Xylazine wounds are a growing crisis among drug users in Philly − a nurse explains potential causes and proper treatment

Progression and healing of a ‘tranq’ wound in a Philadelphia patient. Panels 5–6 show healing after a single surgical debridement during a hospitalization followed by months of outpatient care. Journal of Addiction Medicine^[7]

What causes the wounds?

The medical community does not fully understand^[8] what causes these wounds. Harm reduction advocates in Puerto Rico published the first reports^[9] on xylazine-associated wounds more than a decade ago, and research stemming from their experience found that the substance has direct cytotoxic effects^[10]. This means that when injected, xylazine will kill cells on contact and create pockets of necrosis under the skin.

Xylazine also constricts blood vessels, causes disease of the small vessels and lowers heart rate and blood pressure. Together, these effects restrict blood flow^[11] to the outermost reaches of our vascular system – namely, our skin and soft tissue. Tissue that is starved of oxygen and nutrients due to this restricted blood flow eventually become necrotic and slough away. So, exposure to xylazine via any route, not just injecting, can lead to small areas of tissue necrosis scattered across the body and prevent healing of other skin injuries like cuts and insect bites.

Not everyone in the scientific community is convinced there is a causal association between xylazine and these wounds. For example, I recently presented on a research panel^[12] during which another speaker suggested that a combination of fentanyl adulterants, or the ways in which people use, may be more to blame for the wounds.

In my opinion, this diversity of thought is good because it prompts more rigorous investigation into what’s really going on. But following the published literature and evidence as it has emerged, and working directly with people who use drugs, has convinced me of the connection.

How do you treat them?

There is a helpful wound care mnemonic – DIME – that I’ve adjusted slightly to summarize the most important aspects of treating these wounds. The D is for debridement, I is for infection and inflammation, M is for moisture management, and E is for environment.

Debridement: Debridement refers to getting rid of the dead or necrotic tissue, a hallmark of xylazine-associated wounds. Healing starts at the bottom or deepest part of the wound, but new tissue can’t form with layers of dead tissue blocking the way. In the clinic, we use ointments that gently and gradually dissolve the dead tissue. But a large buildup is best removed in the operating room, and we sometimes refer people to the hospital for this procedure.

Infection and inflammation: All sorts of bacteria proliferate on the dead tissue that accumulates in these wounds, forming what we call a biofilm^[13]. Bacterial biofilms embed in and around the necrotic tissue and form protective capsules, and they are unreachable by even intravenous antibiotics. They cause inflammation and can lead to infection, both of which stall wound healing. So we use strong antimicrobial ointments inside the wound that disrupt this biofilm, in addition to treating infections with antibiotics as they arise.

Moisture management: Our bodies are 70% water, and in areas without skin to hold all this fluid in – like these wounds – there is going to be a lot of drainage. In a xylazine-associated wound, the drainage picks up a foul odor from the necrotic tissue, and this is understandably highly distressing to people. Consequently, we often see people try to dry out their wounds in order to minimize the mess and odor. But wounds need moisture to heal, so we work with folks in the clinic to come up with a wound dressing that helps keep the wound bed moist while managing the drainage in a way that minimizes distress.

Environment: Living on the street with very limited access to showers, bathrooms or nutritious meals is a reality for many people using xylazine-adulterated fentanyl in Philadelphia. It is very difficult for people to keep up with a daily wound dressing change when even their most basic needs, including shelter, food and safety^[14], are not met. I believe that advocating for resources and policies that address these basic needs is a critical piece of treating these wounds.

Providing high-quality wound care that also recognizes the lived experience and realities of people who use drugs is an art and a science. Last year, our nurse-led clinic published recommendations^[15] for xylazine-associated wound care based on our experiences providing this kind of care in Philadelphia. In January 2024, the Philadelphia Department of Public Health also released a comprehensive set of recommendations^[16] that I highly recommend for people wishing to learn more.

People living on the streets can struggle to get their wounds properly cleaned and dressed as needed for healing. Spencer Platt/Getty Images^[17]

Where can people get treatment?

Few traditional health care settings in the area have set out to accommodate the needs of people with active substance use disorder who need wound care. For example, most outpatient wound care settings enforce strict scheduling and sobriety policies. Meanwhile, most hospitals supply inadequate pain and withdrawal management to patients with fentanyl and xylazine dependence, as evidenced by extremely high self-discharge rates^[18] in this population.

There are, however, a handful of low-barrier wound care clinics^[19] in Kensington, the North Philadelphia neighborhood at the epicenter of the xylazine epidemic. These walk-in settings don’t require insurance or payment and welcome people who are still using drugs. The city publishes a schedule of their locations and times^[20].

A schedule of wound care services in the Kensington area of Philadelphia. Philadelphia Department of Public Health^[21]

But most of these clinics have limited hours, operate on shoestring budgets, rely on volunteers and donations, and are simply not equipped to offer the level of care that people often need.

How does stigma stop people from getting treated?

It is well documented^[22] that stigma around opioid addiction – perpetuated by health care workers^[23] and even by institutions and policies^[24] – can prevent people from getting the care they need^[25].

For example, researchers at Thomas Jefferson University in Philadelphia found that people with xylazine-associated wounds are often denied admittance to detox and rehabilitation programs^[26] until their wound has healed. This is true even when they are medically stable and self-sufficient in their wound care.

On the flip side, patients who are receiving treatment for opioid use disorder and who require advanced medical care for their wounds are routinely rejected by skilled nursing facilities^[27], which exist to support people with things such as wound care.

Our clinic patients have also reported experiencing humiliating treatment by staff at methadone clinics because of their wounds. And I have personally observed several instances in Philadelphia when an individual was denied a wound care intervention such as surgical debridement due to their drug use.

These barriers to treatment are highly unsettling, and I’ve sat with many clinic patients through emotional moments as they process the injustice of being denied care at every turn. I believe that providing support and encouragement to people who are suffering with these wounds, while holding health care settings and systems accountable, are equally important as we navigate this crisis.

Authors: Rachel McFadden, Bloomberg Fellow, Penn Medicine Center for Addiction Medicine and Policy, University of Pennsylvania

Read more https://theconversation.com/xylazine-wounds-are-a-growing-crisis-among-drug-users-in-philly-a-nurse-explains-potential-causes-and-proper-treatment-230839

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