(96) Perspectives of Pregnant and Postpartum Persons on Xylazine Education and Home Testing

Background & Introduction: The increasing prevalence of xylazine in the unregulated opioid supply and its impact on pregnancy and related outcomes are of significant concern. Xylazine, an animal tranquilizer, has become a common adulterant in the fentanyl drug supply and when mixed with fentanyl, puts people at risk of increased harms by causing deep sedation, hypotension, and bradycardia not reversed by naloxone. While we always recommend our patients abstain from illicit substance use, this may not align with the goals or reality for our patients, and it is vital that we develop effective harm reduction strategies to mitigate the risks of ongoing use. Xylazine immunoassay test strips (XTS) are a harm reduction strategy that can inform safer use practices but have not been studied in pregnant and postpartum populations. We qualitatively explored the impact of delivering a harm reduction intervention for pregnant and postpartum persons which included: 1) education about xylazine and proper XTS use and 2) distribution of XTS kits for home use.

Methods: Between January to September 2024, we recruited individuals from a large maternity hospital in Pittsburgh, Pennsylvania meeting the following criteria: 18 years and older, currently pregnant or within one year postpartum, and reporting illicit opioid use within the three months prior to study enrollment. The XTS intervention consisted of a brief structured education session delivered by a trained study team member including two online videos and two pamphlets on xylazine, XTS use, overdose prevention, and other xylazine-related harm reduction strategies. Following participants’ successful teach-back, they were given a total of five XTS kits, each kit containing 2 XTSs with interpretation instructions, 2 sterile water vials, and 2 cookers. Two months later, participants were invited to complete a semi-structured interview regarding their experiences with xylazine in the drug supply, using XTS as a risk mitigation strategy, and perspectives on the XTS intervention. Participants were compensated for their time at each study point. Interviews were conducted in-person or over a HIPPA compliant two-way audio-conferencing platform, based on patient preference. Interviews were recorded and transcribed verbatim, and a codebook was developed inductively based on recurring topics. Transcripts were coded and themes were generated by the study team using thematic analysis.

Results: Over nine months, 65 patients were approached while receiving inpatient services related to substance use for study participation and 47 (72%) were enrolled and received the XTS intervention. Among those, 41 (87%) were pregnant and 6 (13%) were post-partum. Among enrolled participants, 32 (68.1%) completed a post-XTS intervention interview. On average, participants were 31 years old, with the majority identifying as white (81.3%), followed by black (6.3%), and multi-race (12.5%). The majority were publicly insured (97%), had an income lower than $30,000 (66%), and had used drug testing strip in the past (56%). From the post-intervention interviews, we identified three major themes: 1) Use of XTS as acceptable and convenient; 2) Xylazine education and use of XTS as empowering; 3) Concern regarding the impact of xylazine on withdrawal symptoms and pregnancy-related outcomes. First, participants found that XTS use was both acceptable and convenient. Many participants indicated XTS were easy to use, provided rapid results, and were reliable. Second, participants found that the information from the XTS education and ability to use XTS to test their substances was empowering, led to behavior change, and served as a motivation for treatment engagement. Third, participants were worried about management of xylazine-associated clinical harms such as xylazine-related withdrawal symptoms, wounds, and the unknown impact of xylazine on their pregnancy and baby. Several participants discussed the intense withdrawal they experienced when using illicit opioids compromised by xylazine and lack of accessible treatment options. A majority expressed concern related to the wellbeing of their baby, including implications for breastfeeding and fetal wellbeing.

Conclusion & Discussion: This study highlights the feasibility and acceptability of a harm reduction intervention focused on xylazine education and xylazine home-testing using XTS for pregnant and postpartum individuals using illicit opioids. Participants found the intervention acceptable, empowering and beneficial for safer drug use, though concerns about the effects of xylazine on their health and that of their babies persisted. While well-received, there was a demand for more information on managing xylazine-associated harms, such as wound care. These findings suggest that XTS kits could be a valuable harm reduction tool, warranting further research on their long-term impact. These findings could also have wider implications for harm mitigation strategies focused more generally on home testing as other adulterants enter the illicit drug supply.

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