(18) Xylazine in the Fentanyl Era: Patient Perspectives on Methadone and Emergency Care

Background & Introduction: Amidst Baltimore’s ongoing opioid use disorder (OUD) crisis, the drug contaminant xylazine presents additional risk of drug-related injury and death. Also known as “tranq,” xylazine is an alpha-2 adrenergic veterinary anesthetic and sedative that is increasingly detected in overdose deaths across the U.S., with Maryland among the highest-incidence states in the nation.1 Xylazine has been associated with increases in the presence and severity of skin abscesses and ulcerations, as well as with increased risk of withdrawal.2 3 These complications can interfere with Medications for OUD (MOUD) treatment and retention, causing discomfort and shame that inhibit people from seeking the treatment they need.3 However, little work has characterized how xylazine exposure shapes MOUD care continuity among individuals currently engaged in treatment. Even fewer studies have integrated laboratory-confirmed xylazine exposure with in-depth qualitative patient perspectives. The aim of this study was to characterize patient perceptions, awareness, and perceived impact of xylazine adulteration on overdose risk, methadone treatment, and treatment retention to clarify the clinical implications of this adulterant.

Methods: This study took place in an academically affiliated low-threshold methadone treatment program in Baltimore, MD serving primarily low-income, racially marginalized individuals with OUD. Study participants were purposively sampled from a larger cohort (N=100) of individuals enrolled in methadone treatment for OUD who had previously consented to xylazine screening as part of a parent study. Our final sample included 9 participants who tested positive for xylazine via saliva sample analysis and 19 who tested negative (total N=28). All patients interviewed tested positive for fentanyl in their saliva sample. Assessments included (1) a short quantitative assessment of OUD severity, substance use history, and social determinants of health and (2) a semi-structured interview to understand individuals’ awareness of xylazine adulteration in their own and local drug supplies, their motivation to take or avoid xylazine, their understanding of harm reduction guidelines, and their perception of xylazine’s impact on their engagement with treatment and/or with somatic medical care. Participant interviews were audio-recorded and the recordings were transcribed and reviewed for accuracy. Transcripts were analyzed using a team-based codebook thematic analysis that combined deductive and inductive coding.

Results: Three major preliminary themes emerged from the data: (1) perceptions of xylazine, (2) impact on methadone treatment and (3) impact on somatic medical care. Of the 28 participants interviewed, 26 reported viewing xylazine negatively, and most avoided it. Of patients who avoided xylazine use, desire to avoid skin wounds and elevated overdose risk were cited as the primary reasons. Three participants reported intentionally seeking xylazine; two subsequently tested positive. Participants who tested positive for xylazine diverged in their perceptions of whether xylazine alleviated cravings for opioids. The majority of respondents also reported that methadone does little to alleviate cravings for xylazine. Despite this, few participants reported that xylazine use negatively affected their methadone adherence or persistence in treatment. Among patients avoiding xylazine, many expressed that the prevalence of xylazine made them more invested in cessation, and therefore more likely to continue with MOUD treatment. Health risks reported by participants included skin wounds, overdose, and the risk of crime victimization while experiencing the intense sedation typical of xylazine. No patients reported that xylazine positivity impacted their willingness to seek physical healthcare from related practitioners within our clinic. Most, however, reported avoiding emergency departments even for severe xylazine-related wounds, citing stigmatizing attitudes from providers about continued fentanyl and xylazine use.

Conclusion & Discussion: Contrary to concerns that xylazine would drive treatment disengagement, participants reported little or no negative impact on methadone treatment, despite the inadequacy of existing medications for OUD (MOUD) for managing xylazine withdrawal.4 Indeed, many saw xylazine as an impetus to cessation and commitment to treatment.5 This resistance to xylazine’s effects may reflect the unique clinical environment: a low-barrier, integrated opioid treatment and Syringe Service Program that prioritizes harm reduction as a framework for patient engagement. While xylazine did not limit engagement with clinic-based medical services, patients reported that xylazine negatively impacted willingness to seek external emergency medical care, a risk given the urgency of xylazine-related wounds. This suggests that targeted emergency-care navigation support is needed. Although outside this study’s scope, medetomidine testing became available mid-collection, and one participant who was xylazine-positive also tested positive for medetomidine, highlighting a need for surveillance and education amidst its rising presence. Broader implications are constrained by the limitations of a one-time, cross-sectional qualitative study, which may not accurately capture trends in xylazine use patterns across our treatment-seeking population. An additional limitation is the lack of generalizability to other MOUD treatment settings without co-located medical care, which may buffer against stigma-related treatment avoidance.

References: 1. Khatib M. Tox Tidbits: The Alpha Adulterants: Xylazine and Medetomidine in the Illicit Drug Supply. Published online September 2025. https://mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2025/AlphaAdulterants-Oct-2025.pdf
2. Sibley AL, Miller CW, Joniak-Grant E, et al. A brick to a bundle: A qualitative study of behavioral responses to xylazine adulteration. International Journal of Drug Policy. 2025;145:105017. doi:10.1016/j.drugpo.2025.105017
3. Jawa R, Ismail S, Shang M, et al. Drug use practices and wound care experiences in the age of xylazine adulteration. Drug Alcohol Depend. 2024;263:112390. doi:10.1016/j.drugalcdep.2024.112390
4. London K, Li Y, Kahoud JL, et al. Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine. The American Journal of Emergency Medicine. 2024;85:130-139. doi:10.1016/j.ajem.2024.08.036
5. Heidari O, Sugarman OK, Winiker AK, et al. Personal Experiences With Xylazine and Behavior Change: A Qualitative Content Analysis of Reddit Posts. Journal of Addiction Medicine. 2025;19(2). https://journals.lww.com/journaladdictionmedicine/fulltext/2025/03000/personal_experiences_with_xylazine_and_behavior.3.aspx