Xylazine in Ohio: Insights from individuals with criminal legal system involvement and a history of illicit stimulant use.

Background: Xylazine, a non-opioid sedative not approved for human use, poses serious health risks. It is primarily found in illicitly manufactured fentanyl, but xylazine-fentanyl combinations also appear as illicit stimulant adulterants. Although strategies exist to reduce the risk of xylazine-related harms, some high-risk populations may be unaware of the drug, including people with recent criminal legal system involvement who use illicit stimulants. Methods: A cross-sectional electronic survey was conducted in Ohio in October 2024 to assess xylazine-related knowledge, attitudes, and behaviors among people with criminal legal system involvement and prior illicit stimulant use. Participants were recruited from Ohio courts. Results: Among 229 respondents (43.5% response rate), 42.4% had heard of xylazine. The sample was 54.6% female, 83.3% White, 3.1% Hispanic or Latino, and mean age was 38.5 years (SD = 9.4). Individuals who had heard of xylazine were more likely to have used fentanyl (35.1% vs. 7.1%) or heroin (35.5% vs. 2.4%) in the past 6 months than those who had not heard of it. Most respondents (75.1%) indicated it was "very important" to know if xylazine is in their drugs and 66.4% would be "very" or "somewhat likely" to use xylazine test strips, if available at no cost. Among people who had heard of xylazine, 83.5% did not want to use xylazine and try to avoid it. Conclusions: Most respondents were unaware of xylazine, despite its prevalence in Ohio. Xylazine education and easy access to harm reduction tools are critical for preventing xylazine-related harms among this high-risk population.