"Anything can happen": experiences of people using opioids in a xylazine market.

Background: Xylazine is associated with a number of negative health outcomes, such as severe wounds and withdrawal. As xylazine increasingly emerges in drug markets across the United States, there is an urgent need for a national response to reduce related harm. As such, healthcare systems, harm reduction organizations, and community members continue to work to identify and develop the best approaches for harm reduction interventions to address xylazine challenges. This study engaged people who use opioids (PWUO) in Philadelphia to explore current experiences with and responses to xylazine adulteration.

Methods: From January to February 2024, we conducted semi-structured interviews with PWUO in the Kensington neighborhood of Philadelphia to explore their perceptions of and experiences with xylazine. We used a Community-Based Participatory Research (CBPR) framework to include people with living experiences of xylazine use in the research process. The interviews were audio-recorded, transcribed, and coded using content analysis to identify themes.

Results: Among 40 participants, 50% were male, 55% White, 32% Latino, half completed high school and 40% were unhoused. Ages ranged from 25 to 57 years old. All reported using xylazine and fentanyl, and a majority (75%) had experienced an overdose in their lifetime. More than half (57.5%) reported injecting as a preferred method for mode of administration. Participants reported profound impacts from xylazine on themselves and the broader community of PWUO in Philadelphia. Conversations primarily centered on four domains of concern: wounds, withdrawal, safety concerns from unconscious sedation, and safety concerns from mobile sedation.

Conclusions: Xylazine had many negative impacts on PWUO, including severe wounds, withdrawal, and sedation, with sedation resulting in increased risk of robbery, physical or sexual assault, or accidents while sedated but mobile. Individual attempts to reduce these xylazine-related harms are insubstantial when placed against structural factors driving these risks. Increased investment in wound care supplies and streetside wound care nursing by trauma-informed clinicians who will not further stigmatize people in need of care may be beneficial. In addition, higher-level policy and programmatic changes, i.e., updating clinical procedures to treat withdrawal, access to housing, and lower barrier treatment facilities, are needed to reduce the harms associated with xylazine use most effectively.