Zeroing in on xylazine - a mixed methods study to explore correlates of reported xylazine use and educational gaps among people who use drugs

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BACKGROUND: Xylazine prevalence has surged in the unregulated fentanyl supply across the United States. In efforts to inform education initiatives for people who use drugs, this study aimed to identify factors associated with reported xylazine use and knowledge gaps. METHODS: This Connecticut-based mixed methods study employed both surveys and interviews. Survey participants, recruited from collaborating harm reduction organizations, were adults who used unregulated substances in the last six months. They were asked about their drug use, knowledge of xylazine, service use experience, and demographic information. Purposive sampling of survey participants was then used to select individuals for in-depth interviews. Topic guides were designed to gain a deeper understanding of participants' xylazine awareness and future learning preferences. Quantitative data were dichotomized based on reported xylazine use and analyzed using descriptive statistics, Chi-square, Fisher's exact, or t-tests. Simple and multiple logistic regression were used to find correlates of reported use of xylazine. Interviews were analyzed using thematic analysis. RESULTS: Between August and November 2024, we surveyed 114 respondents. Nearly half reported lifetime xylazine use (49.1%) and almost three-quarters heard of xylazine prior to engaging in the study (71.9%). Multiple logistic regression revealed that unemployment (OR 6.5, 95% CI 2.4-17.8), past-year fentanyl use (OR 41.1, 95% CI 4.8-354.4), and harm reduction service engagement (OR 5.2, 95% CI 1.6-16.8) as predictors of reported xylazine use, after adjustments. We conducted n=31 interviews; thematic analysis identified four major themes: (1) information about xylazine was obtained from many sources, (2) knowledge about xylazine was gained from using xylazine, (3) some misconceptions about xylazine have developed, and (4) multiple mechanisms for xylazine education are desired. CONCLUSIONS: This study underscores the need for accessible xylazine education to address knowledge and confidence gaps among people who use drugs. Xylazine education should be tailored to one's likely xylazine exposure. Education must be harm-reduction oriented, stigma-free, and incorporate the voices of people who use drugs.

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