#26 Addressing adulterants (xylazine) in the drug supply with Dr. Raagini Jawa and Tehya Johnson, NP

July 25, 2024 | By Zina Huxley-Reicher

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Transcript available via YouTube

Expand your practice to include wound care for xylazine-related wounds and learn how to talk to your patients about harm reduction for xylazine. We are joined by Dr. Raagini Jawa (@Raaginizzle, UPMC) and Tehya Johnson, NP (@TehyaRJohnson, Boston Health Care for the Homeless).

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Credits

• Show notes, infographics, cover art, writer and producer:  Zina Huxley-Reicher, MD 
• Hosts: Carolyn Chan, MD. MHS, Zina Huxley-Reicher, MD and Shawn Cohen, MD 
• Reviewer: Payel Jhoom Roy, MD, MSc
• Showrunner: Carolyn Chan, MD, MHS
• Technical Production: PodPaste
• Guests: Raagini Jawa, MD MPH and Tehya Johnson, NP 

Production Partner: ACAAM

The Curbsiders Addiction Medicine are proud to partner with  The American College of Addiction Medicine (ACAAM) to bring you this mini-series.  ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.

Show Segments

• Intro, disclaimer, guest bios – 01:42 
• Guest one-liners – 03:22
• Case from Kashlak – 7:56
• Definition of xylazine, overview of xylazine in the drug supply and experience of use – 08:38
• Xylazine test strips and other harm reduction strategies – 15:48
• Natural history of xylazine wounds – 19:15
• Creating a welcoming wound care environment – 21:05
• Red flag symptoms indicating need for oral antibiotics and higher levels of care – 26:18
• Steps for wound care – 33:27
• Frequency of wound care – 46:16
• Pain control in the setting of dressing changes – 51:01
• Route switching, harm reduction around injecting at the site of the wound – 52:20
• When to refer to other wound care specialists/plastic surgery – 55:00
• Take home points – 57:05
• Outro – 1:00:17 

Xylazine Wound Care Pearls

1. Xylazine, an alpha-2 adrenergic agonist, is now an emerging adulterant in our drug supply. Patients can use xylazine test strips as one harm reduction strategy to test for the presence of this adulterant in their supply along with local drug testing at syringe service programs etc.
2. Signs and history to look for that suggest xylazine exposure include: increased speed at which someone goes “out” after use, prolonged periods of time that they are not conscious after use, evidence of xylazine-related wounds, and urine drug screen positive for xylazine.
3. Ask patients generally about their skin, and normalize the potential for wounds.
4. Create a safe environment for wound care – non-judgemental, welcoming and use wound care as an opportunity to teach and empower patients to care for their own wounds.
5. Xylazine wounds are painful, so work with patients to have a pain control plan, especially around dressing changes.
6. Xylazine wounds start as small discolorations, evolving into small ulcerations that eventually coalesce into larger ulcers. They are mostly observed on the upper and lower extremities, rarely on the hands/feet or trunk.
7. Effective wound care for xylazine-related wounds includes ensuring the wound maintains adequate moisture balance, debridement to remove eschar and slough with various topical debriding agents, secondary dressings based on wound output, and outer dressing with an elastic bandage or self-adherent elastic wrap to secure the dressing. Ideally, dressings should be changed daily – this does not need to be done in a clinical setting, and often patients can manage their own dressing changes.
8. Consider oral antibiotics when there is evidence of superinfection of the wound, including erythema, induration, and change and increase in drainage around the wound. MRSA/MSSA/Strep coverage is recommended, such as doxycycline + cefadroxil or doxycycline + amoxicillin. If there is concern for systemic infectious signs, a higher level of care, such as ED/hospital, should be recommended.
9. A majority of xylazine-related wounds can be cared for in outpatient, low-barrier settings.
10. Xylazine wounds can heal with effective wound care – which may take weeks to months.

Addressing Adulterants (xylazine) in the Drug Supply with Dr. Raagini Jawa and Tehya Johnson 

Xylazine overview: 

Pharmacology 

Xylazine is an alpha-2-adrenergic agonist that was approved for use in the 1960s as a veterinary tranquilizer. Its main physiological impact is central nervous system depression, leading to sedation (Greene 1988). There is some emerging evidence that it may have some limited activity at the kappa opioid receptors as well (Bedard 2024). 

Xylazine as an adulterant in the drug supply

Xylazine was first seen in the drug supply as an adulterant in Puerto Rico starting in the early 2000s. We first started seeing it in the drug supply in Philadelphia in 2016 (D’Orazio 2023), and the prevalence of xylazine in the drug supply in the U.S. has continued to increase since then, with varying prevalence based on geography. 

Xylazine’s impact on people using and how to detect it

Overall folks using drugs are concerned with the impacts of xylazine as an adulterant (Reed 2022). Folks note concern over the length of sedation after use, peers “going out” quickly, the time it takes for people to regain consciousness after overdose reversal with naloxone, and about becoming dependent on a new substance (Sparado 2023) (Zagorski 2023). 

Dr. Jawa recommends assessing for some of these specific signs and history to help understand if a patient has had xylazine exposure: 

• Ask a patient if anything has changed with how they feel after they use their opioids, specifically if they have noticed any increased sedation. 
• Ask a patient whether they have experienced any unexpected periods where they seem to pass out and wake up many hours later after use. 
• Understanding from a patient whether they have heard about others in their community having similar experiences (suggesting more of a community-wide prevalence/adulterant leading to these changes)

Some places have the ability to send specific urine drug screens that include xylazine which can be a helpful clinical tool 

Xylazine test strips are a harm-reduction tool that can be helpful for patients to understand their drug supply. Each manufacturer of xylazine test strips has different specifics about how to use them and how much to dilute the drug being checked, and thus their specificity/sensitivity vary (Sisco 2023). There are also a number of things that can cause false positives. Our guests recommend understanding what the recommendations manufacturers are for the specific tests that you might have available to your patients.  Additional resources are available in some places such as comprehensive drug checking at local health departments or syringe service programs, which can provide a more full understanding of the range of adulterants in a supply. Additionally, drug-checking equipment is not decriminalized in all states so it is important to understand what the laws surrounding this are in your particular context. Experts have summarized the laws on drug-checking equipment across the US as of August 2023 (Davis 2023).

Xylazine wounds

The natural history 

Xylazine wounds generally start as skin discoloration, which then progresses to small shallow ulcerations. In Tehya Johnson’s experience, people often develop scattered patterns of these small ulcerations before they coalesce into larger shallow ulcerations (McFadden 2024). A majority of people do not present for wound care until their wounds get to the coalesced larger ulceration stage (Malayala 2022) (Reyes 2012). Generally, they are seen on both upper and lower extremities and less frequently on hands, feet, and trunk. Wounds can be at the site of injection but may also present distant from injection sites. Wounds typically have a large amount of necrotic tissue either in the form of eschar or slough and can produce varying amounts of drainage. They often are associated with an odor. 

Beginning to care for xylazine wounds 

The first step in caring for these wounds is to assess and ask patients about their skin in an open, nonjudgmental way. Dr. Raagini Jawa shares that she generally asks her patients, “Are there any spots on your skin that you are worried about? Are there any black areas or pimples that you have noticed?” She will try to normalize these conversations by asking if folks have heard about other people in the community who have experienced these wounds. 

Tehya reminds us that it is critical to build a safe comfortable space for wound care and for these discussions as often these are really hard conversations for people to initiate. These wounds are often severe in their appearance and can have a strong odor (Torruella 2011), which can both be barriers for people to seek care. Our guests suggest making spaces welcoming with things such as comfortable seating, snacks, and thoughtful provision of wound care that partners with patients in their own care. Important things to understand before you begin providing wound care include what a patient knows they can tolerate when their last dressing change was, and what they have been using for their dressings (McFadden 2024). 

When to use antibiotics

In general, xylazine wounds are chronic wounds. They are colonized by bacteria at baseline. Indications of superinfection of the wound such as significant pain and tenderness more than baseline, induration and erythema surrounding the wound, and a change in the type or amount of drainage to be more purulent are when you should consider starting oral antibiotics for patients. Dr. Jawa recommends empiric coverage for Streptococcus, and MSSA/MRSA with doxycycline in combination with either cefadroxil or amoxicillin-clavulanic acid for a short course (5-7 days). 

Overall the visual severity of these wounds often doesn’t correlate with a need for inpatient management. These can be managed outpatient for the most part and our guests recommend in the absence of red flag signs for systemic infection, to trial wound care with increased dressing changes and close follow-up. Red flag symptoms that prompt referral to a higher level of care include fever, wound with exposed tendon/bone or in close proximity to a joint, and concern for superinfection. 

Wound care – keeping the wound moist is the goal 

1. First, think about how a patient is presenting. Will you need to remove a dressing that is currently on the wound? You may need to moisturize that wound with saline, etc., to get the covering off. Be sure to discuss with patients what they know they can tolerate. 
2. Clean the wound—as xylazine wounds tend to be more painful, you can use soap and water or saline preferentially over other typical wound cleansing agents that may cause burning and stinging.
3. If necrotic tissue (eschar—dark, black, dry or slough—yellow, fibrinous, can be shiny) is present, it is important to add a debriding agent such as medical-grade honey, hydrogel, or prescription-strength agents, such as collagenase, to the eschar. If these are not available, use petroleum jelly to provide enough moisture to allow for autolytic debridement of the tissue. During the debridement process, it is normal for wounds to have increased drainage. 
4. After the debridement agent is added, it is important to add petroleum ointment to the peri-wound area and to any tissue in the wound bed without eschar to protect it. Then, cover with a non-stick dressing. If the wound has a lot of drainage, you can use an abdominal gauze pad and/or gauze roll. 
5. The final step is to apply an outer dressing to hold it in place. You can use a self-adherent elastic wrap or an elastic bandage. It is important not to wrap it too tightly. 

Ideally dressings will be changed daily if possible and re-assessed frequently to see if the choice of dressing is working. It is important to discuss how frequently a patient wants to come back for dressing changes and to teach them how to do their own dressing changes and provide them with the materials to do so on their own. Additionally, knowing what other resources are in your area (syringe service programs, mobile vans etc.) that can provide wound care as well can be helpful if someone needs more frequent assistance with their wound care. It is important to provide education to the patients about what you are doing and why you are dressing the wounds the way you are so that they can manage these on their own as well. These wounds do heal but take weeks to months to do so. 

Pain management

Xylazine wounds are often painful, and dressing changes can be particularly painful. It is important to try to optimize non-opioid analgesics and if you are able, to provide full agonist opioids to help during these dressing changes (Philadelphia Department of Public Health 2024). Many patients often have to self-manage with localized continued opioid use in order to tolerate dressing changes. 

Harm reduction

Many patients may need to continue to inject at the site of the wound for various reasons; this is an important discussion to have with your patients and to accommodate dressings to allow them to do this. Dr. Jawa suggests additionally that you can help your patients find alternate injection sites by using vein finders or tourniquets in your office. Other harm reduction strategies may include switching from injection to other routes of use although there have been some anecdotal reports of patients who have switched to intranasal use then developing complications in the nasal passages. These considerations are important to discuss with your patient. 

When to refer

In general, it is rare to need to refer to other wound care specialists or plastic surgeons, but this is also specific to healthcare systems and regions. Times to consider referral include necrotizing fasciitis and when wounds have exposed bone or tendon. 

Links

1. Xylazine harm reduction (patient handout)
2. Xylazine wound care (patient handout)
3. Xylazine wounds (provider guide – Penn CAMP)
4. Xylazine wound care (patient-facing video)
5. Xylazine wound care training (upcoming, training request, video)

Goal

Listeners will develop an approach to the management of xylazine-related wounds and expand their understanding of harm reduction and substance use care for those using substances that may contain xylazine. 

Learning objectives

After listening to this episode listeners will…  

1. Describe the pharmacology of xylazine 
2. Identify xylazine-related wounds
3. Develop an approach to wound care for individuals with xylazine-related wounds. 
4. Educate patients on harm reduction around xylazine 

Disclosures

Dr. Raagini Jawa and Tehya Johnson report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Huxley-Reicher, Z, Jawa, R, Johnson, T, Cohen SM, Roy P, Chan, CA. “#26 Addressing adulterants (xylazine) in the drug supply with Dr. Raagini Jawa and Tehya Johnson”. The Curbsiders Addiction Medicine Podcast.https://thecurbsiders.com/addiction  July 25, 2024.