Scaling up low barrier wound care for people who use drugs: a mixed methods study

People who use drugs (PWUD) have long required wound care-a need that has become more urgent with the rise of xylazine, an animal tranquilizer in the street opioid supply associated with necrotic wounds. When PWUD visit the hospital for wound care, they often face discrimination from healthcare staff and leave the hospital before treatment completion. Low barrier wound care, community-based wound care that is grounded in harm reduction, is promising for meeting PWUD where they are and providing trustworthy, high quality care. Yet, access to low barrier wound care remains limited. This study explored determinants of and strategies for scaling up low barrier wound care for PWUD.

We utilized a prospective sequential exploratory mixed methods design, including semi-structured 1:1 interviews, community advisory board (CAB) meetings, and an online survey. The study was conducted from April 2024-September 2024 in Philadelphia, Pennsylvania and surrounding regions. We included wound care providers, administrators, and recovery specialists of low barrier sites with walk-in, flexible services and harm reduction approaches. The interviews identified determinants of scaling up low barrier wound care, guided by the Consolidated Framework for Implementation Research. We then facilitated CAB meetings and conducted a survey of CAB members to identify community-generated implementation strategies and assess acceptability, feasibility, and appropriateness of CAB-generated strategies. We also generated evidence-based implementation strategies using the Expert Recommendations for Implementing Change compilation.

Participants identified many barriers, including stigma, social needs, local policies, unstable funding, lack of specialized knowledge, and unstandardized evidence. Promising implementation strategies include using mass media to address stigma, developing resource sharing agreements between sites, revising professional roles to spread knowledge, and building academic partnerships to develop evidence. The most acceptable, feasible, and appropriate strategy rated by the CAB was offering social needs services (e.g., food, showers) within low barrier wound care sites.

Many factors at different levels influence the availability and quality of low barrier wound care for PWUD. Our results suggest that communities would benefit from a local needs assessment to identify and tailor strategies for scaling up care. Future work will test the effectiveness and implementation of identified strategies.