Healthcare provider approaches to managing the health harms of xylazine: A qualitative study.

Abstract

Xylazine-adulterated fentanyl use is associated with manifold negative health outcomes, including skin and soft tissue infections, intensified opioid withdrawal, and can complicate medication for opioid use disorder (MOUD) induction. This qualitative research aimed to explore how healthcare providers test for and treat xylazine-related health harms among people who use drugs (PWUD). From February-April 2025, twelve healthcare providers with expertise in managing the health harms of xylazine from three Northeastern states completed an approximately 45-min semi-structured interview to explore organizational capacity for xylazine toxicology screening and clinical management of xylazine-associated health harms. Rapid qualitative analysis was used to analyze transcripts and produce themes. Participants worked in academic institutions (n = 7), free-standing clinics (n = 5), harm reduction organizations (n = 4), substance use treatment programs (n = 4), hospitals (n = 2), and a federally qualified health center (n = 1). Providers infer xylazine exposure based on clinical presentation and rarely order toxicology, which is often unavailable at some institutions. Providers noted three core clinical effects of xylazine use including overdose, xylazine-associated skin wounds, and withdrawal. Respiratory support and monitoring are essential when responding to xylazine-involved overdose. Additionally, wound chronicity, limited treatment guidelines, homelessness, and stigma complicate xylazine-associated skin wound healing. Withdrawal from xylazine typically co-occurs with opioid withdrawal and is worse than opioid-only withdrawal. Xylazine may be worsening experiences of precipitated withdrawal when inducting patients onto buprenorphine. Some physicians noted that medetomidine, a sedative more potent than xylazine, is associated with withdrawal worse than xylazine withdrawal, weakening the efficacy of recently developed xylazine withdrawal protocols and underscoring the volatility of the drug supply. The clinical effects of xylazine do not occur in isolation from the effects of other substances and often compound one another. 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 volatile drug supply, which is likely to become increasingly harmful as new sedative type adulterants, like medetomidine, emerge.