazine, and to assess how these perceptions impact their engagement in harm reduction behaviors.

Methods: We recruited people receiving treatment for substance use disorders at a community hospital. We used Spearman correlations to evaluate the associations between patient characteristics and perceptions of xylazine exposure are associated with harm reduction behaviors. The survey instrument was informed by the Health Belief Model.

Results: Over half of participants (26/49), estimated that at least some of the drugs that they use contain xylazine, and 73.5% believed that exposure to xylazine increased their risk of overdose. Approximately 65% of respondents reported never trying to obtain xylazine, and only 12.2% agreed or strongly agreed that they were more likely to use a batch of drugs if they knew it contained xylazine. Overall, engagement in harm reduction behaviors was limited, with 57.1%, reporting that they rarely or never carried naloxone when using drugs and 77.6% reported rarely or never testing their drugs before use. There was a positive association between the belief that xylazine increases the risk of overdose and engagement in harm reduction behaviors (Spearman Rho = 0.290, p = 0.043). Participants who identified xylazine in their drugs and modified their behavior as a result are significantly more likely to regularly practice overdose prevention behaviors.

Conclusion: Xylazine is increasingly present in the drug supply, yet susceptibility to exposure does not appear to influence engagement in harm reduction behaviors. Limited use and knowledge of test strips, as well as other overdose prevention behaviors, highlights the need for targeted harm reduction education. Healthcare providers in all practice settings should be aware of the potential risks posed by xylazine exposure and prioritize evidence-based care, including harm reduction.