Theorizing causality: A qualitative study of xylazine-related wound diversity and perceived etiology among people who inject drugs.

BACKGROUND AND

aimsIncidence and severity of opioid-associated skin and soft-tissue infections, often requiring intensive and costly medical care, have increased substantially since the emergence of xylazine in the US drug supply. Although progress has been made in clinical and harm reduction recommendations for treating xylazine-related wounds and slowing their progression, the mechanisms remain insufficiently established. This study aimed to describe wound experiences among people navigating xylazine exposure and explore their perspectives on wound etiology to inform collaborative clinical and public health approaches.

designQualitative research as part of a convergent parallel mixed methods rapid assessment.

settingBaltimore, Maryland, USA.

participantsEligible participants were age 18 or over, Baltimore residents and reported injection drug use and xylazine and wound experience in the past year. Participants (n = 26) were evenly distributed by gender and race, mostly over 40, heterosexual, recently unhoused and most frequently injected "fentanyl, in combination with something" or speedball. MEASUREMENTS: Semi-structured qualitative interviews and participatory body mapping, verbatim transcription, iterative thematic analysis.

findingsParticipants classified their wounds from mild (35%) to severe (23%) and commonly reported multiple wounds with shifting severity. Some characteristics matched those typically attributed to xylazine exposure, while others had less clear origins but were still perceived as xylazine-related. A spectrum from pimples, bumps, blisters to deep and blackened ulcerations were considered likely to be xylazine-related and a range of vascular and systemic symptomatology were considered possibly related, as were nasal and throat wounds for those who sniffed or snorted drugs. Participant causal attribution theories related to injection preparation (dilution, contamination), point of contact (subcutaneous tissue, vascularized areas, pulse injection) and interactions with co-occurring health conditions affecting vascular or immune systems (e.g. hypertension, auto-immune disorders). These align with physiological pathways suggested by clinicians and other researchers and offer additional explanations generated among people who inject drugs, drawing on injection-related physiological expertise and lived experience in the absence of formal clinical information. This attribution framework suggests a complex interplay between injection practices, xylazine's physiological effects and individual health conditions on wound development.

conclusionsParticipant causal attribution theories about their possibly xylazine-related wounds align with physiological pathways suggested by clinicians and other researchers and offer additional explanations for wound etiology generated among people who inject drugs.