Responses of Syringe Service Program Staff and Clients to Xylazine in the Unregulated Drug Supply

"The emergence of xylazine has led to several unintended consequences for PWUD [People Who Use Drugs] across North America, such as tissue necrosis and heightened sedation, the latter of which has potential implications for elevated risk of overdose and social consequences (such as being robbed or assaulted) [5, 21]. Here, we identified how the emergence of xylazine has also precipitated a range of behavioral responses among PWUD, with implications for their individual health and the broader healthcare system [22].

"We identified dynamic communication processes through which information about xylazine emerged and spread among SSP staff and clients, ultimately leading to a formal response by the SSP via the use of XTS [17]. Notably, the initial identification of xylazine was driven by clients’ firsthand experiences with the unregulated opioid supply. Clients then shared their observations and experiences with SSP staff, underscoring the importance of building trust and listening to client expertise, which can serve as an early warning system for emerging adulterants prior to adverse consequences. In contrast, many of the official accounts of xy-lazine adulteration are based on overdose surveillance data or medical examiner reports [9, 13–15, 23], which can take time to process. In addition, most official early warning systems focus on mass spectrometry or drug seizure data, which may involve a time lag and is resource intensive [24, 25], especially in the Southern U.S. where comprehensive drug-checking services are sparse [26, 27]. Integrating qualitative insights from PWUD into current early warning systems may provide another avenue for proactive intervention that can indicate the presence of a novel adulterant using relatively few resources and can be scaled locally via SSPs or other settings that serve PWUD (e.g., drug treatment facilities). Indeed, improved collaboration between harm reduction programs and surveillance professionals, including medical examiners and crime laboratory personnel, could circumvent and augment delays in reporting systems. Of course, caution is needed in the development and deployment of warning systems to avoid sensationalizing harms or generating “alert fatigue,” where PWUD and their communities are inundated with information [28, 29]. These findings also emphasize the benefit of embedding research within harm reduction settings to further empower these organizations in responding to emerging challenges."