Treating Xylazine-associated Wounds: Considering a Role for Plastic Surgeons

Xylazine, an alpha-2 agonist used as a veterinary sedative for large animals, has emerged as a common adulterant in the fentanyl and heroin drug supply in the United States.1 Its rapid rise in prevalence and the severity of the wounds it causes has captured the attention of mainstream media and academic literature in recent years. Emerging literature underscores the need for a multidisciplinary strategy to treat this vulnerable population, emphasizing the crucial role of reconstructive surgeons as part of this approach.1–4 As the plastic surgery community evaluates its potential role in treating these wounds, principles of biomedical ethics may be useful for framing relevant considerations in providing care for these patients. Xylazine—nicknamed “tranq”—is often mixed with fentanyl and can be injected, snorted, smoked, or swallowed. Some users may be unaware their drugs contain xylazine, whereas others seek it out for its effect of prolonging a fentanyl high. Although xylazine was intermittently identified in drug samples in the United States starting in the late 2000s, its prevalence has since grown markedly with Philadelphia as the epicenter of the crisis.4 The CDC reports that xylazine-related mortality has increased 1.238% nationwide from 2018 to 2021. By 2023, samples of fentanyl mixed with xylazine had been seized in 48 states.1 Most notoriously, xylazine causes wounds of a severity unlike any others seen before in people who inject drugs. Regardless of the drug consumption method, initial blistered ulcers develop into full-thickness, foul-smelling wounds that often expose and lead to the infection of underlying musculature and bone.5 Although the pathophysiology of these wounds remains unclear, current hypotheses suggest that the drug’s vasoconstricting effects lead to hypoperfusion and subsequent tissue necrosis.1–4 Existing literature on xylazine, primarily from addiction medicine and public health perspectives, advocates for treating both the patient’s substance use disorder and their wounds.1 Although evidence-based protocols for substance use disorders exist, no standard protocol for xylazine wound care has been established. Limited publications on xylazine-associated wound treatment highlight the necessity of involving plastic surgeons in limb-salvaging procedures, explicitly naming reconstructive procedures (split-thickness skin graft, dermal allograft, and flap/soft tissue coverage) in wound care algorithms.2–4 However, this issue has yet to gain significant attention within the field of plastic surgery itself. As the prevalence of xylazine-associated wounds continues to rise, the 4 principles of biomedical ethics can guide the field’s potential role in treating these patients. Considerations of autonomy include treatment decision-making and balancing patient choice and provider recommendations, particularly pertaining to drug abstinence. Nonmaleficence and beneficence are vital for evaluating clinical decision-making in scenarios of reconstruction versus amputation for patients whose ongoing substance use might impede recovery, yet whose quality of life would be severely compromised by limb loss. Finally, the principle of justice presents an opportunity for plastic surgery to contribute to the recommended multidisciplinary care model and to promote health equity by supporting the health care needs of people who use xylazine. Xylazine-associated wounds severely impact quality of life, and plastic surgery can make an essential contribution to the treatment needs of those affected. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.