"You Do What You Have To Do": Risk Environments in Xylazine Wound Care

Xylazine, a veterinary sedative, has become a prevalent adulterant in the unregulated opioid supply and can lead to chronic ulcerative wounds among people who use drugs (PWUD). Without regular care, these wounds can progress and result in infectious and limb-threatening complications. Despite this, PWUD face many barriers to wound self-management and medical treatment. Using the Rhodes' Risk Environment framework, we investigated factors that influence wound care practices and healing among PWUD with xylazine-associated wounds in Pittsburgh, Pennsylvania.

From March to April 2024, we conducted semi-structured interviews with 20 PWUD with at least one xylazine-associated wound and past-90-day xylazine exposure confirmed by laboratory urine testing or self-reported xylazine test strip results. Using content analysis guided by the Rhodes' Risk Environment framework, we categorized individual-level, micro-level, and macro-level factors influencing wound care and outcomes and defined care practices shaped by these factors.

At the individual level, xylazine-associated wound care and healing were shaped by participant knowledge, prior experience, and resourcefulness. Pain, withdrawal, ongoing substance use, and emotional responses like fear and guilt also strongly influenced wound care practices and care-seeking behaviors. At micro and macro levels, multiple factors across the physical, economic, social, and health care environments further impacted wound outcomes, including environmental hazards, resource scarcity (eg, wound supply availability and affordability), health care and public stigma, social support networks, punitive policies, and quality of medical care and access.

Overall, xylazine-associated wound care practices and healing are modified by various individual and structural factors within the risk environment that may lead to disruption in consistent wound care. To improve clinical outcomes, health care systems should prioritize low-barrier strategies that minimize gaps in care, support timely reentry to facilitate wound self-management, and foster continued engagement by addressing the underlying factors that drive treatment hesitation and interruptions.